HomeMy WebLinkAbout0112 ROLLING HITCH ROAD - Health 112 Rolling Hitch Road
Centerville
A= 192-084
S M E A D
No.2-153LOR
UPC 12534
smead.aom • Made In USA
Oil6tU5®NiHSPRODU UE
jF1
OW
TOWN L�OF BARNSTABLE
LOCATION', SEWAGE# S`
VILLAGE Cure ASSESSOR'S MAP.&PARCEL
11 t�o
INSTALLER'S NAME&PHONE NO. Q913 9j d,,®7 - 1/77-01053
SEPTIC TANK CAPACITY /Soo
LEACHING FACILITY.(type) G15 (size)
,NO.OF BEDROOMS
OWNER S ��ian 4 V,i�krrl(A' n
PERMIT DATE: OLO/y - ®5 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 yLeachninFacility(If any wetlands exist within
300 feet of leacty) Feet
FURNISHED BY
13
I
.. c
a
r
TOWN OF
//B��ARNSTABLE
LOCATION ` kAEWAGE #
VILLAGE E_e�l l+—�`1S+`(�Q.. ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 47
LEACHING FACILITY: (type) (size) . X
NO.OF BEDROOO—M—S�,,
BUILDER OR`OWNER l ��c.�45�°� T�=�� VIc� "�1✓�ts�
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
within 300 feet of 1 aclling facility) Feet
Furnished by
l) .
r rs�
r
, r
- — � - �, — � 7 FI F✓m�. fo�o�.,
�c�L
t No. 1 f Fee o
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
v PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4plication for -Misposal *pstem Construrtion permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No j/a /I/N He*--1 d Owger's Name,Address,and Tel.No. /
Q C -,4z�gvsf� 'V ct
Assessor's Map/Parcel 147
I taller's Name,Address,and Tel.No. D igner's Name,Addr d Tel.No.
��"� G��1�i neeisr;►.,c�� 77-5 31
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ;330 gpd Design flow provided gpd
Plan Date .7. Number of sheets Revision Date
Title -p rorg 56 6 C. Jam\S hi
Size of Septic Tank j Type of .A.S.
3
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. f
Date
Application Approved b �J
PP PP Y Date
Application Disapproved by Date
for the following reasons
Permit No. �14 d Date Issued L
No.�}�i/� J —Gj Fee
- � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYication for Disposal pstern Construction 3permit
Ae
Application for a Permit to Construct( ) Repair( ) Upgrade; ) Abandon( ) ❑Complete System ❑Individual Components
{
Location Address or Lot No. / a on j f{�fc46 m- Ow er's Name,Address and Tel.No.
Assessor's Map/Parcel ,� � g�
Ce,� ugv.s !G Vtel tnG n SD�-790 -7/ZZ
Installer's Name,Address,and Tel.No. De igner's Name Addre and Tel.No.
1343 extrwo lon 50� .y7 �. 5� � �g�neeiin�j ��t�s Kok 14-17- 531
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures �, t
Design Flow(min.required) d.r Design flow provided gpd
Plan Date z Number of sheets Revision Date
Title ro 5 C_ S\ .5 >t
Size of Septic Tank 1500 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
ign d Date Z 2 5
Application Approved b
PP PP Y Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued �� t9 /P
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired X Upgraded( )
Abandoned( )by �B* {3 X ri\j +i n
at Q__-R D I 1 1 no H � �/ � P-�C��+ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No r dated D-
Installer Designer r i ,� n r-
#bedrooms Approved desi ow 3 ) f igvd
The issuance of this permit sha not b co trued as a guarantee that the system wi c i ' as yls ®
� ed ;el
¢
Date Inspector
-------------------------------------I----------------------------------------------------------- ------------------_%------ ------
No. ' C_ �/ Fee �—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal &pstem Construction Vermit
Permission is hereby granted to_Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at 1 i Wi n,` i n q 41 -�� / b� (4--n icum i l-P
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction in st be completed within three years of the date of this permit.
Date (n )�1 Approved by
03/12/2014 17:30 5084775313 ENGINEERING WORKS PAGE 01
Town of Barustable
Regulatory Services
2 Richard V, Scali, Interim Director
XAM, Public Health Division
sb39. �a
r�o Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office; 508-862-4644 Fax: 508-790-6304
Installer & Desigmer Certific tioa Form
Date: 1C4 Sewage Permit# assessor's MaplParcel l G
Installer:
Designer:
Address: 17, W. ss7`,e IGR = Address: i M C�►h.r.
On was issued a permit to install a
(date) (installer)
septic system at l -L �,��'� ' k-JN ` �'"1 based on a design drawn by
(address)
dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i,e.
greater than 10' lateral relocation of the W or any vertical relocation of any component
of the septic system) but in accordance with State &ir Local Regulations. Plan revision or
certified as-built by designer to follow, Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in oomph with the terms of
the I1A app a al letters (if applicable) *0 41
PtTER T.
WENTEE
(Install s Signature)
0.3 8I108
ANIFA
esigner's Signatare) rxfflx Designer's' )
PLEASE RETURN TO BARNSTABLE PUBLIC IMA.LTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BO'I'PS THIS FORM AND A5-
BUXLT CARD ARE RECEIVED BY THE BARNSTABLE YUBLIC IFALTH DIVISION.
THANK YOU,
Q:lscptic\Dcsigner Cci&iication Form Rev 8-14.11doc
ti
x
TRANS. NO.:
CITY/TOWN: Le
APPLICANT:
ADDRESS:
DESIGN FLOW: 33o G gpd
REVIEWED BY: DATE:
N/A�t OK NO
Legal boundaries denoted 310 CMR 15.220(4)(a)]
Street, Lot, tax parcel number and lot number noted on plan [310 ✓
CMR 15.220(4)(u)]
Locus Provided [310 CMR 15.2204 t
Plan proper scale? (1"=40'for plot plans, 1"=20' or fewer for
comp onents) [310 CMR 15.220(4)]
Easements shown 310 CMR 15.220(4)(b)] i/
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]-if not, a variance is required [310 CMR 15.412(4)]
Location of impervious surfaces (driveways,parking areas etc.) ✓
[310 CMR 15.220(4)(d
Location all buildings existing and proposed 310 CMR ✓
15.220(4)(c ]
Location and dimensions of system components and reserve
areas. [310 CMR 15.220(4)(e)]
System Calculations [310 CMR 15.220(4)(f)]
daily flow
septic tank capacity(required and rovided ✓
soil absorption system (required andprovided)
whether system designed for garbage grindei r/
North arrow [310 CMR 15.220(4)(g)] ✓
,ExistinE and ro osed contours [310 CMR 15.220(4)(g)]
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)] v
Names of soil evaluator and BOH representative [310 CMR
15.220 4 h and i
Location and date of percolation tests (performed at proper
elevation?) [310 CMR 15.220(4)(i)]
Percolation test results match loading rate? 310 CMR 15.242
Certification statement by Soil Evaluator 310 CMR 15.220(4)(i)]
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR n (� G� V\J,
115.220(4)(n)] "
Address Sheet 1 of 7
r
N/A OK NO
Location of every water supply,public and private, [310 CMR
15.220 4 k ]
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case,
of private water supplywells
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. [310 CMR 15.220(4)(1)]
Water lines and other subsurface utilities located [310 CMR
15.220 4 m if water line cross see 310 CMR 15.211 1 1]
Profile of system showing invert elevations of all system
components and the bottom of the SAS 310 CMR15.220(4)(o)]
Stamp of designer 310 CMR 15.220 1 and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2) or as
.approved for an upgrade under LUA at 310 CMR 15.405 1 k ]
Test hole adequate to demonstrate four feet of suitable material?
310 CMR 15.103(4)]
Test Holes adequate to confirm adequate groundwater separation?
310 CMR 15.103(3)1 ✓
]
Benchmark within 50-75' of system 310 CMR 15.220 4
Materials specifications noted? [various sections of 310 CMR ✓
15.000
System components not> 36" deep (unless Local Upgrade
Approval or LUA requested) 310 CMR 15.405 1 b "���
Address Sheet 2 of 7
yi
N/A OK NO
� _:i Y x'•'.: rs.'' '""�+Y��r r � :.-•� G.s+c3,.y¢ ,� artt ,� r .>y aA." �. n.`'a t t ., ,
'��� �11:LT _. is yea x;�� - k. T`s ! . „ k1�§ti7 1Sd1 i. h'k �Zt` l ;cPteB
Size OK? [310 CMR,15.223(1)]
Inlet tee located ten inches below flow line 310 CMR 15.227(6)]
Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR
15.227(6)]
Outlet tee with gas baffle or approved filter 310 CMR 15.227(4)] ✓
Note regarding installation on stable compacted base [310 CMR /
15.228(l)] ✓
Separation between inlet and outlet tees (no less than liquid
depth) 310 CMR 15.227(2)]
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or permitted for
upgrades under LUA [310 CMR 15.405 1 k ]
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1) and 310
CMR 15.232(3)(f)]
Three access covers (inlet and outlet must be 20" or greater) - /
middle access at least 8" b 7/07 310 CMR 15.228(2)]
Access to within 6 " of grade - one port for systems<1 000gpd,
two fors stems>1000 gpd [310 CMR 15.228(2)]
All at-grade covers secured to unauthorized access? [310 CMR
15.228 2 ]
> 10 ft from building foundation 310 CMR 15.211(1)]
Buoyancy calculation Required/Done [310 CMR 15.221(8)] t/
11-20 Where appropriate? 310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.211]
t �d' 5 kk ik7 is - }I. 8e3#fY"`+ '(t ^ j4N5. jjf*.f1r'bJ ._:f f *2 $3niZaw 4✓i j:;
Mulh A
Required when other than single-familydwelling or flow>1000
d [310 CMR 15.223 1 ]
First compartment 200% daily flow; Second compartment 100%
daily flow [310 CMR 15.224(2) and 3
"U" pipe through or over baffle, outlet of each compartment with
as baffle or approved filter 310 CMR 15.224(4)]
Address Sheet 3 of 7
N/A OK NO
.f 7 F R Yh
;B r`IhIdDING:SI�;WE' NWOTHER
Located at'least ten feet from any water line? [310 CMR ,/1
15.222 2
Disposal piping at least 18 below water line (when water and
sewer cross, see 310 CMR 15.211 1 1
Cleanouts re uired/ rovided? 310 CMR 15.222(8)]
Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02.preferable
[310 CMR 15.222(6)]
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)]
Siphon roblem/ leachfield below pump chamber ✓
Endca s or vent manifoldspecified?
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252(2)(h)]
Materials specified (310 CMR 15.251(5) specifies various pipe
ty2es allowed
DISTRI$' TION°BOX k �i }11 4 �x1� i �
,#K xa ) r v qy,h �r , r T wr vs srg :€ 4, 1
"1 k
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.232(2)(a)]
Splash plate or baffle tee required on inlet/provided? (when /
pressure sewer to d-box or steep pitch of gravity sewer) [310 ✓
CMR 15.323(3)(a)]
Riser if deeper than 9" 310 CMR 15.232 3
Inside minimum dimension 12" 310 CMR 15.232 2
Minimum sum 6" 310 CMR15.232 3 e ]
Watertight;cover if<2000gpd); waterproof manhole if>2000gpd /
1310 CMR 15.232(3)(d)] ✓
^°.s
Capacity(emergency storage above working=design flow)? [310
CMR 231 2
Proper setbacks 310 CMR 15.211 (same as septic tanks
Watertight.20-in minium access manhole at least 20" MUST BE
TO GRADE 310 CMR 15.231(5)]
Service components accessible (not too deep with piping,
disconnects accessible
Alarm floats - alarm on circuit separate from um s specified?
Exceeds two units must have two pumps operating in lead-lag
mode. 310, CMR 15.231(6) and 8
Stable Compacted Base 310 CMR 15.221(2)]
Buoyancy calculations needed ?Provided? 310 CMR 15.221 8 ]
Address Sheet 4 of 7
A
N/A OK NO
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(l)] ✓
Re uired separation togroundwater? 310 CMR 15.212
Aggregate specified as double washed 310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or
>36" deep) [310 CMR 15.241] t�
Inspection ports specified and within 3"final grade? [310 CMR ✓
15.240 13
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document]
GZ �a
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)]
Each structure with one inspection manhole (if>2000 gpd must
be tograde) [310 CMR 15.253(2)]
A--
Aggregate I'minimum.-4'maximum. [310 CMR 15.253 1 (b)]
2' sidewall credit maximum [310 CMR 15.253 1 a ]
In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)1
1 a A $' �d,;TRENCHES 31`Q'CM�R15 251 � `,
-
..., ... ..... ... _.,....r, ....
Width 2' minimum 3'maximum 310 CMR 15.251(1)(b)]
100 feet-maximum length [310 CMR 15.251 1 a ]
Minimum separation 2x effective depth or width whichever ✓
eater 3x if reserve between trenches [310 CMR 251 1 d ]
Situated along contours [310 CMR 15.251(2)]
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document]
BEDnSAS(Manmum;s�zeofbedor^feld 5000 nnd S y
MSs-._
minimum 2 distribution lines [310 CMR 15.252(2)(a
Maximum separation between lines 6' [310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)]
Aggregate depth below discharge pipes 6" minimum, 12"
maximum. 310 CMR 15.252(2)(g)]
.Separation between beds 10'minimum. 310 CMR 15.252(2)(f)]
Bottom area used in calculations only [310 CMR 15.252(2)(i)]
Address Sheet 5 of 7
N/A OK NO
D'ID THE`PL`AN INVOLVE.�jjj'j, "n ,yy��y' } � yif�kb �a
i.:- ...u.. '�� i. f f 3.n, i caY,'i'°.r �:r��FKS^'TM�.E<. lAt;• .�i�.�Fn�. /�av r r s>.s.�:
Pressure Dosed System ? Provided pump and piping
calculations as required 310 CMR 15.220(4)(r)]
Pressure dosing required on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and VA
Remedial Use Approvals]
If used in gravelless system-make sure jet is directed as not to
scour soil interface Guidance Document]
Inspections once per year(systems<2000 gpd) or quarterly
>2000 dgood to note on plan 310 CMR 15.254(2)(d)]
Construction in fill - Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255 3 ?
Impervious barrier and/or retaining wall ? Guidance Document
Impervious barrier installation must be supervised by
,designer 310 CMR 15.255 2
Retaining wall must be designed by Registered Professional
Engineer 310 CMR 15.255(2)(a)]
Side slope not exceed 3:1 ? 310 CMR 15.255(2)]
Breakout requirements met? [310 CMR 15.252(2) and
Guidance Document
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [310 CMR 15.255 2 e
�� �-
{Gravelless stem A�4°proval�Letters] r' >OI%I
Check DEP Approval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface
b ..<.e:.,+ d � y. a�� � N`:w r kf• vX' .(t7,ca r ¢ a.w, ,"+£ c'xg+.:a hNs Sdkw,.JYFe 'ty�'4 a°� � riLksxt "�wt� sv 4C {24ry �`,i' .r Jet
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for
perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has applicant submitted a copy of a maintenance
x.�3 nf's'' ,a F iar 3r .,i, x a e �. r n
VQYlIIlICeS.tr+.. . : r3 � t?fydd ?�tf��j
Are the variances listed on the plan ? [310 CMR 15.220
4
RLS Stamp necessary on plan if a component is within five t/
feet of property line 310 CMR 15.412(4)]
New construction or increased flow proposed- [Refer to 310
CMR 15.414
Address Sheet 6 of 7
N/A OK NO
NllYO .eitehSsdt(he l�ixe(Ls ,f�a z:^'�* x+st ? r c,, 's�: "r. � K� " '�Y�v" t�`
Is the system in a Designated Nitrogen Sensitive Area(Zone lI for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216 - also refer to Policy regarding upgrades of such
existing systems] Q t�
Is the system proposed on the same lot as served by private well ?
1310 CMR 15.214(2
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(1
WJ+1 t JPJtix3 J'Y Y 3
Pumping to septic tank? 310 CMR 15.229
Shared System 310 CMR 15.290]
Address Sheet 7 of 7
1
sW ray
Town of Barnstable Barnstable
Regulatory Services Department `cap y
BARNWAB A Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F. Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 1010 0000 2851 1951
February 18, 2014
i
August Viekman
112 Rolling Hitch Road
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 112 Rolling Hitch Road, Centerville. MA was last
inspected on 12/29/2013 by Ricky L. Wright, a certified septic inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system "Fails" under the
guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Liquid depth in cesspool is less than 6" below invert or available
volume is less than '/z day flow.
You are ordered to repair or replace the septic system within two (2) years from
the date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
I
j
-T-hcM c ean, R.S. CHO
Agent of the Board of Health
i
i
i
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evahl12 Rolling Hitch Rd cent 1014.doc
I
�UV
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
112 Rolling Hitch Rd.
Property Address
August Viekman
Owner - -
Owner's Name
information is required for every Centerville Ma 02362 12/29/13
..
page. Cityrrown State -Zip Code --- Date of Inspection
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.
Important:When A. General Information
filling out forms
on the computer,
use only the tab I
Key to move your
1. Inspector:
cursor-do not Ricky L.Wright
U b
use the return
key. Name of Inspector
B&B Excavation
r� Company Name
14 Teaberry Lane
company Address
Sandwich Ma. 02644
City/Town State Zip Code
(508)477-0653 S14595
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the:inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15000). The system:
❑ Passes ❑ Conditionally Passes ® ,Fails
Needs Further Evaluation by the Local Approving.Authority
12/29/13
Inspectors Signature Date -
The system inspector shall submit a.copy of this inspection report to the Approving Authority(Board
of Health or.DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only.describes conditions at the time of inspection and under the conditions of use
at.that time..This inspection does not address how.the system.will perform in the future under
the same or different.conditions:of use.
t5ins•203 Title 5 Official Inspecti n F r :Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth.& Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 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:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N FIND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
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 pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
��YS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
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
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
M ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. CityrFown 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-
1 0,000g pd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following.have.been done. You must indicate"yes" or"no"as to each.of the following:
Yes No
El E Pumping Information was provided by the owner, occupant, or Board of Health
❑ ® Wem 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
El ® this inspection?
Were.as built plans of the system obtained and examined?(If they were not
E El
available note as N/A)
® ❑ Was the.facility or dwelling inspected for signs of sewage back up?
Z El Was the site inspected for signs of break out?
. ® ❑. Were all system components, excluding the SAS, located on site?
...
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
❑ ❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and.location of the Soil.Absorption System (SAS) on.the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® 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):: 3.... Number.of bedrooms (actual): 3
DESIGN flow based.on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town 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
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)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):
Cesspool overflow to pit.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
original to dwelling
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
N/A
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:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
l;c.J Oil ��'►.�D�P�-�a�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields , number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection first cesspool is completley full .Water level in pit was 3" below invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1 working as tank
Depth—top of liquid to inlet invert equal
I
Depth of solids layer 6„
Depth of scum layer
2"
Dimensions of cesspool 6x6
Materials of construction block
Indication of groundwater inflow ❑ Yes ® No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspool is full,Leach pit water level is 3" below invet. Leach pit also has staining well over invert.
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yy. 112 Rolling Hitch Rd
Property Address
August Viekman
Owner Owner's Name
information is Ma 02362 12/26/13
required for every Centerville
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) t
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below -
❑ drawing attached separately
�h-3i
,'
�
Pl
a
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >12
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
112 Rolling Hitch Rd.
Property Address
August Viekman
Owner Owner's Name
information is required for every Centerville Ma 02362 12/29/13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable P#
Department-of:Regulatory Services
s Public Heaith Division Date
( 3c) I
xusa
26sy. ",�'. 200 Main Street,Hyannis MA 02601
Date.Scheduled Time V Fee Pd, �
Soil Suitability Assessment for Se e Dis
Performed:By: ��� M"c- '� e e 'S E 4 D—L Witnessed By:
LOCATION& GENERAL INFORMATION
Location Address ')//2 �t v rug K` � / Owner's Name ��,9 v y� V f e�/'�rAO.,,%
Address l i Z d..,,i t lv i2
Cc�.�cry�t lR mA-G zo
Assessor's Map/Parcel: 9 2 ' ��� Engineer's Name �e�4r 1•e�e
NEW'CONSTRUCTTON REPAIR Telephone# _56y-7 3 7—'i 7(,pY
Land Use Slopes(90) Z— Surface Stones /xiae'-k
Distances from: Open Water Body ft Possible Wet Area _ft Drinking Water Well�/S� ft
Drainage Way 2�j�d ft Property Line Z J ft .Other ft
SKETCIIS(Street name,dimensions of lot,exact locations of test &pert tests,locate wetlands fn proximity to holes)
t
Z 16 { si
Z3 1
nr T N OF 9ARNISTAEtE
DIVI j r,N
Parent material(geologic) Depth to Bedrock �[
Depth to Oroundwater. Standing Water in Hole: ` Weeping from Pit Face
Estimated Seasonal High Oroundwater
DETERNIINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs,hole: In. Depth to soil mottles: In.
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index Well.# Reading Date:— Index Well level Adj,factor— Adj.i3routidwater Level ,o
PERCOLATION TEST bate der_-__.
Observation Z
Hole# 1�� Time at 9"
Depth of-Perc Z Time at 6"
Start Pre-soak Time® Time(9"-6")
End Pre-soak
Rate Min./Inch. L 2
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
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.
J
Q:ISEPTICIPERCFORM.DOC
I
DEEP.OBSERVATION HOLE LOG 119194._1_—
Depth from Soil Horizon Sod Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (S.tructur6 Stones;Boulders.
l toGravel)
3� C3 5L to a-r
I
DEEP OBSERVATION HOLE 'LOG Hole# 2—
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency. v
A sue. ia��y/Z
DEEP OBSERVATION HOLE LOG , Hole# =3
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Coisistency,
o
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,.Stones;Boulders.
Consistency,%-ClMyell
I _
Flood Insurance Rate Mau:
Above 500year flood boundary No_ Yes _.._
Within 500`year boundary No Yes
Within 100 year flood boundary No Yes
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally-occurring pervious material exist in all areas observed throughoutxhe
area proposed for the soil absorption system? �)cs
If not,what is the depth of naturally occurring pervious material?
Certification i
I certify that on (l 9 q S (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 training,expertise and experience described in 10 CMt.15.017.
Date
Signature,_.� t ,
Q;\SEpTlcvERCFORM.DOC
LEGEND Co n Croeb R N
CBD6493 . _- 98 -- EXISTING CONTOUR c ea o��d' at P° h<n� 3o Pen LnISC cet�a
x 1.00.98 EXISTING SPOT GRADE more F y °mr
4' " oµ
W EXISTING WATER SERVICE Raa°° "°�° w,e�a 4� �D A40-ed L
G EXISTING GAS SERVICE �0� s�F
D
Pg39? P \�� S 79, ooL� -O:H.Vl�-OVERHEAD WIRES , Q� °g9 r�
4 0 a
7, S9,8,' � 1 TEST PIT
x 65,37
�v �\7"0' BENCHMARK
y� �\\c LOCUS
VC�
BENCHMARK x 65,16 LOCUS MAP
OUTSIDE COR./BOTT. STEP ,pp gyp ' NOT To SCALE
EL.= 67.52 (Assumed) ^p �� MBLU 192- 084
/ 65.51 CBDISC
+65.11 GENERAL NOTES:
37,377 SF 65,00 � ?•S0.
x 4�22 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
65,86 50' BOARD OF HEALTH AND THE DESIGN ENGINEER.
65,49 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF STATE , AND ANY
Is, SHED `_-- LOCALE RULES AND IROEGULATIONS,NMENTAL OEXCEPITLASVREQUESTED ABELOW•BLE
x 66,11 --� -310 CMR 15.405(1)(b):
x 66,29 1) A 3' variance to the 3' maximum cover requirement, for
66.96 �-�" �, up to 6' max. cover. S.A.S. shall be H-20 and vented.
x 66.1� 65,86 67,43 \`� S D 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
1 67.341 �• i TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
I 616,77 1 ; EXISTING CESSPOOLS DESIGN ENGINEER.
00
x 66'89 N. �� } TO BE PUMPED, FILLED 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
INGROUND (� ` ( WITH SAND & ABANDONED FROM THOSE SHOWN HEREON SHALL BE REPORTED To THE DESIGN
SWIMMING �� (SEE NOE 14) ENGINEER BEFORE CONSTRUCTION CONTINUES.
POOL - i 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
EXISTING IRRIGATION & x 6 `+4
UNDERGROUND WIRES ELEC, Ot T T 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
(SEE NOTE 10) 66,96 P 0 ' 4 'r THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
(U 66,45 TP-1 \ \^"`� 66,1 ' Z HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
7.36 67,4266,93OD F
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
,N A x 67.16 INSTALL �� x 66.62 N
PROPOSED 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
h
SEPTIC TANK 66.42 �9 6729 CLEANOUT �\ o l 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
co � w AucL` AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
00 000 6B5 66,84 DIRECTED BY THE APPROVING AUTHORITIES.
/ x
m 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
26,E x 66.45 p //'•� 66,94 x 67.03`
(6,95 66.70 ' THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
TP-2 I I�-12' y ��� OF Mgss CONSTRUCTION.
EX SEWER 1 Q 9� 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
I I I EX. SEWER HOUSE (#��2) 9
NE�j INV.-653t x 6�'.36 = G IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
T' iIITP-3 /lNI%=s"5.bf/ T.O.F.=67.57t/ o PETER T. REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
"'III III GARAGE MC TEE
o CIVIL "' 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
j I j j I j 67.31\\` U No. 35109 INSPECTED BY THE DESIGN ENGINEER PRIOR TO BACKFILL.
'h'L�� FO 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
/67,09 {: '.;.'{}.:..'•-;•,y 67.14 PORCH '1 REGIStE� �`�
VENT x PpF IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY.
x 67,15 67 20 1 G
x;.?;>,,: .•; .;;,... 67.36 EN 14. EXISITING CESSPOOL LOCATIONS ARE TAKEN FROM OWNER INFORMATION
i AND AVAILABLE ASBUILT INFORMATION. THE ENGINEER IS NOT RESPONSIBLE FOR
x 67.32, L.
.y� ANY UNDOCUMENTED SEPTIC SYSTEM COMPONENTS THAT MAY EXIST ON THE
:<DRIVEWAY x 67.25 LAP x Lv_�
� Zt �, I PROPERTY.
C
�_ �•�`+�
a3 ? PROPOSED SEPTIC SYSTEM UPGRADE PLAN
204. 1 0 0.00
553.57' x 67.21 csmsC
112 ROLLING HITCH ROAD, CENERVILLE, MA
67,13 ::.t, MA
67.31 '` ,// 66.735 x 66.33 Prepared for: B & B Excavation, 14 Teaberry Lane, Forestdale,
67.22 edge of 67.09 66.56 66.44 OF RECORD Engineering by:
OW P S 66.29 SCALE DRAWN JOB. N0.
povemnt 67,o1 NF
• � UIEKMAN, AUGUST K & JEAN C Engineering Works, Inc. 1"=30' P.T.M. 111-14
ROLLING HITCH ROAD
�12 ROLLING HITCH ROAD 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET No,
CENTERVILLE, MA 02632 (508) 477-5313 2/21/14 P.T.M. 1 of 2
4
NOTE: TO .PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL:=63.16
FOR A DISTANCE OF 15' AROUND THE
SEPTIC TANK PERIMETER!OF THE S.A.S.
INSTALL RISERS & COVERS OVER INLET & PROPOSED D-BOX PROPOSED S.A.S.
OUTLET AND SET TO 6" OF FINISH GRADE INSTALL WATERTIGHT RISER & INSTALL INSPECTION PORT SET TO 3" OF FINISH
T.O.F.=67.57 COVER SET TO 6" OF GRADE GRADE & PLACE REBAR AGAINST CAP FOR LOCATING
EXISTING F.G. EL' 66.7t . VENT
F.G. EL: 66.4t � F.G. EL: 66.5t } REBAR MANIFOLD
MAINTAIN 2% GRADE MIN. OVER S.A.S. TRENCHES
L1 = 120'
L2 = 20' L = 28' L = 11, TWO 2'x3'x32' LEACHING TRENCHES WITH
® SCH4 (MIN.) ® S=1� (MIN.) ® S=1% (MIN.) SCH 40 PERF. PVC DISTRIBUTION LINES
4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC a
6"
10"1 8 7
14" 2' EFF.
INV.=63.50 48" LIQUID DEPTH
LEVEL ADD INV.=62.97 PROPOSED INV.=62.80 SLOPE OF PERF. PIPE = 0.5%
GAS BAFFLE INV.=63.25 D-BOX 32' EFFECTIVE LENGTH �24'2'
'Nil3 OUTLETS (MIN.) I =62.66 INV. EL.=62.50(END) i ' 12
PROPOSED SEPTIC TANK
SOIL ABSORPTION SYSTEM (PROFILE)
SEWER N0.1, INV.=65.3f(VERIFY)
SEWER NO.2, INV.=65.Ot(VERIFY) �ov
N.T.&
�/� MAINTAIN 2% GRADE (MIN.) OVER S.A.S.
NOTES: V / N �-
2 LAYER OF 1/8--1/2" DOUBLE WASHED GARAGE
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE STONE (OR APPROVED FILTER FABRIC)
INVERTS, PRIOR TO INSTALLATION.
2 SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND TRUE BREAKOUT ELEV.=63.16
TO GRADE ON A MECHANICALLY COMPACTED 6" CRUSHED 2�
STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2).
3) INSTALL INLET & OUTLET TEES AS REQUIRED. BOTTOM ELEV.=60.50 TWICE EFFICTIVE WIDTH
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 3' 6 3'
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. 5' MIN. ABOVE BOTTOM OF 12�
1 Nz -
T.P. EXCAVATION OR G.W.
TWO 2'x3'x32' LEACHING TREHCHES
BOTTOM OF TP, EL: 54.9 T SOIL ABSORPTION SYSTEM (SECTION)
N.T.& 3/4"-1 1/2" DOUBLE
WASHED STONE
SEPTIC SYSTEM PROFILE S.A.S. LAYOUT
DESIGN CRITERIA SOIL LOG
NUMBER OF BEDROOMS: 3 BEDROOMS DATE: FEBRUARY 20, 2014 (REF#14,291)
SOIL EVALUATOR: PETER McENTEE PE(SE#1542)
SOIL TEXTURAL CLASS: CLASS I WITNESS: DONNA MIORANDI R.S. HEALTH AGENT
DESIGN PERCOLATION RATE: <2 MIN./INCH ELEV. TP-1 DEPTH ELEV. TP-2 DEPTH ELEV. TP-3 DEPTH
DAILY FLOW: 330 G.P.D. 66.4 A 0" 66.4 A 1 0" 66.5 A 0"
DESIGN FLOW: 330 G.P.D. SANDY LOAM SANDY LOAM SANDY LOAM
65.9 10YR 4/2 6., 65.9 10YR 4/2 6" 66.0 10YR 4/2 6"
GARBAGE GRINDER: NO B B B
SANDY LOAM SANDY LOAM SANDY LOAM
PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY 3s" s3.7 10YR s/a 10YR 5/8 10YR 5/8
PROPOSED DISTRIBUTION BOX: 1 INLET, 3 OUTLET (MIN.) s3.4 C C 32" 63.7 C 33"
PERC
LEACHING AREA REQUIRED: (330) = 445.9 S.F. i 42"/54"
.74 PROPOSED SEPTIC SYSTEM UPGRADE PLAN
INSTALL TWO 2' x 3' x 32' LEACHING TREHCHES WITH STONE MED. SAND MED. SAND MED. SAND
AND SCHEDULE 40 PERFORATED PVC DISTRIBUTION LINES 2.5Y 6/4 2.5Y 6/4 ` 2.5Y 6/4 112 ROLLING HITCH ROAD, CENERVILLE, MA
SIDEWALL: 2 TRENCHES x 2 SIDES/TRENCH x 2' x 32' = 256.0 SF j Prepared for: B & B Excavation, 14 Teaberry Lane, Forestdale, MA
BOTTOM AREA: 2 TRENCHES x 3' x 32........................... = 192.0 SF SCALE DRAWN JOB. NO.
Engineering by:
TOTAL AREA:..............................................................................448.0 SF 56.4 120" 54.9 1138" 55.0 138'
Engineering Works, Inc. N.T.S. P.T.M. 111-14
PERC RATE <2 MIN/IN. "C" HORIZON CHECKED SHEET N0.
NO GROUNDWATER ENCOUNTERED 12 West Crossfield Road, Forestdale, MA 02644 DATE
DESIGN FLOW PROVIDED: 0.74 GPD/SF(448.0 SF) = 331.5 G.P.D. (508) 477-5313 2/21/14 P.T.M. 1 Of 2
II
I