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0079 ROSEMARY LANE - Health
79 Rosemary Lane Centerville A= 147 007 008 IIII � i UPC 12534 No.2.153LOR M"TAX48.YM s � v a � W _ 4 �G }� d I {. --TOWN OF BARNSTABLE LOCATION_7 @(' SEWAGE#�Q VILLAGE AS ESS0R'S / &PARCEL/ 7 087 pa� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY C d LEACHING FACILITY:(typ P NO.OF BEDROOMS 3 S' OWNER tc PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist.within 300 feet of leaching f cility Feet FURNISHED BY 02 z TR 5 9 Ac , oT-- 3 1 5 N. Q -0 13 — 0 Fee Q�✓._ t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppiication for Migog41 &pgtem Congtruction Permit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) 0 Complete System dividual Components Location Address or Lot No. r// OSC /* L1 E Ownnc,'s Name,Address,and Tel.No.., C Assessor's Map—/Par�celi✓� ///C� Installer's Name Address,and Tel.No.(�� /LLBy Desi ner's Name,Address and Tel.No/ Tm� Ste- a ( �dx ', i ichm(5 J 'oZ Type of Building: t� ~�j / B;e/��r,, ��f �6 Dwelling No.of Bedrooms/ Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building �" No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ,5•50 gpd Design flow provided , ,3-0, 6 2 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank ©� Type of S.A.S. Description of Soil aj r 1S A/y E ei— Nature of Repairs or Alterations(Answer when applicable) W29 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 Hea Signed Date Application Approved by Date d — Application Disapproved by: Date for the following reasons Permit No. r :-,u Date Issued_ _�� t No. a 013 — '� f4+c ... h � Fee /6U� Entered in computer: I THE COMMONWEALTH OF MASSACHUSETTS -PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes of -fication for Oigboal 6pmemc Cow5truction,Permit Application for a Permit to Construct( ) Repair(6�j Upgrade( ) Abandon( ) ❑ Complete System dividual Components Location Address or Lot No. r/9 j<10SeAX ie`/ Owner's Name,Address,and Tel.No. 2A r� Assessor's Map/Parcel Installer's Name ddress,and Tel.No. Desi ner's Name,Address and Tel.No -Type of Building: m vl 3 �,e/�.,M. / ��f`b'�y. 1P��nuM G���w�°� A Dwelling No.of Bedrooms ��G�(/ Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building , No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '53V gpd Design flow provided �t gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �� �1D0 U Type of S.A.S. (XJ✓ Description of Soil ��g �Al U E e1_— Nature of Repairs or Alterations(Answer when applicable) w 9) 1�_Hby 15A Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health:.! + Signed {--,, �L�'�� � �ilr-% Date Application Approved by Date Application Disapproved.by: Date for the following reasons Permit No. �d 13 — (D _a- Date Issued ^f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by at v has been constructed in accordance f with the provisions of Title 5 and the or_ isK sal System Construction Permit No. Z e 17 —/2 2 dated Installer / r l.�// Designer #bedrooms 2 Approved design flo&ig ) gpd The issuance of this permit shal/not be construed as a guarantee that the system will`funcfned. Date T `(� Inspecto No. .d 1 ( � Fee f (�✓ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi5po5al 6pgtem Construction Permit Permission is hereby granted to Constiy ( ) Repair ( j/�' Upgrade ( ) Abandon ( ) System located at ,�G111 ri 12 � and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this it. Date / t- 113 Approved by ' W Town of Barnstable �IMHE Regulatory Services Thomas F. Geiler,Director 9�A HAS& ®� Public Health Division 1639. TE0 Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-46d=4 Fax: 1408-790-6304 Installer & Designer Certification Form Date: �1'��1'��i Sewage Permit#�--i 2 P" ssessor's itilap\Parcel ��7 �61 OZ Designer: W004 �m ��C/ installer: Address: © t t 0 I Address: �6 C, NA On �� was issued a permit to install a (date) (installer) septic system at VAaq Lw ,&4dolk based on a design drawn by (ad ess) I L014 dated q_121,3 (A-signer) 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 andj'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 SAS or an,; vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF _Mgss9� DA RE y✓ YR (Installer's Signa re) No 1 �ANITJ (Designer's Signature) 1 (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTA LE PUBLIC HEALTH DIVISION. CERTIFICATE OF CONIPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-26-04:.doc ' I e j / Town of Ba"rnstabie. P#-� U Department of Regulatory Services �� --� Public jiealih Division )`)ate ,�y. ems$ 200 Main Street,Hyannis MA 02601. J Date Scheduled ! Time Fee Pd. ,foil ,suitability Assess' Tent fop S wa,e Disposal Performed By: �I t�/ ' Witnessed By: i LOCATION & GENERAL INFORMATION, ' Location Address .7G1 Q�e �ys/ Owner's Name �t" J ,,x^'- lY.L7 ,�lA I Address S slf'i Assessor's Map/P4rcel: I V/D 07/D0 a I Engineer's Name 11 NEW CON ON REPAM Telephone# �� 3�d n I L Sr' . ' Surface Stones Land Use ��>7��n Slopes(4'a) Distances from: Open Water Body >200 ft Possible Wet Area 7 wat Drinking Water Well �_0O ft Drainage Way y AProperty Line }G� ft Other ft 'of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) SKE7CCH:(Street name,dimcnsioti5 i m 5 � Depth to Bedrock' a" Parent material(geologic) Dep Depth to Groundwater. Standing Water in Hole:' i Weeping from Pit FAce, Estimated Seasonal High Groundwater M art DATE ATION FOR SEAS6�iAL HIG�I WATE I F' R TA ,Yr UbG �S Method Used: I ` i Depth dbperved standing in obs.hole: IiQ ___in. Depth td Sall mott(Cs: i�: 1 I in. orouarlwnter Adjustment W Depth tojweeping from side of obs.hole: A 6CtOr,,.,......�— AO'(3roundwater i evel.,.,,e, Index Well# Reading Date Index Well dl,• j PERCOL"ATI[ON TEST . Date.,,_:wo. Time-. Observation , Time at 9" Hole# i ! I Time at 6" -- Depth of Pere 03 j Time(9"-6") Start Pre-soak Time.@ End Pre-soak -•- ! ' Irate MinJInch Additional Testing Needed(YIN) Site Suitability Assessment Site Passed 'J( Site Failed: + Original:,Public Health Division Observation Hole Data To Be Completed on Back— ***If percolation test is to be condlacted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1)week prior to beginning. DEEP!OBSERVATION HOLE LOG Hole#_� Depth from Soil Horizon Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel Dtl_07t' Sid [o �31v b s� 3s'- DEEP'OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in:) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel) 36``- 1 ti`' 2.s DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Muosell) Mottling (Structure,Stones,Boulders. Consistent %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones.Boulders. Consisten ra I Flood Insurance Rate�Map: Above 50o year flood boundary No Yes v Within 500 year boundary No Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet:of naturally occurring p rviAu material exist.in all areas!observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on I d o (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was.performed by me consistent with the require training,expertise and experience described in 3,10 CMR 15.017. Signature Date 4-l2'13 Q:\SEPTIC\PERCFORM.DOC °F ray Town of Barnstable I� Barnstable Regulatory Services Department i i M LE,a, MASS. a, public Health Division - � MASS. m �A .i639, `0 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7011 0470 0001 4525 6744 April 19, 2012 Mr Richard Shulten 79 Rosemary Lane Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. • The septic system located at 79 Rosemary Lane, Centerville, MA,was last inspected on 3/31/2012 by Patrick M. O'Connell, 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. 5 Failure to repair/replace the septic system with in the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH > orrias McKean, R.S. CHO Agent of the Board of Health f Q:\SEPTIC\L.etters Septic Inspection Failures or Future Eval\TOB Itr I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Rosemary Lane, Property Address Richard Shulten - Owner Owner's Name information is required for Centerville. MA 02632 March 31, 2012 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. General.Information W fi hen lling out forms on the computer,use 1. Inspector: qi only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name VQ 189 Cammett Road Company Address Marstons Mills MA 02648 fe"dA Citylrown State Zip Code r 508-428-.1779. , SI 12855 . Telephone Number ' f. License Number B.-Certification I certify that I have personally inspected the sewage disposal system at this address d that the a information reported below is true, accurate and complete as of the time of the insph'c't�: n. The i pectin was performed based on my training and experience in the proper function and mal(ttonance of o�siteC sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15 3,dof r Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails r� I ❑ Needs Further Eyaluatio-- by the Local Approving Authority a j March 31, 2012 Job# 12-47 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health.or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Citylrown 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 /`M 11: 3nA-`3xist a nv failure criteria evaluated -� in 310 CiUir^��5. G3'or in 310 ...,2 , . ,�. , not 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 tans 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Cityrrown 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 t5ins•11/10 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 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Citylrown 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every 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? t ❑ ® 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 jHealth. ® ❑ 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 4 t5ins-11/10 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 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current!Occupied. 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: !Sins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped 18 months prior to inspection. 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) i ❑ 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-11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 2" l5ins-111110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•'' 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Cityrrown 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 28 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was at bottom of outlet invert and baffles were intact. Tank is structurally sound. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): `Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): 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: I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit ❑ 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.): Liquid level in leachin gpit was at top,of structure pit is in hydraulic failure 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every 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.): 15ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 17 i • ,� Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rosemary Lane Property Address - —-- Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every 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 Front . . . . . . . . . . .iI \ \ \ \ \ r \ \ \ \ \ \ \ \ \ \ \ \ \ \ ♦ \ \ \ \ \ \ \ \ \ \ \ \ 4 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ♦ \ \ \ \ \ \ \ \ Y \ \ '+ \ r ! r / r l / / J / r r / r / / \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ .. 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every page. Cityfrown 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: N/A feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 79 Rosemary Lane Property Address Richard Shulten Owner Owner's Name information is required for Centerville MA 02632 March 31, 2012 every 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 t -\ COMMONWEALTH OF MASSACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: 1,A Owner's Addres a Date of Inspection: ,( ( �,�►�j /r`e�CKJ ���02 Name of Inspector lease print) be,-4- a '� Company Name: k �f t''lzo, ), Mailing Address: P6 2 Telephone Number: CERTIFICATION STATEMENT 1 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 Needs Further Evaluation by the Local Approving Authority Fa Inspector's Signature: `" ``�.. Date: r' 96o'd yr; The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of He DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of,110,0000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate rggional office of the, DEP.The original should be sent to the system owner and copies sent to the buyer, if applicahler and the approving authority. Notes and Comments cZa ****This report only describes conditions at the time of inspection,and under the conditions of use at that ` time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 l.. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 / �� s?- Owner: � Date of Ili ection: .44A(J 5-Z Oy (a ` 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')!10 CMR 15.304 exist. Any failure criteria.not evaluated are indicated.below, Comments: B. System.Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair; as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined".please explain. The septic-tank is metal and over 20 years.old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltratio►i or.tank failure is imminent;System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is.available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health); broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL, INSPECTION FORM -'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION`FORM PART A CERTIFICATION (continued) Property Address: L-C� Owner: Date of pection: AP% ) C. Further.Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to.determine if the system is.failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2: System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for 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: 3 Page 4 of.1 I OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: L ���� QC/h�, Owner: Date of in ection: cxx 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 ffl ponding of effluent Jo the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool . __ �✓ .Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100"feet of a surface water supply or tributary to a surface ? water supply. (J . Any portion of a cesspool or.privy is within a Zone I of a public well. — Any portion of a cesspool or privy is within 50 feet of a.private water supply well. Any portion.of a cesspool or privy is.less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ['Phis 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 amnnonia 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 forma #0 (Yes/No)The system fails. I have determined that one or more of the above failure criteria,exist as described in 310.CMR 15.303,therefore the system fails. The.systein 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no - _ the system is within 400 feet of a-surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: . Owner: Date of i Pection: 44 ' rJ`fic�C70�� Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No j% Pumping,information was provided by the owner,occupant, or Board of Health V-1"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 ? / _ y' Have large volumes of water been introduced to the system recently or as part of this inspection? V_ 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 ? Cam_ Were all system components, excluding the SAS, located on site _j, — 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? V Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing 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(3)(b)] 5 Page fi of 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL +SYSTEM INSPECTION FORM I ART.0 SYSTEM.'INF.ORMATION Property Address: owneth_.... Date of I ection: /,5 olLptrl G� FLOW CONDITIONS RESIDENTIAL t/ Number of bedrooms(design):_a Number of bedrooms(actual).: DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x it of bedrooms): 000 Number of current residents: Does residence have a garbage grinder(yes or no): ND Is laundry on a separate sewage system (yes or no):� .[if yes separate inspection required] Laundry system inspected(yes or no):Iwo use: (yes or no):XQ Water meter readings, if a�vpilable(last 2 years usage (gpd)): Sump pump(yes or no):A/6 Last date of occupancy:� � ��TL(/J(C►' t'LLu:I/t:� COMMERCIAL/INDUSTRIALk/O Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records „ Source of information: Was system pumped as part of the inspect i n(yes or fib): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _oeptic tank,distribution box,.soil absorption system Single cesspool . - Overflow cesspool _Privy -Shared system(yes or no)(if yes,attach previous inspections records, if any) _Innovative/Alternative technology. Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date inst lied(if known,)and source of information: I ll Pitu� Were.sewage odors:'detected when arriving at the site(yes or no):AID Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: `�a/ z2XA Owner: _ Date of I ection: A � � r�S,cWc, BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: /(locate on site plan) ii Depth below grade:_1 1) Material of construction:::�—/Concrete_metal fiberglass_polyethylene - other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: /0 " Distance from top of sludge to bottom of outlet tee or baffle:. � . Scum thickness: e , Distance from°top of scum to top of outlet tee or baffle: !/ Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:. .. .(l2zz 1 z Cit1't01, lf01, Comments(on pumping recommendationnlet and outlet tee or baffle condition, structural'integrity, liquid levels a rel'ated to outlet invert, evidence of leakage,etc.): &ieexn GREASE TRAP:"/ (locate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum:thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: . Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): It 7 , Page 8 of l l OFFICIAL.INSPECTION FORM-NOT FOR.VOLUN'I'ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of It pection: � 1-3 W, (p TIGHT or HOLDING TANK-A/U (tank trust be pumped at time of utspection)(locate on-site plan)• Depth below grade: Material of construction: concrete metal fiberglass__polyethylene other(explain):. Dimensions:' Capacity: gallons Design Flow: gallons/day, Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping. Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: t/ if resent mu t be e e e( p s op n d)(locat on site plan). Depth of liquid level above outlet invert' ' V Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of eakage into or out of box h4tel PUMP CHAMBER./,lk (locate on site'plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(dote condition of pump chamber, condition of pumps and appurtenances, etc.): Q Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1z- X,�. C'. Owner: Lb Date of I ` pection: - J` .,�C�®�o SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type 7aching pits,number: leaching chambers.,number: leaching galleries,number: leaching trenches,numberjength: 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.): Z ex-) CESSPOOLS: A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: — Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or no): . ' Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.): PRIVY:/JL(locate on site plan) Materials of constriction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 1.1 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTIO N FORM PART"C SYSTEM NFORMATION(continued) Property Address: Owne r: 7 Date of I pection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benclunarks. Locate all wells,within 100 feet. Locate where public water'supply enters the building. �3 JUC�� G,,iLc�rn S�lp�e. Cv� , (7i 606 (0 Page 1 I of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Chi Date of pection: � (p SITE EXAM Slope Surface water Check cellar _ Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USES database-explain: You must describe how you established the high ground water elevation: q 11 Permit Number: Date: s £ Completed by: s •HIGH GROUND-WATER LEVEL COMPUTATION f, Site Location: �lJi` G Lot No. >> _ Owner: Address: Contractor: � 1 d �"o12T Address: G� ° Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. ................................................................................ .Date month/day/year i STEP 2 Usi!ng Water-Level:Range Zone and Index:Well Map locate site and determine: O47,'Appropriate index well............................... r- �'�...: ��✓ O Water-level range zone..................................................:.. I STEP 3. Using monthly report"Current Water Resources Conditions." determine current'depth to i water level for index well ........................... month/year . i STEP 4 .Using Table of Water-level Adjustments for index well. (STEP 2A),current depth to water level for index wel (STEP 3), and;Water-1evel zone (STEP 213) determine water-level adjustment ................:. � .. STEP 5 Estimate depth to high water 'by.subtracting.the water- level'adjustment (STEP 4) i ;from measured depth to water i 'level:at site STEP 1) ....................................................................._.( .............. �` i i I Figure 13.-Reproducible computation form. 95 i fie P I r I �r , TOWN OF BARNSTABLE LOC1`.TION 2t;; 11o&lnq4 &7--O-- SEWAGE # "7II.LAGE �/ ASS SSOR'S MAP & LOT NAME&PHONE NO.�0 �Qi1�' SEPTIC TANK CAPACITY LEACHING FACILITY: (type)'- (size) NO.OF BEDROOMS &6g6DER 4RR OWNER !: PERMITDATE: COMPLIAN DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by G� j�Gi? 1,1aaX `64ll 4; 50.7�OWN OF BARNSTABLE $9 ���7r LOCATION 16j/g,, *nl z.44#,c LeI SEWAGE # 44Z f 007 VILLAGE C� j,�iCL.E' ASSESSOR'S MAP St LOT Qo INSTALLER'S NAME & PHONE NO. j/41 wa ,&OS 3iF S/l� SEPTIC TANK CAPACITY k4F� LEACHING 'FACILITY:(type) / (size) QNO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER /f�r t�yLr9S / �tr•? s DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 L 4 cr D- 4 t. , 4. � o aa 8 No..`.:�...- J Fas.. 67 — L� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAILTH ...�0 11J................OF I S .�..-----............................... , vvftrttftvn for Dispas'al Works Tonstrurtion Permit Application is hereby made for a Permit to Construct (tr Repair ( ) an Individual Sewage Disposal � o R osalP g P System at: Iq .... . . ..... .......................................................................... Location-Address / Q .r..�r.......-..- ....._.... 11{ .�-I?:Cll�. i��... �or Lo ..........._s... «!»...._..... .. k .. t yy��(�� 1 '— Ownc� Y�ddres i ..........12Y.- .G tom............:. :.../.. � - ......................................... Installer Address � Type of Building Size Lot....f..�;.Q S . feet �-, Dwelling No. of Bedrooms......_.... �• q a g— �...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No_of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ....... • .......:... . ._.. ...... Design Flow............... ...1�.�....gallons pe n ------------------ ay. Total dail flow.:.... v......................gallons.� t............. .... ..... Septic Tank—Liquid capacity/Q�gallons Length.,S!& .. Width.'.+" . Diaaaeler............... Depth:.... .... x Disposal Trench—No..;,,-,"" Width...........:........ Total Length.................... Total leaching area.....................sq. ft. 3 Seepage Pit No....... .... Diameter....L . ...... Depth below inlet..3.,U..... Total leaching area..._2L.U41sq. ft. Z Other Distribution box Dosing tank " 0-4 Percolation Test Results Performed b a y............. �.........�. ,�.�C..._..... Date........11:iA-A .VA.---..----- L�'1�- Test Pit No. 1................minutes per inch Depth of Test Pit...../..2�...... Depth to ground water.... .. h�.l=.... 44 Test_ Pit No. 2......&A..minutes per inch De th of, Test Pit..... Depth to grouid water... t1�.l.:...... .?- �. . � 1 �....., . . . .....�.Description of Sotl....... ► `S . � ? � .�,.�..�I? s -?t $!...s..g.`;..- - «----- •112..S0.�.P!.'.•'j:•�.'.. 7-,�u��l U Nature of Repairs or Alterations—Answer when plicable................................................................................... :............... ....................•-•-----•---•----...--------.....-•------•------------......................... Agreement: The undersigned agrees to'install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of.'I LZ 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 of health. Sin ...............................•-••---............... ..... ............. ........ ........ a Application Approved By......... :' '......................................... ..... Date Application Disapproved for the following reasons:--...-•----....--•----•--•----....-•-•-•--••.................................................................... --••--•-••-------•-----...-•---•-----.....-•-•-----••-----:.....•.................•----...................................----............................._................. .Date.............. Permit No........ J............._.. Issued.--•-----•- •._.....--•••---.................. r�� Date � �-�, � r p •4 -ra / P • -� �t -� t No......... FEs.... .. . THE COMMONWEALTH OF MASSACHUSETTS BOARD Off' HEALTH , ............U�rJ.................OF\G-r S:)c,�bl�......................................... ' Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal r p S,ysttem at: / ...._ZLDS JG 111Cr C.�1 G��1 E l P r �!1• L.r?�....f ... ..... .i -- -- Location-Adddress. +or Lot No. ........................................................... rl�� :_G,)_: 11 !n 4........................................, r. ► y� ' I Owners/? Address s i+ ........................................... .r. -------------•••-••,-•-• -•-----•••--....---....... Installe Address Type of Building 1 Size Lot...., feet �. Dwelling—No. of Bedrooms........... .................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............ No., of persons....................... Showers a YP g •............... 1' P ----- ( . ) — Cafeteria ( ) Otherfixtures ...:.--•--•--•--••---------------------------......................................................................................................... Q T7 t`C t C�?W-Y, ` Design Flow...............: ....��0....gallons per-person per day. Total daily flow......��v............_..........gallons. Septic Tank—Liquid capacity,&' gallons Length_ %..... Width:`�............. Diameter...-..J....... Depth... x Disposal Trench—No................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No ��. .... Diameter.... ............ Depth below inlet..3.: '._-.:-Total leaching area. �.a sq. ft. Z Other Distribution box ( -')� Dosing tank_( -2- Percolation Test Results Performed by...............)2 fiC� c' c'���• ?L .. .... Date.......1.1:.? `i.:.`�.t�.._..._...... a ...- .. .-••--••-•............... .... . a Test Pit No. 1.......L�.minutes per inch Depth of Test Pit.... '_ �_... Depth to ground water....>`��!`..!"..... Gi. Test Pit No. 2....!-2....miinutes per inch Depth of Test Pit.......rg. ._... Depth to grou}nd water... .�9.hl y 0„� _''�_E-'.1'��.......��.!. Z'2} i - � J__ti "j 7�1.+ r�0 1� . �- .ti��+CJ. `G -� �AO� _/6'l ..... .................. ...... ........... ...._. ..................._.. ............................ O Description of Soil.............. ' =` s` ,. - �i 4" l er.--J_ n- c� 1;r 5 0. :- V -'f......Z- -•v' z- )" hU f ....... 5i1_!.r_..? �..�..�C.._....�:'Vic!t. 1 . YY� aa.....5��__rrI ......... -..1.Z0.....:r.t'"t~' ... .. .. 1 W e' r�•v�ck ;� 2U'3' ��clir s ...41l- ''- t+-il CA .tc. t.........................1r.f ............................................i 1 ... •................................... U Nature of Repairs or Alterations—Answer when applicable applicable............................................................................................... ---••.............•-•------•---•--••--=---•••...•-------•----•••••••••-•--•----••-•----.............------..........---.....•-•---...-•---•----•-••---•-••--•...............•--••...................... Agreement: The undersigned agrees to install the aforedescribed, Individual Sewage Disposal System in accordance with the provisions of TITL: 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 of health. Signed:....................�.:..::............ ,...................... .... --'--- ..Date— Application Approved BY-:` - _`__-' .......�1/�5--_.-•--•...........................•--•-- /<' l Yf Date Application Disapproved for the following reasons: -----------------------•---...........-•-•-...`........---••••--••--•-•-•••-•••---•-••--..•..----- ---•-•..................................................••------••---•-----•----••-------.................---=--.....---------•----------•-•---•-------........_......------------....................... Date PermitNo.......... ............................ Issued....................................................... d7 �f., f'•��� Date ..�,a-�_-..o-.x.,�.r r •�„_.u�a e a._.+,.w� ,a e..��4��, a_.�._,.1.�.'�,_---=.+��e;r.w� -_�_,.��_:,:,-.ate�...>.w„�:..,�,�: «. ..-�. >.,.__ _,-. _.. _�. _.e,d..�,.._...,,.._ .._ _ ___.. THE COMMONWEALTH OF MASSACHUSETTS BOARD•- OF HEALTH . ............OF. ....... � ( i..G................:......:........................ THIS IS TO-GERTIFY, That the Individual, Sewage Disposal System constructed (�) or Repaired ( ) by..................- � ----------------�4.����"- � --�%. ......-.-.--------....:----...--------------•-•--•-•--•--..................----................ .. .... .. Installer a has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...c._'�'.�. ....`.._ ....... dated........../�.�.��._.`�_............... THE ISSUANCE OF BINS CERTIFICATE SHALL-NOT BE,CONSTRUED AS A GUARANTEE TH&T THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... .a . .-•...................................... Inspect ................................................... THE COMMONWEALTH OF MASSACHUSETTS e;r" I BOARD OF HEALTH til R .................OF............... ty - N .C:...... ..:' FEE........................ Permission is hereby granted....----••....-•• C�.............. L•....-......-------------•-••-••-•--.......................................... to Construct O or Repair ( -t)-an Individual Sewage Disposal System atNo........U � .. .�...........C5`sd-....-•------------ ---•......................_.....••----.............. ------... ..._..f ..... Street as shown on-the application for Disposal Works Construction Permit No ...... Dated..____. '-. ............ -_ �: •�a�b Board of Health _ DATE.............................................................................._ r TOWN OF BARNSTABLE P06CATION �,��R.p.or��-s+,� ��/ _ ��-le,�t�I SEWAGE # �j VILLAGE ASSESSOR'S MAP Sk LOT INSTALLER'S NAME & PHONE NO. J'T`, =S-ll f _ SEPTjC TANK CAPACITY LEACHING FACILITY:(type) �Aea � �if `(size) & NO. OF BEDROOMS _ PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER All lets 4 DATE PERMIT )ISSUED: DATEr COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� d r *4- s�. y c- Cl yd' g�� Y r . r EXCERPT FROM THE BOARD OF HEALTH MEETING M TES ON 6/12/12: I. Septic Repair— Deadline Extension: A. Richard Shulten, Jr. owner— 79 Rosem y Lane, Centerville, request an extension of the repair deadline. Mr. Shulten was available at 4:15. Th yeaching tan was almost maximum capacity and he was instructed by the insp at it was at failure level. He purchased the house in Dec 2006. It has been inspected twice since than and pumped once since he owned it which was about a year ago. He believes the groundwater is 14 feet deep. He lives there alone. It is designed as a 3 bedroom system. He has not had any overflowing with the system. Upon a motion duly made by Dr. Canniff, seconded by Mr. Sawayanagi, the Board voted to approve a one-year extension with the requirement of a six-month inspection by a septic hauler to verify it is not overflowing. This does not require a full inspection. (Unanimously, voted in favor.) �_ 3ao / l i 6-n V � Cash t. L dAed 172 0�3� a.e —fy&(A� c>7- r ��� 1'7 .2 C; 7 14 IV f�r V 161, z r rM� - t f 1 Orel - 1� 1 m mE' -� 13 - bra O%r lei r`�1�r+d,�` ���1 ., /��-1,/T2 (�`�{(�' �f/tJ/���_I �'/T►!� � �r/I+''Q Q �� i pa �r it a � . SECTION --SEWAGE - -- 0 -SEPTIC TANK - 5 - "D"BOX.- - LEACH P 1 T TOP OF FDN `43=� (MSL)# "2"OFi/8TO1k" \ \\II t WASHED STONE \ t - OUT- IN- IN• OUT ` I 1 �.0 '_c5 P_ F \ 1. LANE IN- 1 IN- T 1 /T1 jo 3�.�5 TANK 3a.5O 38.00/ F_� 35.913 ELEV. ELEV. ELEV. ELEV. ELEV. ELEV. �'� - 7 U T H. lA3,N fn 4, WASHED STONE 4,0 TEST HOLE LOG � .,� T� P-go39 ,.l,�.(}�1Late, 2-Iz-B� E�= 3Oq L. JT J ,�,\� �'R3�1o�`� Lo 7 WI IJ69, 11-�°o TEST BY T2.�AIZTiflN k,PE. TEST DATE __ WITNESS 3 BEDROOM HOUSE DESIGN o i - T.H. # 1 T.H. # 2 Q N . to 0 _ ELEV. +_ ELEV. qG� NO 4 40's �� PERC RATE 2 MIN/IN. DISPOSER DISPOSER .5 U t Q S t CLEAW " _! ) FLOW RATE 3 30(GAL./DAY) 33O � /�/ �� �� '��.•'• '`(¢ sr.Np {� fu SEPTIC TANK .a.y0' A (1.5)= `�✓'� _s - +I REQ'D SEPTIC.TANK SIZE 10 - SANo 17a" CLEAN LEACH FACILITY 4�7!22e 110' i3b �E>a. iti11% SIDE WALL 2 3 J_ 1�(0( 2.5) = 3 1'9' 12 G/D. I 5,00 a S. O NE Atil BOTTOM la 1 13 a ( �,�) _ ! ! S.op G/D. `-� ? �Q 3�, \ �l sAND /�D ,� TO-TA L 2.4 I56" z S VIA USE: ONE , LEACHING I'll {. 3.1 3$ I Ob .00 l 9� 39 90 WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) 3. DATUM(MSL)+TAKEN FROM....._.( y�l'�� .........QUADRANGLE MAP y" 0F 2.MUNICIPAL WATER........./_�:>............._...............AVAILABLE 3.PIPE PITCH:1/4"PER FOOT w �'°�' ZN F '/ w/; y /` of 4.DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO- /� /Q -44 �� ARN�fly:' ' J ( IN f l 5. MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. / �,A� �4 0/� NE Cyr 1 6.PIPE JOINTS SHALL BE MADE WATER TIGHT 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. I G� IL N STATE ENVIRONMENTAL CODE TITLE 5 O o `^ SITS PLAN � .9 #f2 " o S. Z ovr li�15�ITa�I e T� E�,. 3?.� F�2 fo � u ��zv ,�ip p \ $ o � , Locus: L or et PI�P.CG- �>Jr(l1 c 5AKi, IvlEnl -�,A"12, ti�FSS/OPdAI E ' _--o`-si GisnlR �;yq� /�.i1..f ' c' !.- '`j '�fl ii-66 2 y--- k r REG.PROFNRLINEER �U9PYg'' I REF: L GT E down cape eft.binfteefiag \/ PREPARED FOR: _ `� A I_A N i Qc . l CIVIL ENGINEERS LAND SURVEYORS --------�--- BOARD OF HEALTH f 92 MaIA SL REG. LAND SURVEYOR - - -- _ �i • = 4 CONTOURS -- B TAP. MA.. Yar�Ci..91�A -- ff (EXISTING) - A 15 r/\L' L✓ SCALE—i 3 (PROPOSED)-O-O-O-O- APPROVED DATE / f s _ DATE �C�7 I , 1 , F _ _ - SECTION : SEWAGE - - j �i3 t„� Go2 r� _ z..oT l -- ^c1�4 r Sot.1TM 0�= 1NT - _-- ..' cM+�w_-< I_ 4 . . 4zt u SEPTIC TANK - 5 I - "D"BOX.- -LEACH P 1'T TOP OF FDN "2"OF IISTO 1/2" �{ \ WASHED STONE OUT OUT IN• o 1000 39.o SEPTIC / ePo� Ta 38-2-s TANK 3a.50 38.0° I- ELEV. ELEV. ELEV. ELEV. °u: ,�ir(D -I.: ►OO.OO _ ELEV. ELEV. > +a a / -- + ' �L + �3'_ OF3/4"-Ph" ` IV) 00 �,� WASHED STONE TEST HOLE LOG , - L o T 9 R '��I� P=go39 ,J',CdtJLakl, 2-la BS E1.= 30,� � ! 1 �'A� \�� . LOT ']I TEST BY Z�ifl N k, '��� �: (�I��ERI I I-Z+ �2.�gtT No WITNESS `O� 61 TEST DATE - DESIGN 3 BEDROOM HOUSE T.H. # 1 T.H. # 2 0 -N c a 0 _.yC ELEV..rJ+- p� ELEV. �G'1 NO Ln` t r Q �, 40 DISPOSER DISPOSER I In z-I q PERC RATE 2 MINAN. I4 0 `\ "Ql \ g lr CLEA►1 38.5 11 3pn �7• I FLOW RATE 3 30(GAL./DAY) _p SAND .. . SEPTIC TANK 130 X (I.g)= `�9 \. 44 \ : - 60 35.5 phi) REO'D SEPTIC TANK SIZE 40 C>C> � lJ�i�� �//�a - � � ul CLEAN 340 o,�aa A�� 33�5 LEACH FACILITY ��nrZ. �o, 3 j 0` � 42 Min, lam' �Qa 3'7 00 \ S. • ��'' SIDE WALL '2 �13�:(0( 2.5) = 33• 2 _P N F_ AAl BOTTOM ) Z. 1 h1-0 ( J,q) = 1 I`3- oQ G/D D. SAND `' 31�r.� TOTAL. r _ /b ' USE: ONE LEACHING 1Ob .00I IZ' e,4r Di A, K Ad eff' D6•P'r+i 37 39 NO WATER ENCOUNTERED n NOTES: (UNLESS OTHERWISE NOTED) �I�I✓�[Ci�.�� 1. DATUM(MSL):TAKEN FROM----- G y! f_!. Ef�.r+_.....__QUADRANGLE NiAP t-r� i,� OF - _/_/ l � 2.MUNICIPAL WATER --_----___________________AVAILABLE � OF .PIPE PITCH: PER FOOT 4 4.DESIGN LOADIDI NG,FOR ALL PRE-CAST UNITS:AASHO- /'t' V -44ARM- �•' y A"'9 - 5.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1)FT. ya': OJALA. O ONE G 6.PIPE JOINTS SHALL BE MADE WATER TIGHT �{N7 IL 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. SIT PLAN STATE ENVIRONMENTAL CODE TITLE 5 0 N o. (Z oYG IJLl5Ll'(A0,-P To EI.. 3'1.ci (()(& 10'P�Rc�l. 017 �I 'sue ' 2 �� Locus: der 8 /�Gsr t�tr9r+ iy> ' R01 AC�G vh'(H f-I.EAI4, 1,A F P 1,,'-4 sAN 12, �'`f JSTER ss GISTER`� ^'�!' .(Ti4 G 6 �.4 REG.PROF (fNRLly6�INEE,) 407.6 REF: dT V WOW l CIQe eng/aeear/ng PREPARED FM:. VA:LL-A N D SURVEYORS ------------ 1 CIVIL ENGINEERS --- REG.LAND SURVE _ � LAN - - BOARD OF HEALTH VOR. I,1 I l a2d Alain St.. CONTOURS' (PROPOSED)-0-0-0-0— APPROVED EXISTING)- DATE ��RN� J�O� Mqa dA 4 pA5 SC/jLE 0 ' r,,,. • `" LEGEND C,ENTERVILLE . • ` �-. _ `C ' i � APO `Nv PROPOSED CONTOUR 98 Oh PROPOSED SPOT GRADE �P\,�O — o — 98 -- EXISTING CONTOUR It + 96.52 EXISTING SPOT GRADE O \� EXISTING WATER SERVICE � �0 W TEST PIT m LOCUS �Z � U � RO \ F RTE. 28 s� LOCUS MAP so LOCUS INFORMATION �O. TITLE REF: BK: 21617 PG: 344 PARCEL ID: MAP 147 PAR. 007/008 +42.5 �P IN150 SEPTIC SYSTEM REPAIR PLAN \ LOCATED AT: GENERAL NOTES: \ 9 ROSEMARY LANE 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. \ I 42 CEN TER VI LLE, MA 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE j PREPARED FOR -- LOCAL RULES AND REGULATIONS. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR SO \ 41 .G+ R I C H A R D S H U L TE N TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE EX15T. 1 ,000 GALLON DESIGN ENGINEER. �O. \ SEPTIC TANK 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING APRIL 12, 2013 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 39 1+ 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF \\� OFTHE OR OWNER TO �4ss THE LOCAL BOARD HEALTH FORCTOR PROPER INSPECTIONS DTURING IFY CONSTRUCTION. OF T13M = EL. 42.0 �, D �R •N iM 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. BULKHEAD FOUNDATION \ I RV y I- 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 0. 1140 TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY - -- _ STE�c� THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING EXISTING LEACH PIT 40 N SANITAR��'� CONSTRUCTION. (5ee note 10) ' � O� � 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND REMOVED PER TITLE 5. 63 y�� \QO 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 2 TH_1, ' /2 0) 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY 38-, \/ N 99^ AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY T H- N MEYER CSC SONS, INC. 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING \ I U 14. ALL PIPE TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPEC. OTHERWISE) P.O. B 0 X 9 81 U 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE GRINDER 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING 38 EAST SANDWICH, M A. 02537 (508)362-2922 k� SCALE: 1"=20' SHEET 1 OF 2 J#1514 1 NOTE: TO PREVENT BREAKOUT, THE PROPOSED x NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:35.85 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. T.O.F. EL.=43.0 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER OF OUTLET AND SET TO 6' OF FINISH GRADE SET TO 6 OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. � MAS`S9 F.G. EL=42.0-41.5f F.G. EL.=41.0t F.G. EL: 39.50t F.G. EL: 38.85(MAX.) "a D' R�R SM 9" MIN COVER/ 0. 1140 L = 18't ' 36" MAX COVER L = 45' L = 10'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) C/�E 0 S=1% (MIN.) EL 39.00 ® S=1% (MIN.) 0S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC `S�4NITAR�a� 12- `3 14' 8' 3.8" TO INV.=37.92 48'UQUID INV.=37.67 INVERT LEVEL PROPOSED INV.=36.55 GAS BAFFLE D-BOX 4 ROWS OF 5 UNITS AT 5.0'/UNIT = 25.0'/ROW INV.=36.7 DB- INV•= 35.50 SOIL ABSORPTION SYSTEM (,PROFILE) EXISTING 1.000 GALLON SEPTIC TANK 60" RESTORE VEGETATIVE COVER EXISTING SEWER OUTLET BACKFILL WITH CLEAN PERC SAND r �. � � � lill-hod.ill-hod. I I, I TO TOP OF CHAMBERS BREAKOUT=TOP ELEV.=35.85 34" INV. ELEV.= 35.50 BOTTOM ELEV.= 35.18 EXISTING SUITABLE 2.83' MATERIAL 5' MIN. ABOVE BOTTOM OF T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.83' = 11.32 (5.68' PROVIDED) USE 4 ROWS OF 5 ' ARC 36LP PROFILE ADJ. GROUNDWATER EL.=29.50 _ (3.19" INVERT) UNITS-NO STONE SEPTIC SYSTEM PROFILE TYPICAL SECTION N.T.S. N.rs 3.8" p DESIGN CRITERIA SOIL LOG P#: 13919 } SECTION _T END CAP NUMBER OF BEDROOMS: 2 BEDROOM DWELLING/3 BEDROOM DESIGN DATE: APRIL 11, 2013 SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE #1614 DESIGN PERCOLATION RATE: <2 MIN/IN WITNESS: DONALD DESMARAIS, BARNS. HEALTH ARC36 LP (3.8" INVERT) UNITS DAILY FLOW: 330 G.P.D. DESIGN FLOW: 330 G.P.D. Elev. TP-1 Depth Elev. TP-2 Depth 50 GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) 38. A LOAMY SAND 0" 38.50 A 0" MODEL ARC 36LP Loan, SAND LENGTH 60" 10YR 3/z NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT PROPOSED SEPTIC TANK: 330gpd x 200% = 660 gpd (USE EXIST. 1,000G TANK) toYR 3/2 - 37.91 B - 7" 37.91 B 7" EFFECTIVE LENGTH 60" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. LEACHING AREA REQUIRED: (330) = 445.95 S.F. LOAMY SAND L�, SAND SIDE WALL HEIGHT 3.8" .74 10YR 5/9 101'R 5/8 OVERALL HEIGHT 8" DISTRIBUTION BOX: (4 OUTLETS (MINIMUM)) 35.58 C1 35" 35.58 C1 35" OVERALL WIDTH 34" PRIMARY S.A.S. MEDIUM SAND USE 4 ROWS OF 5 - ARC36LP LOW PROFILE (3.8" INVERTS 2.5Y 6/4 MEDIUM SAND CAPACITY 2.SY 6/4 UNITS WITH No STONE PERC O 34.17N BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF OF CHAMBER) 27.50 132" 27.50 PROPOSED SEPTIC SYSTEM/SITE PLAN 132- ((]] (CHAMBER UNITS) 20 UNITS x 5.00 LF x 4.73 SF/LF = 473 SF PERC RATE <2 MIN/IN. (-C1' HORIZON) 79 ROSEMARY LANE, CENTERVILLE, MA TOTAL AREA = 473 SF MOTTLING OBSERVED AT 108- (EL. 29.50) Prepared for: Shulten DESIGN FLOW PROVIDED: 0.74GPD/SF(454SF) = 350.02 GPD > 330 GPD req'd Engineering by: Surveying by: SCALE DRAWN MEYER&SONS,INC. )Yeller & Associates NTS D.M.M. I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX981 (508) 375-0735 to conduct soil evaluations and that the above analysis has been performed by me consistent with the DATE: CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that I hove passed the Soil Eval. Exam in October, 1999. EASTSANDW/CH,MA02537 508-362-2922 04/12/13 D.M.M. 2 of 2