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0019 RICHARD'S LANE - Health (2)
19 Richard' Centerville S Lane A=230= 167' . _003 S M EAD No. H1630R UPC 10259 smead.com a Made in USA 40vt fcYg I T 1 TOWN OF BARNSTABLE LOCATION L A-wL SEWAGE# ZO obi- S Z 3 VILLAGE C4,fttC/Vc ASSESSOR'S MAP&PARCEL Z 3y I(q1- O o3 INSTALLER'S NAME&PHONE NO. CAg"!kt �-Spl��c5 LLC_ SEPTIC TANK CAPACITY loco LEACHING FACILITY:(type)U STon ake4) (size) I�•S X 3 NO.OF BEDROOMS 3 OWNER I�v✓y+ ram'► 4 'f S PERMIT DATE: COMPLIANCE DATE: I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility No w•w(R I J.)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 L aching Facility(if any wetlands exist within 300 feet of leaching:facility). feet FURNISHED BY y D S G Al A 2- y3 3 - lob .F (3 G o C r� TOWN OF BARNSTABLE LOCATION 1 1 l C�n�r CS IAN— SEWAGE# VILLAGE CanMuryi�L( ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I Un LEACHING FACILITY:(type) PT / 5/1' (size) NO.OF BEDROOMS 3 .OWNER R(IM PERMIT DATE: 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 BYh'j'�d^ FOr'� t lq 6 g A o a as Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /�t G G_ 4Zi Property Address / ON ner ON ner's Name Information is Ces4cre �� required for every page. City/Town State Zip Code Date of sped n Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. ,tn,g�o men A- General Information on the computer, key to he movetab our 1. Inspector. cursor- et not /sti/ / use the return �✓ 0 key, Name of Inspector , aiP Company Name — /t i//o G A/ -.. Company Address ^O n>ban. Gri h s a�'`'i /¢ Od 6(FoZ City/Town l state / Zip Code S��„/ 8� '?p/o Telephone Nu r 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 perfor ned based on my training and experience in the proper function and maintenance of on,site w a�i sewage,,disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of t V Title 6(310 M R 16.000). The system; i1 v; y C.- Passes 1J. Conditionally Passes ❑ Fails 1 ❑ `eeds Further Evaluation by the Local Approving Authority C) 0- UJ fs l� Signatue 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 10,0oo gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, If applicable, and the approving authority. "*"This report only describes conditions at the time of inspection and under the conditions of use at that time. This Inspection does not address how the system will perform In the future under the same or different conditions of use, Mine-3/13 Title 6 Of6clel Ins pec lion F orm Subst0we Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Roperty Address - A ON nerQN $v/ information is ner's Name required for every h 7Y✓�/� Qd`� /oy �� page' Crty/Town State Zip Code Date o nspea n B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/alwayscomplete all of Section D A) System P s: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 exflitration 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): ons-an 3 Tile 60rllolal Iris peollonForm Subsurface Sewage olspeeal System.1`09e 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 ON ner Property Address �f// Information is AH nor s game required for every _-- CP`+4e1-1 Ile j LOP Czz page' Cry/Town State Zip Code Date of I pectic B. Certification (Cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipes)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 I system will pass inspection if(with approval of the Board of Health): p Pe(s). The ❑ 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 Ans•3/13 Title 5 offlew fro pecien Form Subsuface Sewage Disposal System Pege 3 of 17 • N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System/Form -/Not for Voluntary Assessments 12 L if/ Prop Address Ow Ow ner'serty Name � infnforrmm ation is required for every fe 0 Te✓yt ! Q 104 J.) /� 1 page. City/Town State Zip Code Date OfAiispecti0rl B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system Is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal be attached to this form. to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must 3. Other: D) System Failure Criteria Applicable to All Systems: You gIM Indicate "Yes" or"No"to each of the following for al 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 p Eg,--' 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%day flow thins•3/13 Title 5 ofFlcial Ins peCOon Form Subsurleoe Sewage Disposal Syatem•Pape 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sy m Form -Not for Voluntary Assassm®nts Property Address Cw ner Information Is Q"'ner s Name Cle ,, _requiredforevery _ v� ✓V�/ Q�(,,7d Zpec�n page. Ciry/TownState Zip Code Date of B. Certification (cont.) Yes No ❑ Ey--' 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 groundwater elevation. ❑ ��^ Any portion of cesspool or privy is within 100 feet of a surface water supply or / tributary to a surface water supply. ❑ LH' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ l�' An y 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 6 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 bjLq. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 ❑ 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. !Sine•3f13 Title 5 OfSdel Ins pectlm Form Subsurface Sewage Dlepow gy11tem.P80e S of 17 Z Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewag e Disposal System Form •Not for Voluntary Assessments 9 I a Property Address Owner information is Ow ner s Name /' required for every (_,Pvl'y'!`//(/j ` eQol`�oZ page. G1ty/Town State Zip Code Date o Inspection u,p C. Checklist Check if-the following have been done. You must indicate"yes"or"no"as to each of the following: Yes ❑ 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? ❑ as the system received normal flows In the previous two week period? p 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? L�' ❑ Were all system components, excluding the SAS, located on site? �❑ Were the septic tank manholes uncovered opened, inspected for the condition of the baffles or tees, material tof construe iohe interior of tne tank dimensions, depth of liquid, depth of sludge and depth of scum? (� ❑ Was the facility owner(and occupants if different from owner) rovWed 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. L� ❑ Determined in the field (if any of the failure approximation of distance is unacceptable)(310 CMR 15.302�5)1 C is at issue 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): `� Mrs•3n3 Tile50rAclal inspection Form SU*j'8ce Se"9901ep0801 SYStsm,page 6of 17 • P"\ Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 /�L'C' 4 q,�✓ � ,� Property Address e vif' CW ner Cw ner's Name information Is / &/� �6 A required for every en !�y! ` � City page. /Town —� State Zip Code Date Inspection D. System Infor ation Description: / / // 9 ` Orl P cc / g, df o ���s�✓ �i0 s- Number of current residents: Does residence have a garbage grinder? Yes Imo" No Is laundry on a separate sewage system?(Include laundry system Inspection �� information in this report.) ❑ Yes Ly' No Laundry system Inspected? Er * ElYes LEI No Seasonal use? ❑ Yes L�YNo Water meter readings, if available(last 2 years usage(gpd)), Detail: Sump pump? ❑ Yes No Last date of occupancy; t46 fe-v Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpdj 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: Wine•3/13 Title 6Offtal Inapeodon Fam Substone Sewage Dlepoeat System•Pepe 70 f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Al Property Address Ow ner ON ner's Name inforrnatlon is 6 required for every / , b Ez--z page. gtyrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: / -'e 6 � A - o Source of information: . Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type 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/Altemative 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Other (descri be): IAre•3M3 T1080Hlcial InspecdonForm Subkoace SewmeDispced Syatam•Papeeor17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address mormatfon Isner !CW—ne—rsNianive required for every P✓� ✓ 4 page. City own State Zip— Code Date Inspe tion D. System Information (cont.) Approximate age of all co Ponents, date installed(if known)and so cp of information: 0,9 Were sewage odors detected when arriving at the site? ❑ Yes II�No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast Iron 40 PVC ❑ other(explain): Distance from private water supply well PP Y or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth,below grade: c?;1-2 feet Material o nstruction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certific t �❑, Yes ❑ No Dimensions: O Sludge depth: r:;'2 One•3F13 Me"IIGeIInepec Von Form SubauAeco Sewage Wpm Sptem•page 9ofl7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address tG a✓� iptormation is nor Owner's Name required for every �Q✓►'rG(/(//`/e /� Qo16 �� /� �� page. city/Town State To Code Date Inspection —` D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle — // Scum thickness •r Distance from top of scum to top of outlet tee or baffle 8 �r Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Commentson u( Pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): lA V7 .0/ .'�— c r �y f x �K � Gam,� 7�' /✓1 N 'tea Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass g ❑ polyethylene ❑ other(explain): Dimenslons: 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 pum ping: t9ns•3r13 Date TiUa 50f8cid Inspectlan Form Subsurface Sewrege DiepOW System•Pepe 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DisposalSystem Form -/Not for Voluntary Assessments / �t G 4 v 1 � Property Address .e vas Information Isw ner Orr ner's Name required for every CP✓` 7`�✓�/� / Oo�6301 page. CIty/Town State Zip Code Date of I spe tion D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Ons 3M3 T10860ffldaa In8pec6onFOM SuDW90e SOWV9018pogd System•Pape 11 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /9 ol�tc,4a,�s Property Address ON nor ON ner's Name information Is '' Od t3✓!�`/ � Ax L.3 required forevery cell, page. City/town state Zip Code Date of I pection 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.): !C f' 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: We 3/13 Tide 5Ofac d Inspection F orm Subsulaoe Sewage Dleposd System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON nor Cw ner's Name Le V,Jc' information is C-e04✓!v! a �/� d oL 6 3�required for every page. City/rown State Zip Code Date of In coon D. System Information (cont.) Type: �g 4a,--- � ' o /, S ❑ 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� � A !d✓1 C Gt a wr .2,--1' !��H �.z� f d -7s o �Gw�c 4r �� 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 Mrs•3M 3 Tile 5 0fAGal Inspection Form Sub8Wfece Se wapeDlepceel System•PaQO 130f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not //for Voluntary Assessments Property Address— Ow vrf' Information is ner dw—ner s Name / required for every Lecn Y�r/✓� page. City/Town State Zip Code We of nspect' D. System Information (cost.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of soiids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Wins•3/13 710950(odel InePOCUOnForm SubSWW9 SevM9015P089 System•Pepe 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage D4lsgosaI System Form -Not for Voluntary Assassments / W C a✓C,l Property Address ON ner ON ner's Name Information Is required for every page. (Ay/Town State Zip Code Date of In tbn D. System Information (cont.) Sketch Of Sewage Disposal System: ProHde 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 Mere p c water supply enters the building. Check one of the boxes below: hand-sketch in the area below 0 drawing attached separately Q�Ser Qve✓ I I11 1 � 7 k al � -C2 Mrs•3H 3 TI0e6014cd IrlspeclonForm Sub%eweSewegeDlap%W Sptem'•Frege 15 d 17 L .QX Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address Info Isner ON ner's Name required for every �e✓►TT�'y!l!e /✓ //! fJoL63.2 ��- /� page: City/Town State Zip Code Gate ofAnspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 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: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) t[� Checked wit ai Board of Health-explain: M.Ol t T�-�- A 4_1 Checked with local excavators, installers -(attach documentation) ❑ Accessed I ISGS database-explain: You must describe how you established the high ground water elevation: � 'rk I 1A S. 71 � `7 'gq�o L-t 0 Before filing this Inspection Report, please see Report Completeness Checklist on next page. Ons Y13 T11950todalInspeclonForm SubROSCOSg wape0lapoael SWem'Page 16 Of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Properly Address owner Information is Owners me /n requiredforevery p✓"'"�+��► / —=L "vim /ol- /� page. d] r own State Zip Code We of Ins tion E. Report Complelaness Checklist Inspection Summary: A, B, C, D, or E checked U Inspection Summary D(System Failure Criteria Applicable to All Systems)completed Yd System Information—Estimated depth to high groundwater L7 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Wns•3M 3 TI1e60fAc4e1 lnspeotlonFonrc Subsuface SOWNeDlopoo System.Pepe 17 d 17 '` e COMMONWEALTH OF MASSACHUSETTS EXECUTIVE .OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 19 Richards.Lane Centerville MA 02632 r Owner's Name: _ Estate ofM. Ruin sit �J 2i 6 Owner's'Address: Date of Inspection: November 4 2008 Name of Inspector: (Please Print) Jaines M. Ford Company Name: James M..Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and.that the information reported below is true, accurate and complete as.of the time of the inspection. The inspection was performed based on my 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 4coph nditionally Passes eds Further Evaluation by the Local Approving Authority ls Inspector's Signature: Date: November 12'2008 The system inspector shall Nsubmitinspection 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 I O,0.00 gpd or greater,the inspector and the.system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. qq :Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I n OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Richards Lane Centerville MA Owner: _ Estate 0M.. Ruiz Date of Inspection: Noveiiber 4.2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Richards Lane Centerville MA Owner: Estate o1'M. Rum Date of Inspection: November 4.2008 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliforn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of anunonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I I• OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Richards Lane Centerville MA Owner: Estate of Rum Date of Inspection: November 4 2008 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into 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 '/2 day flow ✓ Required pumping more than 4 times in:the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,.cesspool or privy is below high ground water elevation. ✓ 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 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.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 Richards Lane Centerville MA Owner: Estate 0M. Rum Date of Inspection: November 4 2008 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping infonnation 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? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? _✓ - Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ - Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,-opened,,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum? ✓ — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing infonnation. For example, a plan at the Board of Health. ✓ 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(3)(b)]. 5 F Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INS PECTION CT ION FOR M PART C SYSTEM INFORMATION Property Address: 19 Richards Lane Centerville MA Owner: Estate ofM.. Rum Date of Inspection: November 4 2008 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 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION • Source of information: unavailable Was system pumped as part of the inspection(yes or no): - If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract .(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: installed on 9117186-Per as-built Were sewage odors detected when arriving at the site(yes or no): No 6 fi Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Richards Lane Centerville MA Owner: _Estate ofM. Ruin Date of Inspection: November 4 2008 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Cornments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10." How were dimensions determined: Measuring stick Coimnents (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level ivas even with outlet invert. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Continents (on pumping reconunendations, inlet and outlet tee or baffle condition,structural integrity,"liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of I l i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Richards Lane Centerville MA Owner: Estate ofM. Rum Date of Inspection: November 4 2008 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: allons 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: 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.): unable to locate PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Richards Lane Centerville MA Owner: Estate ofM. Rum Date of Inspection: November 4 2008 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6x61000 awl _ 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 o etc.): f vegetation, The leach nit had 3'ofwater on the bottom The scum line was un above the inlet pipe The leach pit was in failure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Cormnents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 I Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Richards Lane Centerville, MA Owner: Estate ofM.Runt Date of Inspection: govember 4 2008 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. S�rc�n C P ova` 8AL� r'1 Q I o a c a- L 10 Page 11 of 11 r" OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Richards Lane Centerville MA Owner: Estate of All, Runt Date of Inspection: November 4 2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to determine.the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting.property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the h'igh.ground water elevation: Using Barnstable to o ra hic and water contours rna s the mays were showing,anyroxiniately 20'+1-to round water at this site. This report has been prepared only for the septic system and components described herein. This septic systenz has been inspected as of the date of inspection and failed. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 1 No. �d�`� THE COMMONWEALTH OF MASSACHUSETTS FEE / BOARD OF HEALTH V �)✓� — OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair (y) Upgrade ( ) Abandon ( ) - ❑Complete System .[:]Individual Components ( l 9;GL.VAdG'5 R¢ls r -4e3 C) / /( �t'� �� 7 ` n 3 Owner's Na a t` J ,\ �a.J S L v4*%C G e."ri- Lc. Map/Parcel# Address Lot# A A ,," Telephone# Installe Name Desig er's Na e i 3 bL Z� y GrA�w�a�-n�`t t �. ' V2 O k1 qV Address ®�r �Z ,Address Telephone(# Telephone# Type of Building: Lot Size .3 W Y Sq.feet Dwelling—No.of Bedrooms Garbage Grinder Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures QQ� Design Flow(min.required)�C�gpd Calculated design flow31L. 3 gpd Design flow provided3LL3 gpd Plan: Date Number of sheets Revision Date Title 6 �:c�,,,grcl S LA4,,-_ a f r it Description of Soil(s) !;., � li4*l G �9 Z Soil Evaluator Form No. I 4q 0 Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS_ (25i�(T'4 GtsOO %79-Y4 f�3 laic I The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date r 'I Inspections zpn FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 NO. a-DOO THE COMMONWEALTH OF MASSACHUSETTS FEE l7 L/ z. G *rlsrv-i-4L BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: individual Component(s) '; ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: UDPW.c rs 0 i,rDia �)e% at i C1 tC C L.4, c, has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved desig�j. ans/`a -built plans relating to application No. d" 3 p g pp • �oa 5� dated 1�-56—� � Approved Design Flow �f�(gpd) Installer t.. ,4�,Cu 1 ✓' I '�C S I Designer: �- C .. c a� a ti t Inspector The issuance of this certificate shall not be construed as a guarantee tithe system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 NO. THE COMMONWEALTH OF MASSACHUSETTS FEE / �lon BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair P.gre ( ) Abandon ( ) an individual sewage disposal system at kck !m +wa. (,_0 ..t as described in the application for Disposal System Construction Permit No. 2-006 r 5 23 dated Provided: Construction hall be completed within three years of the date of thiw-arrml,All l c '1 cc.,ndit ions must be met. Date ! ^ Board of Health__ ' C� J FORM 2 - DSCP DEP APPROVED FORM 5/96 ' FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS- BOSTON 1 NO. �oo� 5a3 THE COMMON��EALTH OF MASSACHUSETTS FEE I ` BOARD OF HEALTH o F APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) - ❑Complete System `❑Individual Components LocaGr3 Q / W�t'� ®Q 3 � �'�`(r,,� J swner'sNa� Map/Parcel# Address i f! {! Lot# Telephone# Installe Name Designer's Name Address ,r Address '• Telephone#'' Telephone# Type of Building: S t•'q�f c4lee^ l i Lot Size �!$�`) Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) ` Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow3`44. 3 gpd Design flow provided 37` gpd i. Plan: Date 12'Z5-Zvo� Number of sheets Revision Date Title r t r / ►r Description of Soil(s) ',Z2 Soil Evaluator Form No. I L 44 o Name of Soil Evaluator to ��gr� Date of Evaluation /a-t 7.2ao€' DESCRIPTION OF REPAIRS OR..sA em ETERATIONS_ (2Si)h k N00 � c 0! `o I/nJ a 'TZ4 e,�t 4 The undersigned agrees to install.the above described Individual Sewage Disposal System in accordance with the provisions of,. TITLE 5 and further agrees not to place the system(in operation until a Certificate of Compliance has been issued by the Board of Health. Signed �i Date l y U Inspections ✓'�" v FORM t - APPLICATION FOR DSCP DEP APPROVED FORM S/96 '� C l'own of tiarnstame ` Regulatory Services BAR Aet.a. Thomas F. Gellert Director � MAIN Public Health Division ::. I'bomas McKean, birector 200 Main Street,Hyannis,MA 02601 office: 508-862-4644 'Fax: Sob i i f Installer & Designer CgliftcIt on,Form Date: 0 ~0(u 09 —,�......5—_. Installer: C s �,�a e. v,Ir.r ► �.. Andress: 2.6 `V 1.r 00� 0kr ld•I-,�hw~, Address: "3 _ 0.Z-�1—3 L_ On D was issued a permit to install a (date) W (instiller) septic syslcrtt.at _ lci ( ,(Jncrd S 1-0 0 e based on a d .sign drawn by jcrtccarcv7f()C dated h rlb^ < E (designer) —,_.._ __. _ — I ceitify that."the septic system referenced above was installed Substantially tht; Hess lly according cc. design, which may include minor approved changes such as Weral relocation of tlu: di.;ttibution box and/or septic tank, I certify that,the septic: system referenced above was installed w.th major changes (i.e greater than 10' lateral relocation of the SAS or any vertical relocs tion of any coinponen; of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow, (J ler's Sigh lurc;j_._.._...__ c��i�r•�.r,,,,�4�, 1., 41N:17 Aes(Zigner's lg e) t . =1 ( esigner'�, wmp 1'iere) F CO L C N is T R •'AT , H .. li:atth.�Se�tic/f7esigncrCertification F6mi , t 4_I L92:0 FLZ 80S DNI833NIDN301 Wd ZV: ZT 600Z-90-NOf- - _ I Town of Barnstable P# Department of Regulatory Services wwerneLK : Public Health Division Date KAM + 200 Main Street,Hyannis MA 02601 Date Scheduled Time Fee Pd.77 f� Soil Suitability Assessment for Sewage isposal Q Performed By:_VA 1-6Aaek , CSC Witnessed By: LOCATION& GENERAL INFORMATION Location Address 11 fZ a j v A b L,2„t a Owner's Name �lC_ Address tot R tel'►4ej S Lve.., Assessor's Map/Parcel: Z3,0 //6 7/0 0.3/ Engineer's Name NEW CONSTRUCTION REPAIR V Telephone# rev %-1•L% V o tg Land Use Vnble-Fo"(y / ceUdent'(&A Slopes(g'o) 1-3 Surface Stones '- Distances from: Open Water Body _ ft Possible Wet Area — ft Drinking Water Well — ft Drainage Way — ft Property Line 7 /—Oft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Ste_ at4eeeln.ej. e6n Parent material(geologic) (3U uweSh Depth to Bedrock '7 130 Depth to Groundwater. Standing Water in Hole: 1 2'0 Weeping from Pit Face Estimated Seasonal High Groundwater 7 i 30 DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Dam{ pbsecvaFian Depth Observed standing in obs.hole: 7 ft. _ in. Depth to soil mottles: t3 in. Depth to weeping from side of obs.hole: 7 130 in. Groundwater Adjustment ft. Index Well# — Reading Date: index Well level Adj.factor Adj.Croundwater Level 4 PERCOLATION TEST bete +:-ri o8 'l ine 1 o a N1 Observation Hole# Time at 9" Depth of Perc Lb�46 4 Time at 6" ^ Start Pre-soak Time @ /0'0 6 AX Time(9"-6") End Pre-soak 10,l 6 A h Rate Min./Inch -L 2 Site Suitability Assessment: Site Passed `t e-S Site Failed: Additional Testing Needed(Y/N) lV Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICIPERCFORM.DOC e — DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. consistency. ravel ritl 2b-(30 C: `A, DEEP OBSERVATION HOLE LOG Hole# 2- Depth from Soil Horizon Soil Texture Soil Color Soil' ''• . . Other Surface(in.) _ 1 (USDA) (Munsell) Mottling '(Structure,Stones,Boulders. Consistency.% ravel) - LS 16Yrfi16 28-130 F4�C5 2 5 Y'0/6 Dose DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nsistency, o Gravel) F DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten Flood Insurance Rate Map. Above 500 year flood boundary No_ Yes .- Within 500 year boundary No Yes Within 100 year flood boundary No✓ Yes Denth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �e.S If not,what is the depth of naturally occurring pervious material? I Certification /0 27r99 I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required trainin , erti a an perience described in 3 10 CMR 15.017. Date Signature Q:\WnC�PERCFORM.DOC Certified Mail#7006 0810 0000 3524 7946 �0ptKE ro Town of Barnstable Regulatory Services BARNFrABLE. 9 �63qMAC•. $ Thomas F. Geiler,Director �p �0 ATfOMAIA Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 ' January 10, 2007 - Thomas Rum 31 Richards Lane Centerville, MA 02623 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II - MINIMUM STANDARDS.OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. } The property owned by you located at 19 Richards Lane, Centerville was inspected on January 3, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violation(s) of the State Sanitary Code were observed: 105 CMR 410.351- Owner's Installation and Maintenance Responsibilities- Observed GFCI outlet that does not work properly (i.e trip) in both bathrooms. . You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by fixing or replacing outlets in bathrooms. *Note Centerville Fire Department has been notified that the smoke detectors on both floors did not appear to have photo-electric sensors on them and are located within.20' of a.bathroom and/or kitchen. They maybe in contact if found in` violation. a Yu%'ayecz�s ) o r 1 w ' to ti is e iv d thin t o 0 a ,e e t e er ' se w.... c o kt M `-v'�� Z- 1��c�bU Gam_c / 6 PM 6 u, 0-0 4'o CL QAOrder letters\Housing violations\Rental ordinance\19 Richards Lane.doc "t C6¢Q2���ta du- S'�u��:Qe:�``���.8-t�-��a.C���- .�Q°�� • Sys'` �� Photoeiectr�c,Ite04480 � Direct Wire a with Battery Smoke Alarm S C Back-up AI 16l)fl«Iwih Jsrot i, rav G atte i Rvr H IJ p(Ij at i fi jy inclu If(I Mo n nl A Octagon SmgtG rrl .,landiud M J Wall Ring ' r, Mw a VId•Ioq,oJl.r.�IKUO'%i ': , ejt�_ ( � / 1 '/�I o> >lJ hn q„wg F 1 is QVd PPOW dL01,ou�lli ui� it I�:re) aro 'AUO:) Il roht.AUDAM t I J 1!.D Ibt �,. _ se�uaw:s oJluo a e m s,(suanul I ,.„$/CSU 7/�UI 3 s � a� u011PIJUISul SSal.ja>ISeq spPi.Nd „8I.I1IM SS@U-11?LJ Gulim „ j@uuoo )im- r o, �r 5F SulJe '� H k ea - ao o1ogd 'uoi .;;xaay .. i Zr of do alge10auuooaajui .. Sri pap1IlUU1 AJ911uS 3 A6 tpinn d �o neg AaaB �e �tAV� i a oul fiLM o AC )osne , SUIJe1V @OL'PSIIIN of aUO.la SS@1- '! �tr'"- � r✓��. ,� vs' ,�,,trt s . 19i'�_.� � �,yam 1 II � / I� r' '�°�s T�.'l .�'1�"r�+ 3 sand f)uuaplows nnolS S.oaaeo Ajl ou)o 1,77 yeg AGolougoal l 6uISuaS ouTaalaojoLid. — _ -- VI I F Luaejd a>Jouas �,: 08bb wall aialaalaoloyd ��• - U_ie1v a>JOWS F i '� ����,r08bti watl �ata��alaotoydk�T ��. F . •r. r .. _ o > 120V AC { CD Direct Wire73 } `° with Battery Bacic-up Smolce Alarm CU CU o C/) Photoelectric Item 4480 R N Single or- Multiple Station 5 cn ''. • Interconnectable Up oL = a C I p 7•J L L�L� u c a � to 12 Firex" Units Co p ,•-. Quick Connect/ D s.C ! Easy Installation U 9' v V '• Five Year - Limited Warranty CD Se incluyen las instrucciones % U en espanol cc , A Q +' m n i n f'hotoelectrec Sensory " � �t°� o a ska ��� for Fast e.tectioniof Slow Smoldering F�r'es�7k ' ' ay yA ; p m ` _tiraµ�':.._ `z`•`g ,a,r,. .�^x,.�;:'..'s"� 'r'".,`.x"�P .S-�`s,��a ,� �.�,-,$_`A .a��u.., z', �ry,.�. xp� •- . Certified Mail#7006 0810 0000 3524 7946 P�oFt►+r<r�,,Y Town of Barnstable Regulatory Services BA"SCABLE, Thomas F. Geiler,Director IEDMAIA Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 10, 2007 Thomas Rum 31 Richards Lane Centerville, MA 02623 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE H— MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 19 Richards Lane, Centerville was inspected on January 3, 2007 by Timothy O'Connell,Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.351- Owner's Installation and Maintenance Responsibilities— Observed GFCI outlet that does not work properly(i.e trip) in both bathrooms. You are directed to correct the violations listed above within thirty(30) days of your receipt of this notice by fixing or replacing outlets in bathrooms. *Note Centerville Fire Department has been notified that the smoke detectors on both floors did not appear to have photo-electric sensors on them and are located within 20' of a bathroom and/or kitchen. They may be in contact if found in violation. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. QAOrder letters\Housing violations\Rental ordinance\19 Richards Lane.doc Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF TH BOARD OF HEALTH mas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Roberta Duane, Tenant Cc: Timothy O'Connell, Health Inspector Q:\Order letters\Housing violations\Rental ordinance\19 Richards Lane.doc �II&w HORBSS WARREN M THE COMMONWEALTH OF MASSACHUSETTS FORM 30 c' t BOARD OF HEALTH CITY/T DEPARTMENT A REDD SS�Q. O sod 3 o-—y(o q q ( y�, iw�JUC erg TELEP140NE a� p t Address l �" ___-____Occupant__ 't Floor Apartment No.— __. No.of Occupants No. of Habitable Rooms (, No.Sleeping Rooms _3_____- No.dwelling or rooming units N9�___ No.Stories.__ _;2— .- Name and address of owner _I- ©)'(o 3 Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : 1 STRUCTURE INT. Hall,Stairway: Obst'n.: n Lo P - Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing, Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom 17, mo. 3 S 1 Pantry Ida -� (�— fin/ Den —Living Room Bedroom(1). IS (, (, Bedroom 2 1 . Bedroom 3 �►� I i I-7 / Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) - THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PER UFiY." �^ INSPECTOR TITLE _ '- O DATE TIME _ P•M• A.M. THE NEXT SCHEDULED REINSPECTION �T. P.M. 4 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. ' �3 TOWN_ OF BARNSTABLE LOCATION',', 1-t' SEWAGE # - ., VILLAGE ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) ((n!)V 44 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No O 10op'� 9iS�QtFyJZ1)M SE�c't�v�K �61C PRE -C�s�p�� a F ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O�FHEALTH .......PM/.�.............OF........--,P,? Appliration for Disposal Works Tonstrurtion Vvermit Application is hereby made for a Permit to Construct (>6 or Repair ( ) an Individual Sewage Disposal System at: Y �...1.` ._R t.. .R: 5---..A 4N.J6..... s..... ......... Locati Add or Lob No. a ............... ..._ ..�C. ...................................... .............................................Address.................•......................... Ins Type of Building Size Lot...-;k�).7®®...Sq. feet �-, Dwelling—No. of Bedrooms.........-.•................................Expansion Attic (IVP Garbage Grinder ( /40 aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ........................... W Design Flow.._....__...7.........................gallons per person pert Jay. Total d�ily ow..........S.S. .---• ---.........g��`�s. WSeptic Tank—Liquid capacityLj gallons LengthS... Width AKIQ..... Diameter..._.__..._.•... Depths.. ...........x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....... .____._......sq. ft. Seepage Pit No ....... Diameter.-._-_0._.__..... Depth below inlet................ Total leaching area..5...Ln......sq. ft. Other Distribution box 4) Dosing tank ) ��// D a Percolation Test Results Performed by._--.� u. .QN 7._...Rn _ Date..........................: --.....---- Test Pit No. 1................minutes per inch Depth of Test Pit..... .��Z... Depth to ground water....V9N�..__. L� Test Pit No. 2................minutes per inch Depth of Test Pit------ ....... Depth to ground water...NOW 67r........ ••... ---•............... O Description of SoiL.Q_.....X.... ..........t............. �►!hedau�±'1_.. k :.... (� ------••----•--- ---------- •-------- •----------------------------------------- ----------------------------------- •----------------------------------�1 .......•-------------------••-•--•-•----••••-------•--••-•---------......----• ------•••••••-••-...._..-••----••-----•--•-•--------•••••-•-••--•----•••-•-••-••----•••••-•--••-••-•••-•-................ VNature 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:ITU, 5 of the State Sanitary Code— The undersigned furthe agrees not to place the system in operation until a Certificate of Compliance has been 's ed th b of It rj ' Signed. . ws - -•---••...••...-•----------•• ....... -- Application Approved BY A = ........... -----......... Date Application Disapproved for the following re ns:---••••-----••--•----•-•-•-••-••-•--••••-..................................................................... ...................................•-•---..........----.....-•--••--•---......---............-----...-------•------••-•-•-------••----------------•-•------............................................ Date PermitNo......................................................... Issued-....................................................... Date J a . No. ?.- F$$ �-.... ........ s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F i I J n� V ti .... ..............oF........ �. lv-S� jL�G Icy C tee. f. Appliration for Uiopusal Marks To' nstrnrtiun Permit I . Application is hereby made for a Permit to Construct O or Repair ( ) an ,Individual Sewage Disposal System at: .. �I G-�1R� •-- .`.... - =� . L .....rJ s=----- ..........z_Q_:7:.....3............ Locatio -Add e ' or Lot No. ..............T f:QM.65....... --------------------•-----•------- ........-------....------ Owner Address a ................ J�-A 1 - -------------------------------------- -----------------------------.........----------------....................----------...---....... Installer Address Type of BuiI in . O� U YP g � Size Lot.. ______________________Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (N4) Garbage Grinder. ( 140 aOther—Type of Building --------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------------------------------------------------------•-----------------•-----•----------------_---- Design Flow.._......_.15................ .......gallons per person per da ' Total dailyflow..___....4 W -- P P P ,� Y• r �� - ---------------- WSeptic Tank—Liquid capacity).1000gallons Length f3..A_..... Width.4`:_t4...-. Diameter................ Depth.V.......... xDisposal,,Trelich—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit,No.....i,......... Diameter... _0---___•-__- Depth Below inlet_ C..p -__.�.. ........... Total leaching area_'s.�......sq. ft. z Other Distribution box ( ) Dosing tank L - V ` S Pe colation'Test Results Performed by.._._�-+, i.... .. M_�........................ ...... Date............ Nest Pit No. l... ...........minutes per inch Depth of Test Pit.....f! .�� _._ Deptlt to ground water....NQNc...._. 44 Test P�tINo {2N`_.........minutes per inch Depth of Test Pit......f......._. Depth to ground water...MINVC....... D X �escrpton o Soil...0 . .. m -I -n.---� f = x U .....................:----•------------------------- -----------•-•------- -•---••-•-•---- -----------...----•-...._•------•---------•-- W U Nature of Repairs or Alterations—Answer when applicable......................_.. ' -•--------------------------•-----....----------•----------•------------•--------------------•----------•-------------------------------------------------•--- .......................................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The undersigned furth agrees not to place the system in operation until a Certificate of.Compliance has been fis/sued the•board of ealth. ry Signed.:.. /I �' f_ .- '7 ........................... 3 Application Approved By............... •---------- -------- •.------•-•----- ------. -•------------- j - ........... ..Date .... -----V . Application Disapproved for the following re ns:------------------------------------••----------------------------......----------------=--------•--•--------- ....................•--...•-----------------•-•...---------•-•-------•-••------•••----......------•....--•••-••---------------•------•-•-------•-•--------•-------•-----••---------...•---........_.... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `F ...........l..V..\!V..Iv.........OF...... 1.J!............................ ........................ Tertif irat a of Tontplinure THIS S TO CERTIFY That the Individual Sewage Disposal System constructed ", or Repaired ( ) bY.............. �...... s, �. -•----------------------•---......--•-------..............---------...------............._........---..................._ Installer _ at--- j _-------...�.�C !4 N� ,!il . �- ��-�-L � �� �../._r=' has been installed in accordance with the provisions of 1TI11 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.�`���.-_��___. � �n " _?7 dated --`- --•-----------•--•--... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ? /DATE......... `- t ,•---......!..�............•---•-----------------... Inspector....--=-----•-------------........................................................ --..r........._ .... ..r....t..._w..�d;:.,....�...r..,....,�}......`�.� �..�_._.�...�.�....._�s.._+5•, .. ...�...__......_�..JI,.,___•_—Tyr --..—.._—_.T.�..��.._.._.�. THE COMMONWEALTH OF MASSACHUSETTS - � BOARD OF .HEALTH © --- .Y..X..I)......... .OF......B.-A 0'�.�..1.�J...LZ. ....... -757 FEE.............V._`... bisposal Works Tunotr ion '"rrmit � 1 � Permission is hereby granted_.... k-A-__ ............................................................ to Construct ) or Repair ( an I'f4dividu t Sewage Disposal System Street as shown on the application for Disposal Works Construction Per 'it No( r__ Dated_._�.�,-Z_ �- 111 { -------•--- ------ - - . ........................ T uard of Ilcalih 'DATE............- --------------- ------ --'---------- -/---•---------. PROVIDE PRECAST CONCRETE - - T.O.F. EL.= 55.1' ± EXTENSION RISER WITH CONCRETE INISH GRADE OVER D-BOX= 52.9'± GENERAL NOTES COVER TO WITHIN 6"OF F.G. OVER 4' SCHEDULE 40 PVC MIN. SLOPE 1 % FINISHED GRADE OVER DIFFUSERS = 52.7' - 52,3' INLET AND OUTLET COVERS. REMOVABLE COVER OVER RISER TO r SLOPE @ 2% MIN. 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE WITHIN 6"OF FINISHED GRADE INSPECTION PORT WITH ACCESS BOX TO " METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL @ FND. EL, 53.6'± FINISHED GRADE OVER TANK EL. = 53•2'± 5" DIA. OUTLET(S) WITHIN 6 OF F.G. (ONE PER TRENCH) CODE AND ANY APPLICABLE LOCAL RULES. 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE f r -EXISTING 4" PROPOSED 4" 9"MIN. DESIGN ENGINEER. SEWER PIPE -�a-7- ---- '- PVC SEWER PIPE 36 MAX. 9" MIN. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL --�-� I 36" MAX. TOP OF SAS/B.O. = 4.9.73' SYSTEM UNLESS OTHERWISE NOTED. 6" T' 3"DROP MAX 3" 9tn ,\- PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN - -- _ 2" DROP MINMIN.SLOPE 1% JOINTS (TYP.) ELEVATION =49.73' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A II 10" 4" PVC IN FROM 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF 1 �*50,rj'+ SEPTIC TANK 4" PVC OUT TO 1.33' nJTYP � THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. LEACHING FACILITY (�-�,P ) 6 TYP 0.90' 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 12"CONTRACTOR CONTRACTOR SHAOUTET TEE 49.67' MIN 49,rjQ I I 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. SHALL VERIFY SIZE 48" VERIFY CONDITIONj 49.30' \-48.40' (LAID FLAT) 2.875'(34.5")--I-----5.75'-�I 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK AND CONDITION OF EXISTING TEES 22"ZABEL FILTER 6"CRUSHED STONE EXISTING SEPTIC AND REPLACE AS 5.0' (TYP.) MODEL#A1801-4x22 OVER MECHANICALLY FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS TANK NECESSARY COMPACTED BASE (TYP.) 5' MIN. 11.50' NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH AND DESIGN ENGINEER. 5 OUTLET DISTRIBUTION BOX 30.0' (TYP FOR BOTH TRENCHES) 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 55.00' ESTABLISHED BASE. FIRST- TO BE INSTALLED ON A LEVEL STABLE ON A NAIL SET IN A TREE AS SHOWN ON PLAN. EXISTING 1,000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEWO FEET L. 9. OUTLET GROUND WATER ELEV.= < 42.17' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION BIODIFFUSER (PROFILE) BIODIFFUSER END VIEW THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT SEPTIC TANK PROFILE CROSS SECTION VIEW _ 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES *CONTRACTOR VERIFY EXISTING ELEVATION PRIOR DISTRIBUTION BOX DETAIL 12 ARC 36HC (#3616BD) BIODIFFUSERS TO THE DESIGN ENGINEER. TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING NOTE: ENTIRE PROPERTY IS LOCATED WITHIN A DEP -T- • REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM APPROVED ZONE 2 AND THE ESTUARINE WATERSHED. r � r • \� ; TEST PIT DATA APPROPRIATE AUTHORITY. . * ti i Gooseberry PERC NO. 12440 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS QI$l$nd ('`�, INSPECTOR: Donna Z. Miorandi, R.S. LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE t ( THEY SHALL WITHSTAND H-20 LOADING. EVALUATOR: Michael Pimentel, E.I.T. I uller DATE: December 17, 2008 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. • � * ♦� •• TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE on w • • ELEV TOP= 53.00' MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. Pt + • � • . • � ! REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, '� • • ; • ELEV WATER= <42.17' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). ° L CUS • PERC RATE _ <2 min./inch 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN a • r SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. i\ Littl 4 •• ' . DEPTH OF PERC= 28"-46" M t • 16. PROPOSED PROJECT IS LOCATED WITHIN: Z �,� r * » ; "' i TEXTURAL CLASS: 1 ASSESSOR'S MAP 230 PARCEL 167-003 a MAP 230 r %• ` -- OWNER OF RECORD: THOMAS J. & MARION 1. RUM, TRUSTEES PARCEL 166 ; ,,� • • * t • 0" 53.00' ADDRESS: THE RUM FAMILY TRUST k • • . Fill 31 RICHARD'S LANE o��lk 9 � . • , r + t 9" 52.25 CENTERVILLE, MA 02632 gSrO�166 :, •o 'y� •. • •G• .I1 0 • r • • r + • Loamy Sand •.+ :fl B FEMA FLOOD ZONE C •• , ' 1! . •=ear r IF ,w N 1 oYr 5/6 -5� MAP 230 °� OS . • ` ' ll; It , • COMMUNITY PANEL# 250001 0005 C Z�, �9 �•.•• ' •� • ' . # 28" 50.67' 17. DEED REFERENCE: BOOK 4827, PAGE 79 / PARCEL 167-003 �" �O �� • 00 • Perc r; -� 21,841 S.F. ± c� V. Z j, 2 ' 4 5 18. PLAN REFERENCE: PLAN BOOK 377, PAGE 65 -art o o� . 11 ` • `* • •• •Ali 46" 49.17' f y „ hV�s � : r ` • • 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. MAP 230 IP (FND ,' 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY PARCEL 113 ! a ` •• •� • • • FOR SEPTIC SYSTEM UPGRADE- JC ENGINEERING WILL NOT ASSUME ANY LIABILITY +s� Medium-Coarse Sand FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. Q I 'r i '• C 2.5Y 6 6 0I.1-,`-52- I ,_'� _ r '= •. Loose S��o,t390 G, p� / ' GRAVEL _ (2 / LOCUS PLAN DRIVEWAY S �S s SCALE: 1" = 1000' 130"1 1 42.17' 3 ; ) / No Mottling, Standing or Weeping Observed 10P�� �� 1 0 / DESIGN DATA TEST PIT DATA LEGEND -PROPOSED INSPECTION PORT WITH 12440 50xO EXISTING SPOT GRADE Cqs LP [� ACCESS BOX TO GRADE TYP OF 2 PERC NO. \ HC- t � 3. / ( ) NUMBER OF BEDROOMS (DESIGN) 3 - INSPECTOR: Donna Z. Miorandi, R.S. - 50 - #19 `- � -- EXISTING CONTOUR \ , 4) / DESIGN FLOW 110 GAUDAY/BEDROOM EVALUATOR: Michael Fimentel, E.I.T. cqs DECK PROP. TOTAL 12 ARC 36HC BIODIFFUSERS r'S� PROPOSED CONTOUR EXISTING �0 / (6 BIODIFFUSERS EACH TRENCH) TOTAL DESIGN FLOW ° 330 660 GAUDAY DATE: December 17, 2008 3-BEDROOM HC- DESIGN FLOW X 200 /o GAUDAY E/T/C EXISTING UNDERGROUND UTILITIES DWELLING SHED TEST PIT#: 2 TOF = 55.1'± �' PROPOSED DISTRIBUTION BOX USE EXISTING 1,000 GALLON SEPTIC TANK ELEV TOP= 53.20' GAS EXISTING GAS LINE o BH / W W-- EXISTING WATER LINE � APPROXIMA TE LOGA T ION OF I=XIS P ING ELEV WATER <42.3= T LEACHING PIT TO BE PUMPED AND O FILLED WITH CLEAN COARSE SAND PERC RATE _ TEST PIT LOCATION EXISTING LEACHING PIT INSTALL 12 - ARC 36HC (#3616BD) BIODIFFUSERS MAP 230 `�-� = LP r53-- APPROXIMATE LOCATION OF EXISTING DEPTH OF PERC PARCEL 167-004 TPI DISTRIBUTION BOX TO BE REMOVED 53.0'� „# /�/ SYSTEM CAPACITY TEXTURAL CLASS: 1 EXISTING 1,000 GALLON SEPTIC TANK HOC TP 2 53.2,7I o p930 /� 0 ,t }/ (TOTAL L.F. OF BIODIFFUSERS)(7.8 SF/LF)(0.74 GPD/SQ.FT.)= GPD PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE 0 �� (60.0')(7.8 SF/LF)(0.74 GAUSQ.FT.)= 346.3 GAL. LEACHING!DAY 0" 53.20' IP (FND <q r � /� 9"EXISTING 1000 GALLON SEPTIC TANK TO Fill 52.45' 13 PROPOSED DISTRIBUTION BOX -�- BE UTILIZED AS PART OF THIS DESIGN j SWING-TIES Loamy Sand TOTALS: ® PROPOSED ARC 36HC(#3616BD)BIODIFFUSER IP (FND) _53'� ,.�/ MAP 230 DESCRIPTION HC-1 HC-2 B 10Yr 5/6 TOTAL NUMBER OF BIODIFFUSERS: 12 PARCEL 167-002 BIODIFFUSER CORNER(1) 65.0' 53.4' TOTAL NUMBER OF COUPLINGS: 0 28" 50.8T S4� TOTAL LEACHING AREA: 468.0 SQ.FT. REV. DATE BY APP'D. DESCRIPTION BIODIFFUSER CORNER(2) 87.1' 81.5' TOTAL LEACHING CAPACITY: 346.3 GALJDAY BIODIFFUSER CORNER(3) 94.3' 85.4' PROPOSED SEPTIC SYSTEM UPGRADE MAP 230 Benchmark BIODIFFUSER CORNER(4) 74.3' 59.2' PREPARED FOR: Nail Set in Tree PARCEL 167-001 Elev. =55.00' NOTE: Medium-Coarse Sand CAPEWIDE ENTERPRISES A rox. M.S.L. EFFECTIVE LEACHING AREA OF 7.80 SF/LF OBTAINED FROM THE C 2.5Y 6/6 DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER (Loose) "MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO LOCATED AT NOTE: ADVANCED DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003 (LAST 19 RICHARD'S LANE MODIFIED JULY 23, 2008). TRANSMITTAL NUMBER=W000052. 1.) MAGNETIC MARKING TAPE SHALL BE PLACED CENTERVILLE, MA = ALONG THE TOP EDGE OF EACH SEPTIC SYSTEM 130" 42.37' SCALE: 1 INCH 20 FT. DATE: DECEMBER 29, 2008 COMPONENT. 0 10 20 40 80 FEET No Mottling, Standing or Weeping Observed ASH OF MA�1� 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN �� jOHN L PREPARED BY: THE LOCATION OF THE PROPOSED LEACHING FACILITY RESERVED FOR BOARD OF HEALTH USE o CHUjCHII_L fit; JC ENGINEERING, INC. TO ENSURE CONSISTENCY WITH TEST PIT DATA N s 2854 CRANBERRY HIGHWAY SHOWN ON THIS PLAN. REPORT TO ENGINEER AND EAST WAREHAM, MA 02538 LOCAL BOARD OF HEALTH IF SOILS ARE NOT SITE PLAN _ CONSISTENT WITH TEST PIT DATA. 508.273.0377 SCALE: 1" -20' Drawn B BSM Desi Designed B MCP Checked B JLC JOB No.1548 Y= 9 Y� Y� wEy�oA4��� - i 4q/1O5 i R, 0^t4 ROLE i CavEf,?, >'v F� D To H/,rt,;-/No* FAT aF F104G '' K.Zt F t Cr RA DE 4' Sch' 40 i::Y G - -- - �� r 2 Ef+ t ^�R�ems, __ _____—_•��--�----—.—__----- r �54 i �" 'rIKS t P.j G-Lr f. z o PATE Jury 3lLi �t98E, NRNCy L rrl-rl 'j� ,- 9.0-Y/, L oG c� .',TUNE A 1 c l91t puN y� —• '�% i, � -- ! / yr !96 TEST rH Soo SIDE OF PFFV,. + TEST HOL; c SNo�I: I T *HT SA NO wzTH 51 LT jv 7 �• L `J✓Ei S:•st I Z. 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