HomeMy WebLinkAbout0055 SACHEM DRIVE - Health 55 Sachem Drive
Centerville
A= 209 009
UPC 12534 '
NA.2-153L0
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s
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TOWN OF BARNSTABLE
+JCATION 5$ Sa�c�c,r� flR SEWAGE# Z019 - ZS 1
VILLAGE ASSESSOR'S MAP&PARCEL Zp q - 9
INSTALLER'S NAME&PHONE NO. B 'k.B EXco-ooA;O.-\ Lin'?- 0653
SEPTIC TANK CAPACITY /DOO !RG-1
LEACHING FACILITY:(type) ` 0 5p,1 Ll c (3) (size) 13 X Z:5 x 2
NO.OF BEDROOMS L
OWNER oa '
PERMIT DATE: -118 19 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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AZ' 43
62 .53'1
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e REAR
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ay- �
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TUV+�I OF;BARNsTABLE _,L .
C SEWAGE#
ViI.IA._ �C v!4ec d ll ASSESSOR'S i�4AP E,t7T
Il�ISTALLE�'�.£'dMM 8t PHONE NO
SBMC.TANK CAk'Af I'Y
LIEACfIING:FACIL:)'£�•tZ
Pi0 OF�3BDl��ly[S
13tJIWE o oWisER
GQIVdPLIAIdt DATB.'
PlERNIITDATE ,:
Soperatton Dcstance Heturresn site Feet
Maxuritim Ad)astesl Gmandwater Table to the Bottom`efLeaclting Facility
Well and�g Faraltt3► E1��Y w�t#s exist
Pjj"t6L. Fest-
an stta ar aiithtn?Ot)feet of leaching faccy)
F�lge o£Wet#aitd and;I.eaclurig FaaTttl'(If a11Y wetlands exist Peet
wittitn loo fee leaelun ' etlitY}
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplitatlon for Bisposal *pstrm Construction Vertu
Application for a Permit to Construct( ) Repair(✓j Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.$$ .DA Owner's Name,Address,and Tel.No^�v`� 1 Ip p-}
Assessor's Map/Parcel Zp9 I 9
Installer's Name,Address,and Tel.No.J3+t,.B EXCaUmAloi\ Designer's Name Address,and Tel.No.
14 _TCat,Scrrq Lo Fresido.lc y''�n- be53 'Da'uc Fla��cr4yp 0 Zo. 331
Type of Building:
Dwelling No.of Bedrooms n y Lot Size a y19 A C sqk. Garbage Grinder( )
Other. Type of Building `RCS icy r�'$ a No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) k4(4 0 gpd Design flow provided 4s y gpd
Plan Date - y- 19 Number of sheets Revision Date
Title
Size of Septic Tank—/000 !qoj Type of S.A.S. 5004a l L1 C 3�
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ZO.-I OTC - 3 NZO 500 Qs2j LI C
Date last inspected:
Agreement•
The undersigned agrees to ensure the construction and maintenance of the afore described on-site Y
sewage disposal system in
P
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.
Si Date -s• 9
Application Approved by Date (
Application Disapproved by Date
for the.following reasons
Permit No._2-D19 — Date Issued
:i ._ - `,'
• �" "7f g
�L N-40M7 5 - - Fee-A/oW
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
RppYiration for -Disposal-*stem Construction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.15S 50kC1,C,M ID PI Owner's Name,Address,and Tel.No. o t
Assessor'sMap/Parcel gpg c� - �C� 1 '�✓�IC�
Installer's Name,Address,and Tel.No.3�,.B Ex CaJc�'��C�n Designer's Name,Address,and Tel.No.
"['rci�cc� zowr.. F'1a�tr-ly {� O Z0X -3 F�aPW'�c�
y LtJ Focc�ldal c 4'l'1 d
Type of Building:
Dwelling No.of Bedrooms lj Lot Size y Z jA1 sc�,$. Garbage Grinder( )
Other Type of Building �r � ,�n�ell No.of Persons Showers( ) Cafeteria( )
f.
Other Fixtures
Design Flow(min.required) y y[� gpd Design flow provided 45 y gpd
Plan Date _ c� Number of sheets Revision Date
Title
Size of Septic Tank loco Qn j Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)�!7—0 9 T2 D �'DD Qa ) 4
-ta Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ;w
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.
Si Date
'7
Application Approved by Date
Application Disapproved by 000, P10 Date
for the following reasons
Permit No. 19 -- 21 1 Date Issued
------------ -----------------------------------------------------
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 XC 1.)r, 1 a e_-,
at rnn, -Q has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.�1 �_ dated ' i�q
Installer ,,� �(r'� ��..� r�� Designer
#bedrooms 1/ Approved design flow q,�'q gpd
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. g
Date Inspector _ A
---------------- -- --- --------- --m ----- - --------------- - -- --i------------- �---- -------------
No. 201 \! 25 1 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction 31ermit
Permission is hereby.granted to Construct( ) Repair ooT Upgrade( ) Abandon( )
System located it
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 permi
Date q1 1?12429 Approved by
Town of Barnstable
P�of.THE ray Regulatory Services
Thomas F. Geiler, Director
• 1ARNnABLE, - Public Health Division
MASS.
`I'Ar 1639. e,`� Thomas McKean, Director
fD MAC
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: 19 Sewage Permit# 2oi9 - 2 51 Assessor's Map/Parcel
Installer & Designer Certification Form
Designer: Installer: 6XQraXu A ;on
Address: fl ROX 331 Address: Jy Tea►.�e c-u L�J
�6 rr iC� r'114arcs-uo.lc nA
On '7 $ - 19 (� R EXe_ja A i o✓\ was issued a permit to install a
(date) (installer)
septic system at 55 _Sack nr1 l) - based on a design drawn by
(address)
dated '1- 4- 19
(designer)
_y 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
distrila-ution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateraf relocation of the SAS or any 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. Stripout (if required) was inspected and the soils
were found satisfactory. OF'
DAVID
D.
Installer's Sign a tAHEf2TY,JR.
No. 1211
4
(Designer' .Signatur ) (Affix Desig p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice foims\designercerti'fication form.doc
r
ai 1
Town of Barnstable Barnstable
Inspectional Services AB-MM;Cac 1 h,
IIARNb'TAB[.E,
9�p b q: Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A.McKean,CHO
FAX 508-790-6304
n;
CERTIFIED MAIL# 7015 1730 0001 4987 9521
February 27, 2019
WILMINGTON SAVINGS FUND SOCIETY FSB
D/B/A CHRISTIANA TRUST
C/O SELENE FINANCE LLP
9990 RICHMOND AVE STE 400 S
HOUSTON,.TX 77042-4546
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 55 Sachem Drive, Centerville, MA was inspected on
02/13/2019 by Shawn McElroy, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1q95 TITLE V (310 CMR 15.00) due to the following:
• Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS or cesspool.
You are ordered to repair or replace the septic system within one (1)year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean,
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\55 Sachem Drive Centerville.doc
t
sty
Town of Barnstable
MAW
i � M
Regulatory Services Department
-- - ---~Public Health Division ---
200 Main Street,Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
E 1 YEAR DEADLINE CRITERIA
Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form :;
'1 i,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y
-r V 55 Sachem Dr
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
required for every Centerville MA 02632 2-13-19 ss, .
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.
A. Inspector Information mil #- (Slow'
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l 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 theproperty 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
2-13-19
ns ctor'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.7/2M018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
I'.) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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:
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
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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 El ❑ 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.7/26/2b18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
r� 4. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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 asses if the well water analysis, performed at a DEP certified laboratory, for fecal
Y P Y , P rY,
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
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
c,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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 Y2 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
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
# Ur�,�a
� > 55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632. 2-13-19
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 C.4 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?
® Wasthe 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
hf Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r,
55 Sachem Dr _
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 0
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:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
y Title 5 Official Inspection , Form
�Ir�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1: > 55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
page. City/Town 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: N/A
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
I
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
i,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r> 55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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
r ❑_ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1996
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: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
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
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
6"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: 1000 gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
20"
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
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
C�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
..
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
page. Cityfrown 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
r� Title 5 Official Inspection Form
i-i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. .•T,;;, 55 Sachem Dr
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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
1"
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-box had water level 1" above outlet invert.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
C;,l Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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 Ab
sorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 5-Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ 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
Title 5 Official Inspection Form
,ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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.):
Infiltrator leach field was filled beyond capacity and into d-box at inspection.
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 Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
cam` Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt I@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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
3 Title 5 Official Inspection Form
iCl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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
0:
r� dr
7 `• .
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
s Commonwealth of Massachusetts
Title 5 Official Inspection Form
l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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: 12
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed.site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
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
p Title 5 Official Inspection Form
I� wa
�i�f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 2-13-19
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
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
rc DEPARTMENT OF ENVIRONMENTAL PROTECTION
V 1..
3
r'
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name: ( C't1 2w?p�-,
Owner's Address: -7:) / "
Date of Inspection•
Name of Inspe plea e Mt
Company Nam G �- t4,e Yl y[
Mailing Address:
Telephone-Number:=�),C"--:2 cfi, ra:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that thl information reported
below is true, accurate and complete as of the time of the inspection.The inspection was perfo imed based on rj
training and experience in the proper function and maintenance of on site sewage disposal syst rns. I arnJa DEPI
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). Thesystem:
_Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
'. F 'Is .
Inspector's Signature: Date: / (1^
The system inspector shall submit a corgi 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.
} Notes and Comments t
f.
e ... ..
•< ****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 I
Page of 11
OFFICIAL "INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: +
Owner:
Date of Inspection: ��� �O(t
Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D
A. yytem Passes:
_ I have not found any information which indicates that any of the ti,ilure criteria described in 310 CMR
15
.303 or in 3 10 GMR 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 followin statements..If"not determined'_'please
explain.
The septic tank is metal and.over 20.years old* or the septic tank(whether metal or not),is structurally
unsound,exhibits substantial infiltration or exfiltration or.tank failure is imminent:System_will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. ;system will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replace' .
ND explain:
The system required pumping more than*4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION, FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of In pection-:
C. Further Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board ofIlealth in order to determine if the system
is failing to protect public health, safet or the environment.
1. System will pass unless Board,if Health determines in accordance with 310 CMR 15.303(1)(b)that the
system_ is not functioning in a inanner 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 systetn has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet ofa
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
"This system passes if the well water analysis,performed at a DEP certified laboratory,for col iform
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: "
;k
.p
i
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: �� �
Date of Insp ction: ® c�a�
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
_ l6 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
_ V Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
Required pumping more than 4 times in the last year NOT d;'e to clogged or obstructed pipe(s).Number
of times pumped
wAny 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.
Sr Any portion of a cesspool cr privy is within a Zone 1 of a,public well.
_ } Any portion of a cesspool cr privy is within 50 feet of a.private water supply well.
Any portion of a cesspool cr privy is less than 100 feet but greater than 50 feet from a private water
supply,well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the.well is free from pollution from that facility and the presence of ammonia
nitrogen,.and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are;triggered. A copy of the analysis must be attached to:,this form.)
(Yes/No)The system fails. I have determined that one or more(,.f 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•
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 suppl`r
the system is-within 200 feet of a tributary to a surface drinkingr_water supply
— _ the system is located in a nitrogen sensitive area(Interim Welliead 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 1] ;
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.B
CHECKLIST
Property Address:
t �-
Owner:
Date of Inspection:
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No V
t/ 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 ?
l/ 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 sj`stem 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 siins 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
o"f 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?
i
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)]
,i
YI
,i
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �� ✓/lt�i
Owner: de-t'9XP"'
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL t--�
Number of bedrooms(.design): �RI.5
Number of bedrooms(actual):
DESIGN flow based on 310 C 203 (for�xample: 110 gpd x#of bedrooms) ..
Number of current residents
Does residence:have a garbage grinder(yes or no): A
Is laundry on a separate sewage system;(y s or no)jt .[if yes separate:inspection required]
Laundry system inspected.(yes or no)
Seasonal use: es or no
(Y :)
( 17F��D ra�j
Water meter readings, if avai 'ble(last 2 years usage gpd)):
Sump pump.(yes or no):
Last date of occupancy:'
COMMERCIAL/INDUSTRIAL/V/0
Type of establishment:
Design flow(based on 310 CMR 15.20): gpd
Basis of design.flow(seats/persons/sgf,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 inspectioh-(yes or no): !
If yes, volume pumped: gallons--How.was quantity pumped determined?
Reason for pumping:
TYP F SYSTEM
eptic tank,.distribution box,soil absorption system
Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes, attach previous inspection records;if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
-Other(describe):
Approximate ge of all co p ents, e installed 'f known)and source of information:
-
Were sewage odors:detected when arriving at the site(yes or no):
Page 7 of I I
OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART C
Sys
'T'EM.INFORMATION(continued)
Property Address:
Owner: Z7i
Date of Inspection:,
BUILDING SEWER(locate on site plan) A/d
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:_&_ ocate on site plap)
Depth below grade:
Material of construction:--Llconcrete_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: _ /(a
Distance from top of sludge to bottom of outlet tee or baffle: Z'1
Scum thickness:
Distance from top of scum to top of outlr:',tee or baffle: Ll Jl >
Distance from bottom of scum to bottom"'of outlet Xee or baffle:
How were dimensions determined:
Comments(on pumping recommen(fatioias; inlet and outlet tee or baffle condition, structural integrity, liquid levels
s related to outlet invert, evidence of lea:,age,etc.): /J
D: ^%
1/
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.):
Page 8 of 11
OFFICIAL.INSPECTION FORM-NOT FOR"VO,'LUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM"INFORMATION(continued)
Property Address: ast1 a
r:
Owner.: / - y
Date of inspection:
TIGHT or HOLDING TANK: t!V (tank must be pumped um ed at time of insP ection)(locate on.site plan)
J
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): i
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:inif 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 or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
ft
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: r > A
Date of I pection
SOIL ABSORPTION SYSTEM (SA§J: (locate on site plan,excavation not required)
f
If SAS not located explain why:
Type
leaching pits,number:_
:1-ieaching 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),:
Cam: t
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.):
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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM.
PART C 5
SYSTEM INFORMATION'(continued)
Property Address:
Owner:
Date of Ins` ection ,
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks'or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
C�
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1
Page 11 of 1 l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 9L Zr
Date of In pection: �3aJ
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
ZAccessed USGS database-explain:
You must describe how you established the high ground water elevation:
11
i
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: Lot No.
Owner: Address:
Contractor: / Address:^ ✓//�/ � cS�j'� '
r,
Notes: ✓"� �0/�A✓4 /`�/' 15
STEP 1 Measure depth to water table
to nearest 1/10 ft. ..:........................................................................... Date
month/day/year
STEP 2 . Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well..................................`.•`................
OB Water-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... 7'
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ........................................................................ .................
STEP 5 Estimate depth to high water
by subtracting the water- .
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) .............................................................................................................
Figure 13.--Reproducible computation form.
15
I
1.0
1._...,.I ...
. I
' I
i
IlTOWN OF BARNSTABLE
:ATION SEWAGE #
'II-CAGE Ce f Cc(•J/ ft-- . ��.
ASSESSOR'S MAP& LOT�� ' gym;, .'
INSTALLER'S NAME&PHONE NO. --11,,Vf 0A ?1/4-
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) " F n�fb(CSJ(size) (7�. I X
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 0 —7,— 9 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility
Furnished b '"y Feet
-- , ,
Gas IRc�An 0,F
f3 a
193
1
O
l
..n„r,r- R� -t':'. r}' '�>r.' „Y.; u -✓,.,, ">-+-- f_'+.<�*^'�;-.•hr.>.y�..�c+,w.r,-rwt!rr -r-r.r..-s+wk�a-�.,+,.�"--"�, A.�+rtiY •:-•.r'-2'"rv...-�.;.. ,.-..-.,,,,_,.,,.q,r °�
TOWN OF BARNSTABLE BAR-W WIND 346
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager Rtr(1AA ( 6 ut vrt.11'
Address of Offender 5,51 5411 ,M rr rn MV/MB Reg.#
Village/State/Zip eJtrre //'P e17 o.) (x 3
Business Name f ;'-10 „ am/pm1, on 9/ 5 ,/20P6
Business Address r Vr J
Si44nature of Enforcing Officer
Village/State/Zip
Location of Offense //i� r � /.af� i�drA %ire ,
f{�} j f^ Efif*cing/Dept/Division
Offense T+zVv+ rf 1�&l,reAr + f 4 r-/`/0 � 1i1 P ! : ;ts�ei�riSP� C (f(tzre ff r�r llf���c•��
r r j
Facts
j !' ,at� t, Ir Jj .L r.,ir(�{t�t ,.F..r,/J eM, r�/•t,rlr —N.- .,�.� �E,,,Xe�sr�,'v�+S
Thil"s will serve only as a warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
...�....f-. +^..^^.,' �..�.,,-_ s. ,...._.:. ..........7•-...- ,... ,. ,�„-y.;.. ... �„,M« pc, r- ,,...,-...+rr?>.an+.r-r:-.,.e.=..--.-.,;:_.. R.n,,.R,..-a-�. ...,.'. �..r._ „-...,r....,-t-. - .
TOWN OF BARNSTABLE BAR-W
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager t_icr'1('. f 0
Address of Offender ` � ,.� f , r MV/MB Reg.#
Village/State/Zip <r,-ftr /40' r`j ?
Business Name er q qu am/;m; on l 120t_
11, r <r
Business Address M/
! f' Si4nature of Ehfbrcing Officer
Village/State/ZipIk,�c�
Location of Offense lift, T .t � :1.r�tfa^.,�,•�+ r �,� :'r ,. '#1k."e.Alr'hA�
Enfo cing/gept/Division
Offense T, ! f - 1 tt1^t,),rr„ "Facts
't I
This will serve only as a( warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve~ voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
Cc TO OF BAIZNSTA1jLEv (�Or✓II®
.t ��r V SEWAGE # `7 ,3-
L LOCATION ITON/�'�� �C�F 1P_i/V'1 � �v �
(Vl"T LAGE ( �0g,-r al 'E, AS SSOR'S MAP & LOT .vat
P NAME&PHONE N �r - ' e-77`'.��
SEPTIC TANK CAPACITY O
rrff
LEACHING FACILITY: (type) 1'►• Cs (size)
w/ )G
NO, OF BEDROOMS
BUILDER OR OWNER i
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) . Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
7 D
� o rocx) "qallon
`�1 ........
JTOWN OF BARNSTABLE /
LOCATION �� �FJC�e•--" ZZ SEWAGE # ���'" :�Z
VILLAGE �ey? ee.Vl ASSESSOR'S MAP & LOT241F,""
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 15�8
LEACHING FAciLrrY: (type) D)Pi U ck 4f 02s (size) 9b"k
NO.OF BEDROOMS
BUILDER OR OWNER .�.�•�.�f�
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Y.
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) ° Feet
Furnished by
G�rz 1'QPaa dF L�ovSe- 1
f� R
No. 7� Fee
THE COMMONWEALTH OF MASSACHUSETTS G
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
,Appcation four Zigo at *pgtem Congtruction Verntit
�`IVe
Application is hereby made for a Permit to Construc )or Repair�n On-site Sewage Disposal System at:
Location Address or Lot No.. Z - - Owner's Name,Address and Tel.No.
AG r7H V---TZ_-
Assessor's Map/Parcel ®Q` � �
_ oz��
Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No.
Vim✓ -
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow am— gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) =cep 1`� :k
PLC. '%-
�-
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_bp Environmental C de a of to place the system in operation until a Certifi-
cate of Compliance has sran e
Signed Date 7"T
Application Approved by 0& Date -
Application Disapproved for thpfollowinjg reasons
I ^7
Permit No. Date Issued
-----
- No. ; z Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
t , 1
e.S ppl cation for Mig gar *pgtemc Congtruction Permit
Application is hereby de for Permit to C�ruct )or Repair k--")'Oan On-site Sewage Disposal System at: i
Location Address or Lot No. Owner's Name,Address and Tel.No.
{
Assessor's Map/Parcel /� O Q ' Ih,4tzs A4 L Z6,rN c--T- f
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms?� Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow -S3� gallons.
Plan Date - l'infiber ofishfs Revision Date 1+`
Title
Description of Soils
Nature of Repairs or Alterations(Answer when applicable) -T'y--S AA
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 th Environmental C de of to place the system in operation until a Certifi-
cate of Compliance has b7r s�. Hje
-
Signed Date _7 116
Application Approved by Date=G
Application Disapproved for th following reasons
Permit No. Date Issued
————————————————— - —————————————— ————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
S TO TIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(✓)on �l�
by cre S Installer TZ
at X-5 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Constructi Permit No. _ �k dated '"" ` �
Date / Inspector /� �.' �/ .�
ar
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE TWAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
# No. .- r --------- -------Fee
' THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
Migpoe al 61 Congtruction Permit
.
Permission is hereby granted to o 0 -�
to construct( )repair( %-)-A On-site Sewage System located at No.# s
Street
F and as described in the above Application for Disposal System Construction Permit. _3�<-
No- Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below. 11`` j
�y ® _1 Date: � -�- / � � Approved by � ,lei.
t/ Board of Heal
i
2
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANSI
t
hereby certify that the application for disposal works
o -
construction permit signed by me dated 5-7—9(a , concerning the
property located at ) 'S 5 � e . r e Ce � meets all of the
following criteria:
1
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
f
SIGNED: ::Z
DATE: .
LICENSED SEPTIC STEM INSTALLER THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a cettifled plot plan,
this plan should be submitted].
r � c
��
��Gtf
G
_____
r---
.. _ .. . .
TOP OF FOUNDATION COVERS
BROUGHTO BE WATERTIGHT AND.TO WITHIN 6"OF FINAL GRADE SEPTIC SYSTEM PROFILE Flaherty Environmental Services
EL. 62.0' EL. 60.0' (not to scale).
4 INSP. PORT W I 3" OF GRADE CLEAN SAND P.O. Box 339
2" of e"to�° DOUBLE WASHED EL. 60.0' Han�vich, MA 02645
4"CAST IRON or EQUIVALENT PEASYON57OR GEOTEXTILE
MIN. PITCH 1/4" PER FOOT FILTER FABRIC l 774.994.1166
a°SCHEDULE 40 PVC PIPE 4" SCHEDULE 40 PVC PIPE
FLOW LINE (flist2'tobe%VeI1 : ; VENT IF REQUIRED
20' 2.4% 5' 1°i6 5 0'
—�
:.'•: L.EXIST. 14 ® Ooo°000°e
EL EXIST °o°0°0°0°0° ° 0°°°o°o°c
L.57.4' 0000000 0 ° 0000 .'® 0°000°000
0°° ° ° °°°°0°O° ®� 0°0°0°o°e j` EL57.03' 0 0 0 0 0 0 0 0 0 0 o
EL.57.2' o 0 0 0 0 0 � ®��� 0 0 0 o e 2.0
GAS BAFFLE (H-20 -BOX) EL.57.0' 0000000000°000000 00000000�—
0 0 0 0 0 0 0 0 a o 0 0 0
•:'., 4 000000000 °°°O°° •. d °O°°°O°OC EL.55.0'
•`' 'i 6"CRUSHED STONE OR SOIL ABSORPTION SYSTEM
'•s •' MECHANICALLY COMPACTED (3) 500 GALLON H-20 CHAMBERS
1000 GALLON SEPTIC TANK
WITH 4' STONE AROUND IN A
(DATUM: ASSUMED) EXISTING 31s t0 1," DOUBLET'WASHED STONE 12.83'W X 33.51 X 2'D CONFIGURATION
BOTTOM OF TEST HOLE EL. 49.5' EL. 49,5'
I USGS ADJUSTMENT: N/A LOCATION MAP
60 '/ GROUNDWATER ELEV: N/A
DRIVEWAY 60 58 Rt.28� (n
62
DECK
EXIST, 1 M
SAS ,r 1
N 1
O Z3
100IGST EXISTING0 y � LOCUS NTS
D� O DWELLING C
7;
i m � tHOF
a DECK
r DAVID
15,0' +
FLAH H
O •',r t ,� 1 O
O a��/STEaF.
;^ O • LOT 15 X
0,48
�' ACRESt
MAP 209
i LOT 9 DATE.•71412019 REVISED:
62 ��Z
TH-1 58
LEGEND
BENCHMARK: , SITE AND SEWAGE PLAN FOR
6 6 6 GAS LINE TOP OFOFNDN �6032 B&B EXCAVATION, INC./
W W W_W- WATER LINE 60
E E. E-•�-- EXIST, ELECTRIC DAVID HOLT(TODAY R.E.)
99 EXIST, CONTOURS
55 SACHEM DRtVE
—— 99 PROP. CONTOURS CENTERVZLLE, MA
EXIST. FENCE SCALE : 1" - 3 0 I
60
REF.PS 198 PG 47 PAGE 1 OF 2
f
........... .................................... ................ ........... ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
GENERAL NOTES
DESIGN CAL CULA TIONS - S YS TEM DETAIL Flaherty Environmental Services
P. 0. Box 331
1. ALL PRECAST COMPONENTS TO BE H-1 0
RATED UNLESS OTHERWISE SPECIFIED.
NUMBER OFACTUAL BEDROOMS 4 Harwich, MA 02645
DISTRIBUTION BOX(ES)AND ANY 774.994.1166
COMPONENTS WITH ANY ANTICIPATED GARBAGE DISPOSAL UNIT NO
VEHICULAR TRAFFIC TO BE H-20 RATED.
2. THE DESIGN OF THIS SYSTEM DOES NOT TOTAL EST/MATED FLOW
ALLOW FOR THE USE OFA GARBAGE (I 10 GA LIBRVA Y X 4 BR) 440 GAL./DAY
33.51 —
GRINDER.
REQUIRED SEPTIC TANK CAPACITY 880 GAL.
3. MUNICIPAL WATER IS AVAILABLE. —
4. ALL CONSTRUCTION TO CONFORM WITH
SIZE OF SEPTIC TANK 1000 GAL.(EXISTING)310 CMR 15.000 AND ALL OTHER
APPLICABLE LOCAL, STATE AND FEDERAL SOIL CLASSIFICATION
CODES AND REGULATIONS.
12.83'
5. INSTALLER/CONTRACTOR TO
REVIEW& DESIGN PERCOLATION RATE <2 MINANCH
VERIFY ALL ELEVATIONS AND DETAILS
AND REPORT ANY DISCREPANCIES TO EFFLUENT LOADING RATE 0.74 GAL.1VAY1F72
DESIGNER PRIOR To coNsmucnoN OR
LEACHING AREA
ASSUME ALL RESPONSIBILITY,
(2)x(33.5'+ 12.83)(2) = 185 SF
6. INSTALLER/CONTRACTOR IS
33.5'x 12.83' =429 SF
RESPONSIBLE FOR MAINTAINING SAFE 614 SF x 0.74 =454 GP0
WORK AREA, VERIFYING ALL UTILITIES
AND NOTIFYING "DIG SAFE" USE(3)500 GALLON H-20 CHAMBERS WITH 41 STONE
(1-888-344-7233) 72 HOURS PRIOR TO AS DIAGRAMMED INA 33.5'X 12.83'X 2'CONFIGUR4 TION
(LINEAR LINEAR FEET)
Z ANY CHANGES TO OR DEVIATIONS FROM
THIS PLAN MUST BE APPROVED IN
RESERVE LEACHING CAPACITY
NIA
WRITING BY FLAHERTY ENVIRONMENTAL
SERVICES AND LOCAL BOARD OF
HEALTH.
8. FINISH COVER OVER COMPONENTS IS
NOT TO EXCEED 3'PER 310 CMR 15.000 (NTS)
UNLESS SHOWN PER PLAN
9. ALL ABANDONED SEPTIC SYSTEM
COMPONENTS TO BE PUMPED DRY AND
SOIL EVAL UA TION
FILLED WITH CLEAN SAND OR REMOVED
TESTHOLE#1 TPT-19-51
7ESTHOLE#2 TPT-19-51 OF
AND REPLACED WITH CLEAN SAND. Evaluator. David D.Flaherty Jr.,RS,REHS Evaluator. David D.Flaherty Jr.,RS,REHS
1 O.ALL COMPONENTS TO BE PROVIDED SE#2755 SE#2755
David Stanton,RS BOH Witness: David Stanton,RS
BOH Witness.
WITH WATERTIGHT ACCESS PORTS Date. June 18,2019
Date. June 18,2019
WITHIN 6"OF FINISH GRADE. F
11.ALL SEPTIC TANKS, DISTRIBUTION 211
BOXES AND PIPING TO BE INSTALLED TH-1 ELEV 60.01 TH-2 ELEV 60.0'
QtsTE�
WATERTIGHT. 0'-6- FILL 0.-6. FILL
NITAM
12.NO KNOWN WETLANDS OR WELLS
WITHIN 150 FEET OF PROPOSED
LEACHING.
P77
13.THIS IS NOT A CERTIFIED PLOT PLAN PERC
I
AND UNDER NO CIRCUMSTANCES IS THIS
PLAN TO BE USED FOR ZONING OR "I certify that on November 12,2W2,I have passed
the examInadon approved by the Department of
BUILDING PURPOSES. Environmental Profectlon and that the above
analysis
14.LOT IS SHOWN AS ASSESSOR'S MAP 209 f has been performed by me consIstant with the SITE AND SEWAGE PLAN FOR
LOT 9.
required traInIng expertise,and experience dedescribed8& 8 EXCA VA TZON, INC./
— In 3 10 CMR 15.018(2).
DA vzD HoL r(TODA Y R.E.)
15.LOCUS PROPERTY IS NOT LOCATED
WITHIN AN AQUIFER PROTECTION
6'-126' C MCS 25Y614 55 SACHEM DRIVE
6"-126" C MCS 2.5Y 614
CENTERVZLLE, MA
DISTRICT(ZONE II).
G.W.ELEV.IVIA
G.W.ELEV.MIA BOTTOM M-2ELEV. 50.0'1
BOTTOM TH-1 ELEV 49.5'
PAGE20F2 DATE.•612&2019
................................................................................................................................................................ .................. .................... ..................................................................................................................................... ................................................................................... .................................................... .................................................................................................................................................................................................................. ................................................................
y
DW 88 DESK
........... MASTERIL
h' CLOSET
/FP;Iv11LY v ��.. UTILITY �
- ROOM KITCHEN
i
qs
i
._J MASTER REF i`o
BEDROOM
10
Tffm
® HALF WALL HALF WALL
�.. ;
i i
,
LIVING
AREA
o
V'" v UP .. -
� � MASTER DIRA
11°� OFFICE/ BATH
STUDY DH �
GARAGE
\\/ owER A I I I 1
I I I
FARMER'S PORCH
1 I I 1
I I I 1
a s a a o o W42o o a
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