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HomeMy WebLinkAbout0202 ROLLING HITCH ROAD - Health 202 Rolling Hitch Road Centerville P A = 193 065 I /fit n NbQ — �4:by. L;� 12543 {c.53L0R r: �7�4GS.MN , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < tit 202 Rolling Hitch Road ;- Property Address Nicholas J. Bowes ' Owner Owner's Name information is Centerville MA 02632 2/05/19 -1 required for -` every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. Inspector Information �'I#i 35 �- When filling out p g forms on the computer,use Michael Aucoln only the tab key Name of Inspector to move your AL Cape Septic LLC cursor-do not Company Name use the return key. 618 Route 28 Company Address West Yarmouth MA 02673 City/Town State Zip Code 508 771-4200 SI 13944 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2//08/19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 7a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: System is working properly hydrolically and structurally. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !( 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City(Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 car, Commonwealth of Massachusetts Title 5 Official Inspection Form )JoSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 cam, Commonwealth of Massachusetts �n I Title 5 Official Inspection Form 7; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s � 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Existing 1000 Gallon Concrete Septic Tank with a DB3 Concrete D-Box and two Leaching Trenches Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 years usage (gpd)): Detail: 2018- 105,000 Gallons, 2017 - 146,000 Gallons Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: 7 Years, installed in 2012 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): (Tight) (Yes) (None) t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 4" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 Gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,000 Gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 6" Scum thickness 4" 3 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The structural integrity of the septic tank appeared sound. The tank is 8" below ground and there is a 12" x 16" inlet concrete cover and an 8" x 12" outlet concrete cover. The inlet and outlet have Sch. 40 PVC Tees.The liquid level is at the outlet invert. No evidence of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The Distribution Box has a 20" concrete cover(4"deep)on top of a 20" ADS Riser.Top of D-Box is 24" deep, is level, has two Sch.40 PVC outlets (with levelers), outlets were equal. No evidence of soil carryover or leakage into or out of box. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts M1 Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City(Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Two 32'x 3' x 2'deep trenches with 4" Sch.40 perforated pvc pipe and stone with a 4" pvc observation port at grade, no water in bottom of system, (stone looked clean and dry) (soil dry) (no signs of failure) (vegetation normal). 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is Centerville required for MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 �Ol�t -1'Cl'cG V� 4AD a A A01i S t Zo Z. g � c 3 � � o Z � g G Z 5lr,grr Z5rV5.r t-�rr t— �r1 I - off LO, — p r t5insp.doc•rev.7/26/2018 11tle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +10 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: May 11, 2012 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: Perc test on May 11, 2012 shows no water encountered at 10' depth plus. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !a`r 202 Rolling Hitch Road Property Address Nicholas J. Bowes Owner Owner's Name information is required for Centerville MA 02632 2/05/19 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 t TOWN OF BARNSTABLE a. LOCATION Qp;J fZQJ1.'r-,0 )4i4ck Rol SEWAGE# af)/g •/S7 VILT AGE Can-Icryi 11 C• ASSESSOR'S MAP&PARCEL /93-G S INSTALLER'S NAME&PHONE NO. E)(CaV(x4i on q')?•01 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (z) Tr c A c k c S (size) Z x 3 x 3 3 NO.OF BEDROOMS OWNER Rr+r15 -oDcr-IicS r PERMIT DATE: COMPLIANCE DATE: S•073. 1 ea.' 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 y FURNISHED BY N -23 ' s -B1 =z4 ' A2= U T32= 2,71 h G3 ' IV -Db = 37' DI-4= 131 LF oJo No. ZO Q �7 7 _ _• r Fee-4 100 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN'OF BARNSTABLE, MASSACHUSETTS Yes ZIPPIication for MisposaY bpstrm Construction Permit Application for a Permit to Construct( ) Repair( tKupgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. .1 r A D I fin H 1 � Name,Address,and Tel.No. u Assessor's Map/Parcel �)Tr,&,jI�C 6­00�+t5 C5o e),Z-vi ` I90 Installer's N e,Address,and Tel.No. Designer's Name,Address,and Tel. lN.o. _5+r3 LXcova+ton (5M 411-a66 �� � inee�cn 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.re tired 33 gpd Design flow provided 2 LA 9 gpd Plan Date 1 2 Number of sheets Revision Date Title�l �n_ lje pion Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Y 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 ealth. Signed Date Application Approved by Date 511:7/2-0('— Application Disapproved Date for the following reasons Permit No.Zo IZ— 119 7 Date Issued 51l Zo t—L rr No. 70 a-^'1 Fee /C0 o r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: da. ,...- F:,. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Mispos'aY p8teltt_�OII�tCUctiOU Permit Application for a Permitto Construct( ) Repair( 4pgrade( ) Abandon( ) ❑Complete System,- ❑Individual Components Location Address or Lot No. �O� O (j!1 N 1 [� Q er's Name,Address, and Teel.No. Assessor'sMap/Parcel c�NTE �l�C9 — r�iy'��' 1��•+ Install ' Nome,Address,and Tel.No. Designer's Name,Address and Tel.No. bM txcovai ion (5og)-4+ii-0053 Dovwn Cam_ Sri 9<<AeeF1n Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures rr��II '' QQ Design Flow(min.re uired gpd Design flow provided J'^I -1 gpd Plan Date 3 Number of sheets Revision Date "Title LP I 1 C,l n Size of Septic Tank Type of S.A.S. Description of Soil f Nature of Repairs or Alterations(Answer when applicable) r Date last inspected: , Agreement: J 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 ealth. Si ed Date [, Application Approved by - U Date Application Disapproved Date for the following reasons Permit No.Z© (Z— 1 r) 7 Date Issued 5 l �? Z-o(-Z- ----------------------------------------- - _ = = - _ -- - - ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS T CERTIIF�Y,that the On-site Sewage Disposal system Constructed( ) Repaired(V Upgraded( ) Abandoned( 3rt 13 G-)(Lo v fi at �,Q 2— U 1 1 n I has been constructed in accordance with theV,,eo s of Title 5 an .. a f�orfDisposal System Construction Permit No.ZO1�' f ti dated 3 ��1 Z o L Installer Designer (�it bedrooms Approved de^sign�flow gpd The issuance of this vermitoshall not bd construed as a guarantee that the system/will fungi- es .e.. Date P' 3/ Inspector --------- ---------------------------------------------------------------------------------- - --- ------- - - ------------- - - s' -_ r _ No. �Z " Feek"� o� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstrm Construction Permit Permission is hereby granted to Const(rucct,( ) Reep, it(fV/) Upgrade( ) Abandon( ) System located at O(d KaCJ I I C ��VTC�.y►r_�E 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 must be completed within three years of the date of this permit/ ----_ Date / / 2 Z Approved by(/" / `� I Town of Barnstable Barnstable P�pP THE_►a, O� Regulatory Services Department ;gica .tF I, BAR039- E,�•�1 Public Health Division m MASS. 9 t639 ,� �'A?F0 MAt 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 #7011 0470 0001 4525 6751 April 30, 2012 RMS Residential Properties 8742 Lucent Blvd., Suite 300 Highlands.Ranch, CO 80129 RE: 202 Rolling Hitch Road ORDER,TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system located at 202 Rolling Hitch Road, Centerville, MA,was last inspected on 3/16/2012 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: • System is in Hydraulic Failure You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with in the deadline period will result in future enforcement action. ER OF THE BOARD HEALTH ean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\T013 ltr Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13839 Logged In As: Parcel Detail Wednesday,April 25 2012 Parcel Lookup Parcel Info Parcel ID 193-065 Developer LOT 38 Location 202 ROLLING HITCH ROAD I Pri Frontage 127 Sec Road I Sec Frontage Village CENTERVILLE I Fire District C-O-MM Town sewer exists at this address No I Road Index 1379 Asbuilt Septic Scan: Interactive I 193065 1 Map'' Owner Info owner RMS RESIDENTIAL PROPERTIES LLC I Co-owner Streetl 8742 LUCENT BLVD., SUITE 300 I Street2 City HIGHLANDS RANCH I State CO zip 80129 Country - Land Info Acres 0.34 I use Single Fam MDL-01 I zoning RC Nghbd 0105 Topography Level I Road Paved utilities Public Water,Gas,Septic I Location Construction Info Building 1 of 1 Year 1977 ( Roof Gable/Hip ( Ext Wood Shingle Built Struct Wall g Living 1348 I Roof Asph/F GIs/Cmp I AC None Area Cover Type [,:WDKj' Style Ranch wall Drywall Rooms nt Bed 2 Bedrooms I _4 — e 14 Model Residential I Int Floor Carpet I Rooms Bath 2 Full I s 9AS 2 z GAR 22 BMT Grade Average Heat Hot Water ( Total 5 Rooms I i ,d Type Rooms 4a stories 1 Story I Heat Oil I Found- Poured Conc. -- Fuel ation Gross 3124 Area Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13839 4/25/2012 � � �`�� l l; �i� ��� i�- � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal/System Form -Not for Voluntary Assessments M 202 Rollinj4. '' ►" a Property Address - RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I J`— use only the tab 1. Inspector: J key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 City/Town State Zip Code 508-477-0653 S 14595 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 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/16/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector andltl�e system owner shall submit the report to the appropriate regional office of the_,DEP Tt%e ongmaf 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 notadtlress hoWv th sy m will perform in the future under the same or different conditions of use. ) N l� jk t5ins•09/08 / V Title 5 Official Inspection Form:SubsuNcewage Disposal System•Page of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 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 ;M 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. Cityfrown 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow L15,ns108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y _ rY GSM , 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts H . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. City/-Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16112 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): n/a Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Febuary 2012Date 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-09/08 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 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 20-30 years 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 >20 well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage Septic Tank locate on site plan): P ( P ) Depth below grade: 1 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: 5.2x5.2x8.6 Sludge depth: 6" t5ins-09/08 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 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 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 31" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good shape tees present, sign of back up solids on top of pipe due to failed S.A.S. Recommend pumping tank. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 resent: P ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): no d-box 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/OB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in failure water level was well over inlet and backed up into pipe. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form v o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma. 02632 3/16/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system; including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately O 0) t Ai`-23 / 2= 3 t5ins-09/08 Title 5 Official Inspection Forth: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 ,M 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 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: >12feet 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-09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 202 Rolling Ridge Property Address RMS Residential Properties Owner Owner's Name information is required for every Centerville Ma 02632 3/16/12 page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 uLceLFj3Jia� a yl<��LceS• I IhoTiq as T. GefleTi o DlIl`eetoE AA_q5Tl(SJIlc ""_ler!llth 'IlVIleL(o C Thomas MCI!?eonq Director lM Nfiain Street,Hy ouais,1&k 02601 Csice: 508-962-4644 Fax: 508-790-6304 instancy & Designer cCertill'�eadom Worm Date-(5 Sew2ge Permmft# `xa MapTarcell ]�esngmera V U vJ �•.— � e /f�Pn 1�m���Illle�e CAiI/�i, I/1� Address'. "(�� M � ,�_ U I, Address: N fe, ate✓�o�.`�- I�r `'�'��' l: On was issued a permit to install a (date) Q /(installer) ,( septic system at do l`'�l �j ` 1-6/-- based on a design drawn by (ad ss) 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. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the Sp S or any vertical relocation of any component of the septic system) but in accordance with. State & Local Regulations. Flan revision or certified as-built by designer to follow. ��N OF M,gSS9cy �o DANIELA. o OJALA (Installers Signature CIVIL q No.46502 $1GIsTEa��,�```` ZONAL EN (�eslgTler's SlgLaL Te) (Affix Designer's Stamp here) PLEASE RETU.P-N TO BARNS\BLL NOW 1C HEALQH �A�/AS�cCp1?. i.El�TTICA E O � Cie � d� ARIL NOT BE BSS EED eTNTH, BOTH �Tt�s F RM ANL AS-B€JTiF T C k �E RECEIVED BY TBE BAPMTSTABLD PUBLIC M AL R HA DIVISION. THA,D 1�YOU. Q:Health/Sgtic/DesignerCer ficatioaFonni.3-26-04.doc Town of B ar ustaWe P# Ill&rbf iDepartznGaat of Regulatory 5t rvices `( Public Ile. Ith DiMsi®�n irate o,? /d DAlWBTAB[,E, a Public 200 Main Street,Hyanuis MA 02601 9 pate Scheduled G� C Time f' Fee Pd. ` 0 0" Foil Suitability Assessment for Semy .e Disposal 1'crfonned By: Witnessed By.: ]LO CA7 ION ark GENERAL][11T7ORNIIATION �^ Location Address es_OZ �011t fcj� Owner's Name RMs Address LO L�lr Asscseor's Map/Parcel: / 93/lp� Englucer's Nautc fJW n I e NEW CONSTRUCPiOPd REPAIR Telephone It Land Use. e4A, Slopes(%) SurCace Stones Distance's from: Open Water Body rf Possible We[Are4 Ct Drinking Water Well ft Draihu.ge Way t ft Properly Line _R Other 7 ft S KE'7I'CIHI: (Sheet name,dimensions of lot,exact locations of test Boles SL perc tests, locale wetlands-1n proxinuly to Doles) V I � �� na C) Ln Parent material(geologic)_ V' LA__,A! 11- A Depth r,tp Betlrocl Depth to Groundwater. Standing Water iu 1[olt: Ndv`�C— Weeplhg 1'I'onl fait Pfwe _ Aj U Estimated Seasonal High Oioundwater ]DIET EBJVIII\TA7C][ON FOR SEASONAL HIGH WATIC1,11 TABLE Nlelhod Used: Depth Observed standing in obs.hole: In. Depth 10 salt alutlkm; Depth to weeping from side of obs.hole: OrouildwltlaY Adauslment nR —Cf. Index Well✓# Reading Date; Index Well level �r AaJ,f'ietor_ A41,Clrounlwuter Uvel Observation Hole If Cinl�tit 9" '_y� Depth of Per yU�l y/r1�4.5HNh) Tlu'ipal6" --- I Start Pre-soak.Time @ �/ ,aV _ Time(9"-6") End Pre-soak `'!l J b Rule Min./lncli Site Suilabillly Assessment: Silt Passed_V Site,.Faileti: Addilional Testing Needed(YIN) /✓ Original; Public Health DiYi:;ion Observation Hole Data To Be Completed orl Mack----------- ***If Pea-colatiola test is to be coliidueted vvitYltiaa 100' o,f vvefland, you must first l OUEY 011E Barnstable Conservation Division at least oue (A) week prior to Ibegiafl ihig. Q:\SEPTIC\P13RCF,ORhd.DOC D!]C]C][b-OBS.lG'][�17-ATION glf®)C + LOGDcplh from Soil Irori2on bole # Surface(in.) Soil Texture Soil Color - (USDA).. Soil Other g (Stru (Munsell) Mottlin `•� j cture,Stones';Boulders, Con istrncy. C70' ravel A L15 z ,� nn !vy 2GI, 2. �5 IUYa I , D)]E]EP OpS ER VATION KO L.1C]L 0G Depth from Soil Horizon Hole # Surface(in.) Soil Texture Sail Color (USDA) Soil Other tPrru"Sell) Mottling (Structure,Stones, Boulders, �(J. ��/ Consis e c %Gravel �.. Y i Z ��;• LS z . DREPORSERVATIONETOLE LOG Depth from Soil Horizon Soil Texture ][�aal�# 5i,rface(in). Soil Color, Soil(USDA) (Munsell Other Mottling (Structure,Stones,Boulders. • ['.o sisteney.9"a Onvell ------------- �— DJr',�L P OBSER V'A.11 JLO `V JLA+lJ+1L E, .. Depth fi'orn ' Soil Horizon � ®� Hole# z Surface(in.) Soil Texture Soil Color (USDA) ., Soli Other (Munsell) Mottling (Structure,Stones; Boulders, Consistent_ v.�a�e11 — — ---------- r,good Ifuusaurance Rate Bea p. Above 500 year flood bouncinry No Yes 1 Within 500 year boundary No Yes ' Within 100 year flood boundary,No� ]ire t0� of Natulraa11y ()e_ ou¢rjrjnR]EDg¢�v_ous Materlal Does at beast four feet of naturally occurring pervious material exist in all areas observed thl'aughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious mat®1'ial� Ce>rtflg-- ae�tso�v .. A certify that on Qp,-- y. (date)I have passed the soil evaluator examination approved by the Dapai irncnt of Environmental.Protectioii and that the above a,nalyais was performed by me consistent with Ilia required training, expertise and experience described in 10 CAIIt 15.017. Signature 1 /� �� Date . v , ();1S2PTIC\PERCT0RM.D0C t TOWN OF BARNSTABLE LOCATION ,?p;j Rn a;,, tl;4,A Ra VILIAGE (� SEWAGE# �.n-Icr �, 11 C ASSESSOR'S MAP&PARCEL INS TALLER'S NAME&PHONE NO. -L93'G S xea SEPTIC TANK CAPACITY ppaa�1 a 04 -s LEACHING FACILITY.(type) .r e n c =e (size) �X 3 x 3 No.OF BEDROOMS � OWNER PERMIT DATE: Separation Distance Between the: COMPLIANCE DATE: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility Feet site or within 200 feet of leaching facility any wells exist on Edge of Wetland and Leaching Facility(If any wetlands exist within Feet 300 feet of leaching facility) FURNISHED BY Feet -B 1 =24 ' T32= 2? ' h G3 � lg ' D-b ° 37' G4} = 21 ' DL4 131 E e s TOWN OF BARNSTABLE LOCATION 202 SEWAGE# c N VILLAGE ASSESSOR'S MAP &LOB' ( /3 aos ;a C INSTALLER'S NAME&PHONE NO. == SEPTIC TANK CAPACITY e C' a, LEACHING FACII,ITY: (type) OTOAP'l -77 NO.OF BEDROOMSS = BUILDER OR OWNER ' ry � PERMITDATE: COMPLIANCE DATE: I a: m Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 3 AC/50 bo-"3" LV A-TION - SEWAGE PERMIT N20: ; fvT_ 3.8 _�_i'o//,.:�� minx, e- V I L L A.G E INSTIA LLER'Sn NAME & ADDRESS r%A/17f5 //off/f��il/ B U It D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 4, h ) L ;M COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P Z W RE �® n � d 9 a F iOAPPARCEL JUL 2 9 .2004 3t TOWN OF BARNSTABLE LOT 0� HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 lc)J 0�o)' Owne 's Name: PAYSON JONES Owne 's Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Date of Inspection: 7/5/04 ' Name Df Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telept one Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certif y that I have personally inspected the sewage disposal system at this address and that the information reported below is true,a curate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintena ce of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Titl (310 CMR 15.000). The system: X Passes _ Conditionally P Yls _ Needs Further ' luation by the Local Approving Authority _ Fails Inspector's Signature: Date: 7/5/04 The s stem inspector shall submit a copy) f this inspection report to the Approving Authority(Board of Health or DEP)within 30 da s of completing this inspection.If th system is a shared system or has a design flow of 10,000 gpd or greater,the inspec or and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent tc the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYST M'S USEFUL LIFE. **** his report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title. Tncne.rtinn Fnrm 6/1 VM00 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prope ty Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owner: PAYSON JONES Date of Inspection: 7/5/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S stem Passes: X 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. Comn ents: SYST M PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYST M'S USEFUL LIFE. 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. n/a 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: n/a n/a 0 servation 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 Healt ): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND a plain: n/a n/a T e 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 a plain: n/a Page of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Prope ty Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owner: PAYSON JONES Date c f Inspection: 7/5/04 C. f urther Evaluation is Required by the Board of Health: _ Co itions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protec 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 I 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Pagez of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owner: PAYSON JONES Date f Inspection: 7/5/04 D. 'System Failure Criteria applicable to all systems: You nats.1 indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool •X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 MR 15.303,therefore the system fails.The system owner should contact the Board.of Health to determine what will be es nec ary to correct the failure. E. arge Systems: To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You ust 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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 unde Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner shou d contact the appropriate regional office of the Department. d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owne : PAYSON JONES Date or Inspection: 7/5/04 Check if the following have been done.You must indicate "yes" or"no"as to each of the following: Yes No X _ 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 X _ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffle or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of sub urface sewage disposal systems? he size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacc ptable)[310 CMR 15.302(3)(b)] 5 iRage6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owner: PAYSON JONES Date of Inspection: 7/5/04 FLOW CONDITIONS RESI ENTIAL Nurnbc r of bedrooms(design):2 Number of bedrooms(actual): 2 DESIC N flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220 Numbc r of current residents:2 Does residence have a garbage grinder(yes or no): NO Is laun on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundiy system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): r&a- Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL v Li -3NW Type of establishment: n/a Desigr flow(based on 310 CMR 15.203): n/agpd Basis f design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Indust-ial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: n/a Last d to of occupancy/use: n/a OTH R(describe): n/a GENERAL INFORMATION Punir ing Records Sourct of information: n/a Wass stem pumped as part of the inspection(yes or no): NO If yes volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYP OF SYSTEM X Sel tic tank,distribution box,soil absorption system _Single cesspool _Ovc rflow cesspool _Pri _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Inn vative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from systein owner) _Tight tank Attach a copy of the DEP approval Othe (describe): n/a Appr ximate age of all components,date installed(if known)and source of information: 1977 PER OWNER Werc sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prope y Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owner: PAYSON JONES Date o Inspection: 7/5/04 BUIL ING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC 4 Distan a from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth elow grade: 6" Materi il of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimen ions: L 8' 6" H 5' 7" W 4' 10" Sludge depth: 1" Distan a from top of sludge to bottom of outlet tee or baffle:33" Scum I hickness: 1" Distan e from top of scum to top of outlet tee or baffle: 6" Distan a from bottom of scum to bottom of outlet tee or baffle: 17" How v ere dimensions determined: MEASURED Co ents(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outl t invert,evidence of leakage,etc.): SEPT C TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE. GRE SE TRAP:_(locate on site plan) Depth below grade: n/a Mater al of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dime sions: n/a Scum hickness: n/a Distar ce from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date f last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to out et invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Proper ty Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owner: PAYSON JONES Date o r Inspection: 7/5/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth )elow grade: n/a Materi il of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimen ions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no):NO Date o last pumping: n/a Comm nts(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BO K IS STRUCTURALLY SOUND. PUM CHAMBER: -(locate on site plan) Pump in working order(yes or no): NO Alarm 3 in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propet ty Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owner: PAYSON JONES Date o Inspection: 7/5/04 SOIL BSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 AL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology:. n/a Coma ents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD 2' OF LIQUID IN IT AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN 2' OF LIQUID IN IT.BOTTOM IS AT 8 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Numb r and configuration: n/a Depth—top of liquid to inlet invert: n/a Dept of solids layer: n/a Dept of scum layer: n/a Dime sions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRI Y: (locate on site plan) Mate ials of construction: n/a Dime sions: n/a Dept of solids: n/a Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a 4 Page 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owner: PAYSON JONES Date of Inspection: 7/5/04 SKET H OF SEWAGE DISPOSAL SYSTEM Provid 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. W DAU& 0 0 5n 3 0 3-1 I Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propel ty Address: 202 ROLLING HITCH ROAD CENTERVILLE,MA 02632 Owner: PAYSON JONES Date o r Inspection: 7/5/04 SITE XAM _Slop _Surface water _Ched cellar Shall w wells Estima ed depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You st describe how you established the high ground water elevation: HANI AUGER- 12+FT. TOWN OF BARNSTABLE i•L ,ATION 2-0 OA SEWAGE # 4 VILLAGE ASSESSOR'S MAP & L OIE J a�' INSTALLER'S NAME&PHONE NO. `� C. SEPTIC TANK CAPACITY 17.51 C LEACHING FACILr Y: (type) (sip ) NO. OF BEDROOMS z7 BUILDER OR OWNER AM 04 —' ' ry r— PERMTTDATE: COMPLIANCE DATE: Ca m 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#ny wetlands exist within 300 feet of leaching facility) �? / m Feet Furnished by �/I -7 �v A r � AG50 0 a y L0•'CA-TION' SEWAGE PERMIT NO: ',� _', VILLAGE 7P �i/e, INSTALLER'S NAME & ADDRESS `- va BUILDER OR OWNER Xw DA T E P E R M I T I S S U E D 1 < < -V--77 ' DAT E COMPLIANCE ISSUED I y4 f ` O• c'�1r~tGL� F[aMIL_�(„ ►AO GArz?3,c(.� Zrzf 330,E (rJQ % 4-95 6.P.D. > SPo�AL PIT u56 tQcao SAL. EXPO' 16' Peorasa-a+�J ' S,U&V,/ALL AeE-A l5O S.F. I CT ToT,o L J, D�L�7`i F1oil ToTA l- t`it�►I._�f t='Craw = �� 330 6:PU. /Bt i �ouND. y �.Sr�C_DLL�TIO►.:I C�hT� � I►,! 'ZticIIJ 02 l..�SS. . ",_- �` t,1�J7 ► M I2-1. ov RtCHARD- AL nAKTER TEST Fes• :Q9 ToP 1-No z ioo.o e iuv 74 l o p m f s'�,�'. �PP l ooa 11•ry 4'P„RP. DIST 1w• GA.L. 97Z Box X.?f ScprIc I o A', S,Q+/Oy IWV. Ta�lK ��aY I oOo 9¢zo I,N� IM/ ,64>r c�A L. 9u 5fi 94 75 14.0 4' LAN `A PST PE4 La f��s Vc„ru. nolvr � .� WAS+JED • STo+J� Pf SA�Jpy 4ea r, C-C--ZTtFtED PI.bT LoC.A.TIOr" EL-B ► to SGAL� Sc.AL1- I bAT>✓ I C m 1 t-r 14'= -4 T E-(A 7 T 14 C-;- 40Nu4 no iJ S"o,a►J Pl-to I�,1 ►4 G a t--t r.l?'t_z51•,1 Gcalrl nL:.�(S. W I TI•d T I-1��- S I D� t�l►-lE: Lt3fi V rCvjIQGAAc:i, T-; ©1= -TO W t" c;-- �3A,Q�sT/�BGE �<�l a't`t'`� 1/t LL A BAXTr- t.1YC I�Jc:- �2EGlS T'C_tZ�D '1-AF-�G SU2�'�Yul'=.> A� 05TE�VlI_li"= v INC r1Si, API _1 CA," 1_•tr ��,t:_ a;c1-, ic., ►a{���cc,nt�����_ Ln-c- t_I N�<� �_ Y__t..Ai Wi`df:• ��. 70-1 7/;L, W­ THE COMMONWEALTH opMAesAC*ussrrs ' ���~��� ���� ����""" ~�� v;:.v �--- � �--.OF--u."~^���� ���--------' � ��������� ��� Di ���°V ��~°�� �� � w� ^~~v-v----~~----~ ~--~ ----nr`---� --'--~~~~' ~~`--~--~-~�~--~~ �--~-~~- � - Application is hereby made for u Permit to Construct Repair ( ) an Individual Sewage Disposal � �-2c� ......... -----'-'--- ' otcation- ress Lot No. Z dr Ow ddress Installer Address T e of Building Size�Lot.... 67 -Sq. feet � ------- Dwelling—No. _ Bedrooms_ ----_-_-----------_----`,___- '-'_ ` ' _-'--"- Grinder- ` ' � Other—Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( ) Otherfixtures - ........................................................... ' -_-- ----' . Seepage Pit No.. Other Distribution:�_ ,�o_ ­�------ ........_41- ------------------- ~~ Percolation Test Results Performed by-- ........................................ Date...Id. ......... 1.4 Tcu � � . ] m �utcay�r� � Test ���--.-_---- D��� to o�000d r �t�r--.-.----_�D 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wutec.-_'-____ 0 --'-.-- '-.-_--__--'_.-...--.___-------__--___--_--_-_-'-----_-__'_-.-_--'_____' ��- �u�� � or ��u�o �o�� �b� ou�u�u Alterations ayyucuou�...... ........................................................................................ ---------'--'---'--'-'—'---------------------'---------'---------------'----'------ ^^grccozcur: The undersigned agrees to install the uforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITA 11 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until u Certificate of Compliance has been issued bv the board of health. ' --~-~--' ...... -' /DaIJI ig LApplication Approved By......... v--77 ozj - --------------------------- ------—-----—----D a-te-------------- � Date - No....................... W* .......W.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEA�T ....... .........OF...... ........................ .......... Appliration for Disposal Works Tonstrurtion Prrmit I Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syst55 aV "�k�' .......0!:;�-- �ress - ocali;n or Lot.No.-40' /L ....... . . ... go........................ .......................... .............................................................. .................... .... .................... .......... ............ ... .............. ...... :;17------*------ Type of Building Installer ...S-q.--feet U. Dwelling—No. of Bedrooms.........;:. .............................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures —------------------------------------------------------------------------------ Design Flow......... $7 -----------------------gallons per person per day. Total daily flow............................................gallons. W4 Septic Tank—Liquid capacitye�llons Length................ Width................LDiam,eter................ Depth................. W .0 Disposal Trench—No-----------------------_Width....................5!44 Length... ;iE" � 9t �aching area----...............sq. ft. -------40t e' ------------------1, .......... Seepage Pit No.444111' ........tK 0040�..44:aching area..X9AP..sq. ft. ;z Other Distribution box osing tank Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutesperinch Depth of Test Pit.................... Depth to ground-water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------------------------------------------------*------------- ----------------*-------------- ----------*.......... .'C) Description of Soil........................................................................................................................................................................ 1% �4 ---------------------------------------------------------------------------------------------------------------........................................................................................ ................ ....................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable.........................................................................................I...... . ...................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I'LlE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board ofLhealth. Si d.... ............. ­------------------ -------lt�da*�/ Application Approved By........ ..... .......... ............................ Date Application Disapproved for the followin4 ................................................................................................... ...................................................................................................................................7!.............m....................................................... Date PermitNo..............................;t.......................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT ......../............................OF...... ......... Trrfifiratr of Tompliana y....THIS I, TO CERTIF�Yqhat))[Oindividual Sewage Disposal S7stem constructed �O A�®r Repaired b, ­------------ ...... ....... --- ----- ........................ .......... ........ ..... ............ at.......... --------------------- ------ ................. ........................ f ml has been installed in accordance with 'e provision-, o y 'Q-E 5 of.The State Sanitary Code as described in the X� ' - application for Disposal Works Construction Permit NA ................... d-.i,ted--../ ........................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............41::�Z---el--Zdf�............................. Inspector-------�' ............................................................................. THE COMMONWEALTH OF MASSACHUSETTS BOAR�, F HEA1 43 t' 'Vt4tj� .. ... ......OF.... ."..0 .................. 'oil . .......................................... F E........................ No......................... E, Dispostat Works �v tr it prrutit Permission y granted.... - --------- ........ ....... ............. AF . ............I...? ........ to Construgt. or Repair S n I dividual Sew at --- --- . ............. ............... N tr y- ?trS as shown on the application for Disposal rks Constructi�on P it IN.pe'.M. Dated.... ... IV x0o ....................... ---------------------------------- 6e- Board of Heapr DATE................................................................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ALL SHALL TE SYSTEM PROFILE MARK DS WITHC MAGNETIC TTAPE OR BE COMPARABLE MEANS FOR FUTURE LOCATION. NOTES C PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) z ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 1. DATUM IS APPROX. NGVD ' Oak Street TOP FOUND. EL. 70.1' 2. MUNICIPAL WATER IS EXISTING \ MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 67.0' - ponds " 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT. .three P PREC;QTEE PROVIDE INSPECTION PORT TO WITHIN 3 OF FINAL GRADE RISER 4. DESIGN LOADING FOR ALL PROPOSED PRECAST Lo u WequQquet 2'0 68 2' 4"OSCH40 PVC UNITS TO BE AASHO H-10 , Lake PIPES LEVEL 1ST 2' 2" DOUBLE-WASHEC) PEASXISTING 14" TONOR GEOTEXTILE FABRIC 5. PIPE JOINTS TO BE MADE WATERTIGHT.64.510- SEPTIC TANK** TEE 66.8E*' ¢ a ° ° ° ° ° ° ° ° ° ° 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE ° ° ° ° ° ° ° ° ° ° 0 ° ° ° ° ° ° ° ° ° WITH310 CMR 15.000 (TITLE 5.) 70.000 000 ° o ° o ° o ° 0000 ° oo0 0 o°°°°°o°°°°°°°°o°°°°°o°o°o°°° °°o°o°°°O00000 o°°o°°°°°° o°° o °000°o°o°o°0 64.0 a°o°o°000°o°000°o°o°oog°g°g°g°o°oog o 000°o°o o°o°o°g°g000g oGAS BAFFLE:; 0000_ 0000000000000000 000 0000000 eoo_ 00000°00000°000°0000000000000000000 0 000000 00°000000000000 0 0 t° ° ° ° o ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° 00000 61.84 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND 1 . :: 64.25' 64.08' 4" PVC SET AT .005'/' SLOPE OTHER P FOR LOT LINE STAKING OR ANY G�\�� c r o° NOT TO BE USED E :::.;,.. ':,..•' • ON 6" DOUBLE WASHED 3/4" - 1 1/2" STONE E URPOSE c a ) a 6" MIN. SUMP 2 - 32'x 3' x 2' 6EEP TRENCHES I \\,fir 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. 12" MIN. INT. DIAM. ' � � 6" CRUSHED STONE OR MECHANICAL 5 74 9. COMPONENTS NOT TO BE BACKFILLED OR COMPACTION. (15.221 [2]) CONCEALED'WITHOUT INSPECTION BY BOARD OF (4.2% SLOPE) ( � X SLOPE) HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. FOUNDATION- EXIST. SEPTIC TANK 60' D' BOX 10' LEACHING BOTTOM TEST HOLES 1 & 2 EL 56.1' 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS. MAP FACILITY CALLING DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION OF ALL UNDERGROUND & NOT TO SCALE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT OVERHEAD UTILITIES PRIOR TQi, COMMENCEMENT OF WORK. UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE ASSESSORS MAP 193 PARCEL 65 PRIOR TO INSTALLING ANY PORT10N OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED CONDITIONS IF NOT SUITABLE SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. AP DISTRICT 12. EXISTING LEACHING FACILITY SHALL BE PUMPED ESTUARINE PROTECTION DISTRICT LEGEND AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. 99- EXISTING CONTOUR X EXIST. SPOT ELEV. SYSTEM DESIGN: 99 PROPOSED CONTOUR 703 GARBAGE DISPOSER IS NOT ALLOWED 198.41 PROPOSED SPOT EL. x 63.82- 8S' TH1 TEST HOLE468 643 -6,-) 60.92 EXISTING 2 BEDROOM DWELLING S x 6 83 62 2� SLOPE OF GROUND 6 x 62.40 I DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD UTILITY POLE \ 66 6R - 64 x 64.69 USE A 330 GPD DESIGN FLOW FIRE HYDRANT 6S _ � - SEPTIC TANK: 330 GPD_(2) _ 60 09 �/ J NOTE NOT ALL sYMeas MAY APPEAR IN DRAWING 54 65.44 RE-USE EXISTING 1000 GAL. SEPTIC TANK ** 6 SHED ��-- 66 -^� 66 EXISTING LEACH PIT SHOWN 2 67 x 6.2 66.62 LEACHING: TEST HOLE LOGS PER AS-BUILT CARD x 67.76 67.19 h+ ' s' ' SIDES: 22 32 + 3 (SEPTIC TANK LOCATED VIA [ ( ) 2 ('74 207 GPD�� 67.43 `��� 2 6) ARNE H. OJALA PE, SE INSTRUMENT I BOTTOM 2[32 x 3 (.74)] = 142 GPD ENGINEER: ' 4 67.78 68 `````` x 67.7 TOTAL: 472 S.F. 349 GPD WITNESS: DON DESMARAIS, RS 40 6g 24 b �� Q MAY 11, 2012 98 x d6.06 USE (2) 32' LONG x 3' WIDE x 2' DEEP DATE: 67.93 x 68.70 1 TS < 2 MIN/INCH 32 Q LEACH TRENCHES OF PERF. SCH. 40 PVC PIPE AND STONE PERC. RATE = DECK SLAB 68.03 69.18 CLASS I SOILS P# 13638 6399 PAVED DRIVE x 68.54 ELEV. ELEV. x� 9 1 .81 �1 �65.70 4 , 4 , 7.98 .1 off67.0 0't v 67.0 \ DECK J 67.4 i,t 1.09 _OVER HEAD UTILS. 6 x EXIST. - - - / DWELL. 22 69# FILL A x 65. 1 x 72 \ x 68.87 x 1 TOP FNDN. `�W �S p O - - -x 66.01 , MA SL 68. 8.46 8• = EL. 70.1' 7. 20 APPROVED DATE BOARD OF HEALTH q/g � x 67.95 68.54 O - N ' LS 7„ 10YR 2/1 65.81 TITLE 5 SITE PLAN 10YR 2/1 �^ x 6 . �8.62 / I V OF 799 x 68.46 LOT 38 _ E / Q E MS 15.025± SF I MS` 10YR 6/1 . 201- ROLLING HITCH ROAD 9 " 10YR 6/1 9„ x 67.52 6,9 - x 5 � � � CENTERVILLE LS B \ x 68.07 �8•94 ' SOr MC. H o „ PREPARED FOR 1OYR 5/6 1OYR 5/6 BENCH MARK SILL o����� sSgctiG Ias'`� 22" 65.1 22•" 65.1 AT SLIDER ELEV 71.1 I mo ° DAAfFL �} B&B EXCAVATION/RMS DANIELA. _ C 1 C 1 110.46' IVI� OJA � ' PERC FS FS No.46502 No.40 s MAY 1 1, 2012 V. " D 60" 2.5Y 6/2 60 2.5Y 6/2 / ! k . � � �(`( off 508-362-4541 C2 C2 1 IEL cm fax 508-362-9880 s MS MCS 166.53 ' CIVILL OJAI-A (1) 0 downcape.com „ 7.5YR 5/8 56.1' 130" 7.5YR 5/8 56.1' ��No.46502� Pooe4o`60z down cQ�e enB/neering, //1C. 130 s �� o S �� Su , civil engineers NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 j`I�, L °h'A" r, land surveyors 939 Main Street ( Rte 6A) 12- 1 13 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675