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0039 SEA MARSH ROAD - Health
39 Sea Marsh Road Centerville A = 227 126 Omr, II ford, NO. 1521/3 ORA 10% • s i I TOWN OF BARNSTABLE E C L6CATION 3� �� 9�S'f �/' SEWAGE #07610a' 3 VILLAGE C4�si+r/ r / ASSESSOR'S MAP & LOT 7` b INSTALLER'S NAME&PHONE NO. ����� C Doi FTiritt'o+J 89L SEPTIC TANK CAPACITY C— LEACHING FACIL=: ('type) J-ao CL C i�r a � (size) /3 NO.OF BEDROOMS 7 BUILDER OR W rt6V PERMUDATE: /e /G COMPLIANCE DATE: I � U Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �t 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 r�i qF L'ngiwvr.-���g Lef'T' E c G3- �y' Commonwealth of Massachusetts (e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �e 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is ,� MA 02632 6/15/20 required for every Centerville - 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 �51# i4U41 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6/15/20 Inspe Signatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 r c Commonwealth of Massachusetts �d lF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown 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 FIND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �m I� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owners Name information is required for every Centerville MA 02632 6/15/20 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts 113 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address P Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown 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. ❑ z 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 op Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v, 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been.introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts - (t� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owners Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Engineered plan on file at BOH Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry-system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection Form i- � p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u, 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial 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: To be pumped post inspection per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Original septic tank per age of the home, new D-box and chambers 2002 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appaers to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace-1/4" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown 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 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •u— 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 d-box is 2' below grade, cover raised to 6"of grade, no adverse conditions observed t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: _ 3 ❑ 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 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.): Chambers were video inspected and are damp at this time, top of chamber is 2'6" below grade, no indication of past hydraulic failure 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.): t6insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown 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 Forth:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �. ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t; 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Cityrrown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 TOWN OF BARNSTABLE EC SLOCATION •iE /47?IT 5 �J SEWAGE#'c70a; VILLAGE_Csi!�l�v/ �r // ASSESSOR'S MAP&LOT INSTAII ER'S NAME&PHONE N0. .T� „S'J�.ri e•> �Egg SEPTIC TANK CAPACPTY I,OOD C- LEACHING FAcmrrY: (type) Qy GG C ry 6— (size) /3�X NO.OF BEDROOMS BUILDER OR`C�:-�' PERMITDATE: /e /G COMPLIANCE DATE: 0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S� 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 Ir within 300 feet of bathing facility) Feet Furnished by F E'?"Z�'°�*'"�';g . �9 yi �fi l ? L�1 -7' I Commonwealth of Massachusetts ,o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 page. Citylrown 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: >120' 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: 2002 NGW 120" Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 2002 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 17'msl and nearby surface water at 1'msl You must describe how you established the high ground water elevation: See above 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 �'° Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Sea Marsh Rd. Property Address Drew Owner Owner's Name information is required for every Centerville MA 02632 6/15/20 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 I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 N D THE COMMON EAL H OF UETTS " FEE BOARD OF HEALTH (� 1GY I y O F Md=0WRa APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair A) Upgrade (*% ) Abandon ( ) - [:]Complete System ❑Individual Components 'Med ftr6l Road T&W +&t-ffo brew Location Owner's Name 2'Z'7 5 Sea.&42cin l d. C&&r,9 o2612 Map/Parcel# �/ Address /_0V0 Lot# Telephone# Installer's Name esign is Name atel 19 I�Z Address Address SDA TelepFondf#, Telephone# Type of Building: Ze-61 deAA t Lot Size 36 Sq.feet Dwelling—No.of Bedrooms y Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) //D gpd Calculated design flow_*6 gpd Design flow provi Pdu gpd Plan: Date 17//Y/02, Number of sheets Revision Date pI�AOFMgssq Title S � Description of Soil(s) 'b MIAIMEN Nm e d � LLIAM Soil Evaluator Form No. Name of Soil Evaluator -0-1.4 Grn,I X Date of Evalu ''o 83N < O DESCRIPTION OF REPAIRS OR ALTERATIONSSee- a4aLljd pia.-i r Sg/ Nv 4 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agre not to pl e s o emtion until a Certificate of Compliance has been issued by the Board of Health. Signed ate Inspection 77 FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 W)N , TH EF, .'114KON, �E*ALT OF MIA OM V E 'USETTS 'FEE 7 ..Z�T,7 BOARD OF HEALTH :@WAI OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair (X) Upgrade (� ) Abandon E]Complete System [-]Individual Components 3 95ip_4 Mgr- C� Road III! _1dAA) lAvdy hno6q Location i Owner's Name `3 5 Z_,,a a IM d 12 d: (f&Jtero///(1, 0 Z&3;.>- Map/Parcel# Address 0 Telephone# Installer's Name lesigner's Name -266 fil a /t 01'kA,*A- 114 (1215")l 14) Aj Add' Address -7 44�� 09-7,95_-661,96 Telepfiond# Telephone# Type of Building: PSI eA)-fla Lot Size 3j,7X Sq.feet Dwelling—No.of Bedrooms 14 Garbage Grinder Other—Type of Building No.of persons Showers Cafeteria Other fixtures Design Flow(min.required) #01M gpd Calculated design flow YYO gpd Design flow provided V53 gpd Plan: Date Y/07- Number of sheets Revision Date AAA Title S&Aj6i 4t 6 sno.Co Des of SOS) /5 o'k) Soil Evaluator Form No. Name of Soil Evaluator Brea,.)-tlird4t4 Date of Evaluati LLIA F f L) civil ai DESCRIPTION OF REPAIRS OR ALTERATIONS S,02 a4l; AO la.) No.32883 The undersigned agrees to install the above described Individual-Sewage Disposal System in accordance with the f TITLE 5 and further ag not to pl the ti until a Certificate of Compliance has been issued by the Board of Health. vcoi e s Iln a ra on unti Sign(ed f 7 /1 14 /AiDate AInspectiona VV FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ——————————— NO '3 COMMONWEALTH OF MAssACHUSETTS FE E EE I BOARD OF HEALTH CERTIFICATE OF COMPLIANCE ! Description of Work: M/I OC ndividual Component(s) Omplete System The undersigned hereb certify that the Sewage Disposal System;Constru9ted( ),Repaired(V)/Upgraded(V3'"Abandoned( by: at has been,installed in accordance with the isions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application N( __31ated Approved Design Flow_(gpd) Installer Designer: Inspector ��k"/ —Date 1)LI'do The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. �; �o� T E COMMONWEALTH OF MASSACHUSETTS FEE �O BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby grantedto Construct,( )'Re air ( pgrade Abandon an individual sewage disposal system at 3!e t_Ou, — y '06?!4�;; b�I_llzf as described in the Application for Disposal System Construction Permit No. dated Provi&M-"Construction sh 11 be c&plet-d within three years of the date of this p mit.Alli cal,' ditionsqnust be met. Date Board of Health FORM 2 - DSCP 'DE-P APPROVED FORM 5/96 FORM 1255 (R:EV 5/96) HOBBS&WARRENTM PUBLISHERS,- BOSTON TOWN OF BARNSTABLE LOCATION _ �9�s �� SEWAGE #,AlJOa A3 VILLAGE CA�s�✓! // ASSESSOR'S MAP & LOT ME INSTALLER'S NA &PHONE NO. �"���I�i�i C.GkYle rl,02 O X?Vk/k SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 1-00 6L G% r a �) (size) /3�X 3-?j',K,21 NO.OF BEDROOMS BUILDER OR —r / PERMITDATE: COMPLIANCE DATE:—�y 1 axla 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 is 01- -7 ' ( � L3— i I 10/10/2002 23:53 5087751096 PAGE 02 - Bic 15709 P:g 170 *87673 10-08-2002 & 08226a DEED R EST I. C WHEREAS, John Otis Drew and Anita J. McCarthy-Drew, of 39 Sea Marsh Road, Centerville, MA 02632, are the owners of the land, together with the buildings thereon, in Barnstable (Centerville), Barnstable County, Massachusetts, bounded and described as follows: Lot 26 on a plan of land entitled "'Riverview Landing' Subdivision Plan of Land in Centerville Barnstable, Mass. for Daniel C. Hostetter et al, dated April 9, 1976, Barnstable Survey Consultants, Inc., 411 Main Street, West Yarmouth, Mass.", which said plan is recorded at the Barnstable County Registry of Deeds in Plan Book 305, Page 42. See also Plan Book 305, Page 44, 46, also recorded at said Deeds. with an address of 39 Sea Marsh Road, Centerville, MA 02632, and hereinafter referred to as the property. WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to the Issuance of a disposal works construction permit for the upgrade of the soil absorption system at the property, requires the owners of the property to restrict the number of bedrooms in the house at the property, and to record with the Barnstable County Registry of Deeds a document evidencing such restriction. NOW THEREFORE, we, John Otis Drew and Anita J. McCarthy-Drew hereby agree with the Town of Barnstable Board of Health to restrict the number of bedrooms at the property to the four (4) bedrooms that currently exist; and hereby place the following restriction on the property: 1. The house located at 39 Sea Marsh Road, Centerville, MA, may have no more than four (4) bedrooms; and 2. This restriction shall be permanent, run with the land, and be binding upon all successors in title. For our title see deed from Anita J. McCarthy-Drew to John Otis Drew and Anita 10/10/2002 23:53 5087751096 PAGE 03 Bk 15709 Pg171 087673 J. McCarthy-Drew dated April 22, 1985 and recorded with Barnstable County Registry of Deeds in Book 4498, Page 035. Witness our hands and seals this day of October, 2002, �/z 9 /,** /L� __ J Otis Drew Anita J. M arthy-Drew COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, ss. October �r ,2002 Then personally appeared the above named and acknowledged the foreing instrument to be free act and deed, before me NOTARY PUBLIC MY COMMISSION EXPIRES: PATRICIA A.HALE Notary Public Cammon�YCelth of?r[assAchira4tle Mr Commission E * November 26,20D4 J Town of Barnstable Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. August 29, 2002 Mr. Brian Grady, R.S. G.A.F. Engineering, Inc. 266 Main Street Wareham, MA 02571 RE: 39 Sea Marsh Road, Centerville, A= 227-126 Dear Mr. Grady, You are granted several conditional variances on behalf of your clients, John and Anita Drew, to construct an onsite sewage disposal system at 39 Sea Marsh Road, Centerville. The variances granted are as follows: 310 CMR 15.211: The leaching facility will be located only two feet away from the property line, in lieu of the ten feet minimum separation distance required. 310 CMR 15.211: The leaching facility will be located only sixteen feet away from the foundation, in lieu of the twenty feet minimum separation distance required. 310 CMR 15.211: The leaching facility will be located only five feet away from the slab foundation, in lieu of the ten feet minimum separation distance required. PART Vill, SECTION 1.00: The leaching facility will be located 95 feet away from a vegetated wetland, in lieu of the 100 feet separation distance required. These variances are granted with the following conditions: (1) No more than four (4) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and Grady similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to four (4) bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (3) The septic system shall be installed in strict accordance with the engineered plans dated July 14, 2002, signed by the designing engineer July 15, 2002. (4) The condition of the existing septic tank shall be inspected for soundness and any signs of ex-filtration by the designing engineer at the time of construction. The inlet and outlet tees shall also be inspected at that time. (5) The designing engineer shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the submitted plans dated July 14, 2002, signed by the designing engineer July 15, 2002. These variances are granted because the physical constraints at the site severely restrict the location of the soil absorption system due to the proximity of the wetlands adjoining the property. It is the opinion of this Board that the proposed new soil absorption system is designed to meet the maximum feasible compliance standards contained within the State Environmental Code, Title V. Sinc ely yours Wayn Miller, M.D. Chair n - Gradyl ' July 16, 2002 Barnstable Board.of Health , 200 Main Street Hyannis,MA'02601. RE: Tile V Upgrade 39 Sea Marsh Road Centerville G.A:F.Job,,No..02=5533 •' DearMembers of the Board: On behalf of the applicant; we respectfully, request the following,variances � ' pursuanf'to 310 CMR 15,:405 These variances are necessary due to the lot size,; Af k location of,wetland,topography and other site constraints. 310 CMR.15.211 (setbacks)AW ■ System;shall be setback 10 feet:from property line. A 2-foot+setback.is provided to the street line: . ■ System shall be:setback 20 feet from cellar.wall' A 16-foot setback-is provided. System shall be setback, 104eet from slab foundation. ,A 546ot setback isprovided. < i1, 4 � . A variance is also requested to the;Town•of Barnstable 100-Fo6t,Setback regulation This regulation required systems be setback I00-feet from wetland. -4 A.95-foot setback is provided As designedAthe system is,approximately 10'to ` 12 Meetabove the water table., If you requir`e,any.additional information lease contact me directl .. . Sincerely, t G.A.F. Engineering, Inc 41;6- � - Brian R. Grady,R.S. WARER`AM'' MA � .,m Enclosure ' 0257 ii 508 295'6600 i FAX`508 295 6634 A „$ .Aar • ,. , ., - ,,, YASec1\WINW0RD\5500\5533=DREW.\TITLE V UPGRAD 7-16.d6c.' - 4`GAFENG@bAPECOD NET :c DATE: a U� NAP O� FEE: iARNsrABLE. MASS. i639. `0� REC. BY Town of Barnstable SCHED. DATE: A1,13A �Ov?— Board of Health 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Summer Kaufrn m,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION Property Address: 39 Sea Marsh Road Assessor's Map and Parcel Number: 227/126 Size of Lot: 30,73.6 Wetlands Within 300 Ft. Yes X Business Name: No Subdivision Name: River View Landing APPLICANT'S NAME: John and Anita Drew Phone.:_:"., 508=775-0476 _ Did the owner of the property authorise you to represent him or her? Yes ✓ d>Io """ PROPERTY OWNER'S NAiyIE CONTACT PERSON Name: J.ohri -an-a--Anita Drew Name: Brian Grad — G.A.F. Engineering, Inc. Address: 39 Sea Marsh Rd. , Centerville, MAAddress: 266 Main St. , Wareham, MA 02571 02632 Phone: 508-775-0470 Phone: 508-295-6600 VARIANCE FROM REGULATION(List Reg) REASON FOR VARLAINCE(May attach if more space needed) See attached plan See attached letter NATURE OF WORK: House Addition C]CCC❑❑ House Renovation ❑ Repair of Failed Septic System Checklist(to be completed by office staff-person receiving variance request application) _�— Four(4)copies of the completed variance request form ^/ Four(4)copies of engineered plan submitted(e.g.septic system.plans) ` Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restauuant',dtchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters mast be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals (same owaer/leasee only],outside dining variance renewals(same owner/leasee only],and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.FL REASON FOR DISAPPROVAL Wayne A.Miller,M.D. 4:\HEAI+TH\WPFILES\VARIRE4.D0C 07/25/2002 00:20 50137751096 PAGE 01 SKETCH/AREA TABLE ADDENDUM Flle No. 97-243 Property Address 39 Sea Marsh Road City Centerville State MA County Barnstable Zip Code 02632 Borrower John O.Drew&Anita McCarthy-Drew Lender/Client Cape Cod Cooperative Bank First Level Sec cr-id Level 1 Cr r - - - - I 50' I I I 6ect-aorn Fcrri Iv Roan 1 �, 1 1 I Bath Beci-ccm Deck �48• 42' Bath Ki taherl Di ri rig Room 1 9oth ® 1 I Bedrtovn I Li\.i rg Room l L�rt}y Fwer 1 50' Accrn 1 1 O' 22• Gage 22' 26' SCALE; 1 inch 18 feet AREA CALCULATIONS SUMMARY LIVING AREA CALCULATIONS Area Name of Area Size Total& Breakdown Subtotale GLA1 First FLoor 2100.00 2100.00 50.00 X 42.00 2100.00 GLA2 Second Floor 1125.00 1125.00 50.00 R 22.50 1125.00 POR Deck 4W.00 490.00 GAR Garage 572.00 572.00 TOTAL LIVABLE (rounded) 3225 3225 OAWS APPPAJSALS APGX SOMWARE 21 o-80e-aSee APX-e 100 Apse 1t roperty Location: 39 SEA MARSH ROAD MAP ID: 227/126/// ision ID.15914 Other ID: Bldg#: 1 Card 1 of 1 Print Date: 07/09/2002 10 �QrTrMUCTlONDETffi � v 771. > ,z' . a c?r, $ ement Ud. Ch. escrrptron Commercial Data Elements ty ype M Uape Cod Element r. Description 6 odel M Residential Heat&AC10 rade B Custom Grade Frame Type Baths/Plumbing, tones 1.5 1 1/2 Stories BAS ccupancy 0Ceiling/Wall 12 BMT 1 ooms/Prtns 50 xterior Wall 1 4 Wood Shingle %Common Wall 2 Wall Height bu oof Structure 3 able/Hip oof Cover 3 sph/F GIs/Cmp 2 5 nterior Wall 1 5 Drywall k r emen �o e escnptron actor FHS 2 nterior Floor 1 14 Carpet omp ex 4 BAS 3 2 12 Hardwood Floor Adj BMT nit Location seating Fuel 4 lectric leating Type 7 Elec Baseboard Number of Units C Type 1 None Number of Levels %Ownership 50 10 edroorns 4 4 Bedrooms athrooms Bathrooms 0 Full % .. otal Rooms Rooms nadj.Base Rate 60.00 Size Adj.Factor 0.88089 3ath Type Grade(Q)Index 1.31 2 GAR 2 itchen Style Adj.Base Rate 69.24 Bldg.Value New 290,947 26 Year Built 1983 ff.Year Built (A)1989 rml Physcl Dep 11 uncnlObslnc 0 Mu con Obslnc 0 Code I Description Percentage pecl.Cond.Code da lulu single Fam pecl Cond% 10 verall%Cond. 99 Deprec.Bldg Value 288,000 DR-OUMMMATU& YARD F BUILDING-EXTRA E,-4TURRSB o e Description UB Units Unit Price Yr. Dp Rt %Und Apr. Value tree ace , BFA Bsmt Fin-Aver B 800 15.00 1989 1 100 10,700 7417711) UB= SDIR]GIAR SSC IUIV Code Descnptron Living Area Uross Area NJ.Area Unit Cost Undeprec. Valite vrs , oor D , �39;£52 BMT Basement Area 0 2,300 460 13.85 31,850 FHS HalfStory 19190 1,700 1,190 48.47 82,396 GAR Attached Garage 0 572 200 24.21 13,848 WDK Wood Deck 0 520 52 6.92 3,600 25/2002 00:20 5087751096 PAGE 01 SKETCH/AREA TABLE ADDENDUM Flla No. 97-245 property Address 39 Sae Marsh Road Cliy Centerville State MA County Barnatable Zip Code 02632 Borrower John O.Drew&Anita McCarthy-Drew Lender/Client Cape Cod Cooperative Bank First Lever Seccnd Level 1 O' I so' i I i Be�aa1� Frnily Room I so' 1 Elath Bect-oern Deck �4B' 42' Bath ki tchcn Di 'rt3 Rccn1 I Sect crrtl 2 I Ek3Lh ® ( l I Elect-mrn I Li .irgR=m Lcund-y FoyQ 1 50' Rmom I 10, 22' Gag= 22' 25' SCALE; 1 inch = 18 feet AREA CALCULATIONS SUMMARY LIVING AREA CALCULATIONS Area Name of Area Size Totals Breakdown Subtotals GLA1 First FLoor 2100.00 2100.00 50.00 x 42.00 2100.00 GLA2 Second Floor 1125.00 1125.00 50.00 x 22.50 1125.00 FOR Deck 480.00 480.00 GAR Garage 572.00 572.00 TOTAL LIVABLE (rounded) 3225 3225 OAVIS APPRAISALS APGX 90FNVARE 210-BOa68W APX•!100 Apes H 9J7 9, 2�oa— all- r °FINE r Town of Barnstable P# JO 1, 2 6JI Department of Regulatory Services BAMSTABLE, + 2 O G , MAS& �� Public Health Division Date �jDlfo Mpt�� 200 Main Street,Hyannis MA 02601 Date Scheduled D Tune U` Fee Pd. AR6 ' Z�6 LOT Soil Suitability Assessment for Sew ge Disposal Performed By: Witnessed By: try i sa LIE t L4[ 9 Ir �;�, rc�L 4� yr,Lt .1,' � �/,,/ n..m•' ,i.t li,d:'il �' ,ii1rfF !., 'I ,!....... Ni. , . Location Address �c Owner's Name aim p r�,e W 3q Se vv �, P Address 306, �t?:.t ✓,%Lf'SLZ Q.L1 62n�¢rv,'lle Cep +Orurlft Assessor's Map/Parcel: , / Engineer's Name G•4F�'uet u e.e JY4 v NEW CONSTRUCTION REPAIR Telephone# Land Use Re,,51C4 ey +z Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area 100 ft Drinking Water Well ^ ft Drainage Way /00 ft Property Line _f$r ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) �q �e r:5 R Parent material(geologic) D 4rw A s 4 Depth to Bedrock —� Depth to Groundwater: Standing Water in ZU Hole1 IV(7A(: E I¢T l Weeping from Pit Face /Uti1r-6 /I—T/20 6 / Estimated Seasonal High Groundwater > Zo o t!,.nh,'_'� t =..J L...�I :...:!... Method Used: Depth Observed standing in obs.hole: /VOMC A-T"/La` in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ � .164� drtYkb n,4,k Lr 5 ..ftnll r1:k:.rd. d,.n.:,,,d>i.'.i. Observation Hole# J— Time at 9" Depth of Pere L/O'J v Time at 6" Start Pre-soak Time® J0 1/7 Time(9"-6") End Pre-soak Rate Min./Inch Z Site Suitability Assessment: Site Passed t� Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back--------- Q:HEALTH/W P/PERCFORM ! '!!�r r i LiildJ { �NJ,LjIR��nY IN WIN, \������ ���J- r�r 1 fj 9l �Y��4�r%�s �........ .�'I...,:. -:.! .. ... .. �~.4] r4r_f...-._ .W,:r ,.�. ......r .:....5 _n u, r. Depth, Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) `(USDA) (Munsell) Mottling Structure,Stones,Boulders. Consistency.%Gravel 16 3 2 is z (Zu Scw8 2. .6. .t,,. Depth from Soil Horizon Soil Texture Soil Co, Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. [Consistency,%Gravel .. IV .-W, Ni14 ... ' :'�rG °t 5�.9= li. ,.•:?.! .�!... .,!.�l' a 4 I,.. .' ? .f.�..:... ....5d..._2.4���.:[consistency, Deptli from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. %Gravel 0 # Y s}.,.tFo i,.,. t Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. Consistency,%Gravel Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No— Yes Within 100 year flood boundary No X Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? S If not,what is the depth of naturally occurring ervious material? f C)li Certification I+certify that on l (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the'required training,expertise and experience described in 310 CMR 15.017. Signature Date 7 D L Q:HEAt,TH/WP/PERCFORM i THE COMMONWEALTH OF MASSACHusETTS 7 BOARD F HEALTH c,'Wq..........OF..... �+ .�3. ---------------------------------- Appliration for Disposal Marks Tonstrnrtiun rrrmit Application is hereby made for a Permit to Construct (N or Repair ( ) an I dividual Sewage Disposal Sy at: �� ...... �._ .---M ... �. r... !_ .-.------------------ _ _.... affpLrrtion ,/��r�s. :Y .`I/...._..._ L���. /.:. i.! ... Lot No �... .»... B / Address W ' ................... ........ ... ........... .7'ZZ.[� .................... ......... -----...---.......... ......_................-•----••---... Installer Address Type of Buildin� Size Lot.-'���Mi(-sq. feet U Dwelling= .o. of Bedrooms................... ---..---..-.-----Expansion Attic 4_)k::) Garbage Grinder (� 04 �Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures W Design Flow......................� b?...........gallons per person day. Total daAy flow............................................ long., WSeptic Tank—Liquid capacity-l gallons Length..... Width..gf....A... Diameter................ Depth......." x Disposal Trench—Np..................... Width... .1............. Total Length...... ._...... Total leaching area..................sq. ft. 3 Seepage Pit No..................... D' eter........ .-.---. Depth below inlet......... Total leaching area.;X, ..sq. ft. Z Other Distribution box (b j Dosing nk 0.4 Percolation Test Resylts2 Performed by..... ........... : .JIWJ,4.. Date----. -`..�.`-.....--3---14 1.4 Test Pit No. 1..........:.....minutes per inch Depth of Test Pit...... �..�.._.. Depth to ground water..Ov'��...... 44 Test Pit No. 2................minutes per inch Depth of Test Pit........�.�....... Depth to ground water....._� � ....................... .. ...... �..... ... .. O ............... Description of Soil--- ............/ . ... J14.-....� 1.�._...... - ..........................................._..... W ............................................................. .....•......................................................................•----------.......--•-••----•------------•------------.........------...........................................-----....... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................••------.......................................................................................--•-----................•-•-•---.........---.........................--------•---•... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i 111M 5 of the State Sanitary Code he undersign further agrees not to place the system in operation until a Certificate of Compliance has b ss by the b d lth. Signed... .-•-•-•---•-•-.. .. ...... . ......-� ......../....Date. .....__... Application'Approved By........... .. /`� �st.. ._.. 1,1 � - ........ .......... .. Date Application Disapproved for the following reasons:-----••-•----•...... ..... ...................................... ...............0.........................-- ........................ ................................... ........................................... ......_................................................................................ r Date PermitNo..................................................._.... Issued..................................................... Date < < A No. :3 f � �-._• Fss_..... THE COMMONWEALTH OF MASSACHUSETTS BOARD r y �j F ,� ?HEALTH r� LE..........OF.......�! h'.� a1:�.'�::E................................. Appliratiun for Disposal Works Tonstrurtiun j1rrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an I dividual Sewage Disposal Sy at: 7, 2-6-fZ6- M 12�lv PeV_ C_0eeX�)_e- Ap Ja/�l C' —®wteaP Addr W ,� ••...........................................Installer............................_..........- -----.....------...-------...------•-•--...—Address...................._..........»....».... aj Type of Buildin g .. Size Lot. J�- ,. 3!�.Sq. feet U Dwelling1Vo. of Bedrooms................... ___.__....._..__Expansion Attic ( Garbage Grinder O `4 Other—Type e of Building No. of persons............................ Showers A, YP g ..................••------•- P ( ) — Cafeteria ( ) 04 Other fixtures ... ,--.............................................................................................................................................. WDesign Flow....................... ..:............gallons per person perj day. Total daily flow......a: c).....................gallons,. WSeptic Tank—Liquid capacity.K��.gallons Length.....:76n. Width..V..:��_.. Diameter................ Depth..'.. .. Disposal Trench—Np. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No......../.....-...... D' eter........ Depth below inlet............. Total leaching area.A� ..sq. ft. Z Other Distribution box (� Dosing ink ( ){ , Percolation Test Resykts Performed by..... a�_. _. ..` ....._......` ..�;,,,{t �c1. Date..... ............�-�...... _..... .1 a c -- Test Pit No. 1................minutes per inch Depth of Test Pit..... .IA......... Depth to ground water..6v. �...... GT4 Test Pit No. 2................minutes per inch Depth of Test Pit........ ..... Depth to ground water......t:.......�:._... f D Description of Soil....."' f t�''1' �`�A�. — j + �a.,�j�. .................. •c..... �' - �l - . --.. �. W -------------------- ------------------------------------- .- UNature of Repairs or Alterations—Answer when applicable.......................... .................................................................... .............................................................-.....................................................................................................................•.................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code he undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ss by the b9perd lth. M Signed... . .. _.......-! ..... ..:... •....... •----•- A Application Approved B .,�.- : j� .......................... PP PP y..... .... .......� _... .... .tom, f. = 1 �1� aw. " ate Application Disapproved for the following reasons--------- ...........1---- .............................................................................»..» ..........................0....-- ........_. ....................................................................................... Date » PermitNo...................................................»..:. Issued...................----------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............................................................... ................. fUrtif irate of Tomplianrr . THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ,( ) or Repaired ( ) by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_».-»-.» r at_............n',.,oZ.......�2..r:.............. _ ---..1V/InI., �stalle'_ 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.... ........•.. dated................................................ . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SA�FACTORY. DATE........................................... �`'�--�°�'-................ Inspector........ .G .. = =------------••---------•--••----.....--•-•-•---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No... t�. ......OF................................................................................•--• Fa>s......Y..t......... Disposal Varks Tonstrurtiott thrmit Permissionis hereby granted..................... c-. ..............................................................................---....---.....»»»» to Construct ( � or Repair ( ) an Individual Sewage Disposal System atNo......... ..�� $'.r r .........4,ref:. ?.........A-e,�............. ..................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated....................0..................... ....................................................... DATE. Board of Health FORM C-1255 CITY & TOWN FORMS, INC. 369-9708 LOCATION � l SEWAGE PERMIT NO. VILLAGE al Ile- 1 N S 7 A LLER'S NAME i ADDRESS i� R U I L D E R OR OWNER DATE PERMIT ISSUED y oDAT E COMPLIANCE ISSUED M 1-14 s �'�_ HA rzsk rya AP;A "VIA IA J7 I Al Is If TO Y;7/, '-A=w TAwy IFY4 rIA15 Fixe—� 4. V kiv N'V Ko L "To Yz' VjAe,',H��v 150TT= V,11 V-4.71FIlL At IL L-- /B L- �.3 A,) ri;;�41- 6 Z-AAl KJ`7T ilk Te"s 4-2- 5 (s- Q cap 2, >�� ►.� 1 j t.} ,��,�' 'x, ., ¢ f. , , 4 k %li il�)434 RA TP th, d7 , K PROVIDE PRECAST CONCRETE EXTENSION 5" DIA. OUTLET(S) FINISH GRADE OVER CHAMBERS GENERAL NOTES TOP OF FOUNDATION RISER WITH CONCRETE CO I--- COVER TO WITHIN REMOVABLE COVER 100" ---- ELEV.= - 6" OF FINISH GRADE WHEN NECESSARY. 4 PVC FROM FINISH GRADE OVER D-BOX= I o p 2" LAYER OF 1/8" FINISH GRADE @ FND. EL.=^�_ _ FINISH GRADE OVER TANK EL.= ^t D-BOX ®®� ® ®®®® ®�®®55EI ®® QOo W ED DOUBLE ®�® ®®® p Op . WASHED STONE 1 . UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION 20 MIN. ACCESS COVERMETHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE (TYPICAL FOR 3} 36"MAX, 36"MAX. pop ®�®®®®®®® ®®®� ®®® ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES. 3/4„ TO 1 1/2" p pp O Op DOUBLE WASHED STONE 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD 4 C.I. OR t PROVIDE WATERTIGHT 102 OF HEALTH AND THE DESIGN ENGINEER. _ 6 3 3" DROP MIN. 3 9 JOINTS (TYP.) :' ! 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL SCHEDULE 40 PVC 1O„ 4" PVC IN FROM —•-• BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED. 14» _ _ .. ._ SEPTIC TANK 4" PVC OUT TO — ACHING FACILITY PROFILE OF CHAMBERS — TYPICAL FOR � CHAMBERS 11 -- • LE 4. 4" SCHEDULE 40 PVC PERFORATED PVC PIPE SHALL BE USED L 32" MAX. 62" INSIDE LEACHING TRENCHES OR LEACHING FIELDS. e_,..- "�' __.. 5. SLOPE ALL SOLID PIPE AT 1 .0% MINIMUM. SAS BAFFLE 6 CRUSHED STONE o pp 1 IN. OVER MECHANICALLY p O ' ® p0� 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. Ik q 6XI "I t - COMPACTED BASE 33" ®®®®® O wl,� 147N. GGN I FIB ®®��� 24" 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED a" k ��fioN — T DISTRIBUTION BOX O O ®®®®® PRIOR TO BACKFILLING WHEN SYSTEM IS NEARLY COMPLETE AND TO INSTALLED ON A LEVEL STABLE Oa p� READY FOR INSPECTION. SYSTEM IS NOT TO BE BACKFILLED BASE. FIRST TWO FEET OF OUTLET O Op WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF .HEALTH PIPES TO BE LAID LEVEL. I GALLON CONCRETE SEPTIC TANK ---�I � AND DESIGN ENGINEER. I CROSS SECTION VIEW LENGTH WIDTH DEPTH GROUND WATER ELEVATION _-- - MIN. 8. ELEVATIONS BASED ON��I_�I TANK SHALL BE INSTALLED ON A LEVEL STABLE BASE NOTE: CHAMBER TO BE A 500 CROSS SECTION OF CHAMBERS �.,... 1G.} DISTRIBUTION BOX . DETAIL- GALLON DRYWELL OR M RS DETAIL 9• CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO SEPTIC TANK PROFILE CHAMBERS B E CONSTRUCTION THROUGH DIG-SAFE AND ANY OTHER APPLICABLE NOT TO SCALE NOT TO SCALE APPROVED EQUAL NOT TO SCALE AGENCIES. REPORT ANY DISCREPANCIES TO THE DESIGN ENGINEER. 10. NON-SHRINK GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR TEST PIT DATA LEAVE ALL CONCRETE STRUCTURES IN ORDER TO PROVIDE WATER TIGHT SEALS. lack 1-10 ', .�. .r, W 4 �o r • � INSPECTOR: I�Ik�LI t, T'f'A ;i'"�"l',�t .I DATE: f., 1 1 . ALL TANKS SHALL BE WATERTIGHT TROUGH MANUFACTURERS SPECIFICATIONS as e..,• ° OR APPLICATION OF ASPHALT OR SYNTHETIC POLYMER SEALER. SOIL EVALUATOR: ._L*KIAfsJ �'I,61i' CERT. #: rox 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS Iss �0 I`o°' 3 TEST PIT #: I TEST PIT #: TEST PIT #: LOCATED UNDER PAVEMENT, DRIVES OR TRAVELLED WAYS IN WHICH 1 1r+1 CASE THEY SHALL WITHSTAND H-20 LOADING. „ Gq © 96.o ,, �.�: e�k ELEV TOP = ELEV TOP = ELEV TOP = fad 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND so p,, • ELEV WATER = ELEV WATER = ELEV WATER = M�,.! ��� � ,•,, a 'b,9 ov.aa,o•.,. FINES. . •aw ( (" I 1°• � ---�, �`'p-- PERC RATE = ItitIN/IN PERC RATE = MIN/IN PERC RATE _ MIN/IN 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND ,i Ir UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES l.1n,7�wa.aw�„r`�l V I d7. 1''�I �. I� EL�M • ( t Ma�'' , J .,9 Vh-.LID .Ht rF.w. %-.ri DEPTH OF PERC= . DEPTH OF PERC= DEPTH OF PERC= OF LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN F s''�•• °'T°"` COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN TEXTURAL CLASS TEXTURAL CLASS TEXTURAL CLASS o.❑o� - ACCORDANCE WITH 310 CMR 15.255(3). 21 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES © w�. ' ' •• 14G FOUND IN SITE CONDITIONS FROM THOSE SHOWN PRIOR TO y I2L ® '.°'.� O�1 '757, CONTINUATION OF WORK. IZ7 2vt ® Lol.c IL• 16. PROPOSED PROJECT IS LOCATED WITHIN: '^� ® ASSESSORS MAP .� :_e- - --_. ... ZONING DISTRICT --- - BUILDING SETBACKS F: ft. S: ft. R: ft. "= / r -' �`` i 11 FEMA FLOOD ZONE �ELEVATION I AS SHOWN ON COMMUNITY PANEL # S50 t _ 17. OWNER OF RECORD: ADDRESS: OC _, DESIGN DATA LEGEND mz -_. '. NUMBER OF BEDROOMS + 100 EXISTING CONTOURS �'�- NUMBER OF PERSONS �--�?��--- PROPOSED CONTOURS G GAS LINE u,r�I�I iG- ViAK DESIGN FLOW Ilf GAL/DAY/BEDROOM E&T ELECTRIC/TELEPHONE LINE �j 5rTVE � /2- TOTAL DESIGN FLOW G L/D w WATER LINE -AW I<: �` r ��-' -il r 7 GATEiA FAk_,1 NI " ' 4 SOLID SCHEDULE-40 PVC PIPE SEPTIC TANK: -- -- --- -- 4" PERFORATED SCHEDULE 40 PVC PIPE / _ :� ----— �--�------- LIMITS OF OVERDIG G L. X 2009� PTI TANK.LSMIN�5IGN 5 SIZE PERACITY REGS LIMITS OF WETLANDS USE GALLON SE C ( ) O WELL LOCATION / � TEST PIT LOCATION L� O \ \ O O SEPTIC TANK ` / `�^ LEACHING TRENCH: o DISTRIBUTION BOX ,C � _ w �'`,r- SIDEWALL CAPACITY EROSION CONTROL 2 X LI' (LENGTH + WIDTH) X (DEPTH)= I SQ.FT. ft �:r r. lr � L-I �j 9�j 2 I d SQ.FT. X AL SQ.F`T.= GAL. LEACHING/DAY % j BOTTOM CAPACITY (LENGTH) X I � (WIDTH)- � 5Q.FT. J gSQ.FT. X a,7 GAL SQ.FT.= ?� GAL LEACHING/DAY xII ItiI �; . _.... __- r.I5)14A A-r07 AW n5 --'�17 s r 1 ., TOTALS: � JC"� TOTAL NUMBER OF CHAMBERS -- ? _ r�,r -e_ ,1AF fi ( _ G .l �I Ki '1�f M _:. I�'�'' 1 I 1_ ( lfi�l[. 'r G.i'L - 1 TOTAL NUMBER OF TRENCHES FCC~ TOTAL LEACHING AREA SQ.FT. k I ; N I'" eiX 1.= .1 REV. DATE BY APP'D, DESCRIPTION - TOTAL LEACHING CAPACITY GAL./DAY r� ,v ''�- 5, , �l r � " U ►�I "' APPROVED BY: SEWAGE DISPOSAL SYSTEM DESIGN � f _._._ PREPARED FOR - _. -„_ T I ''� """' RESERVED FOR BOARD OF HEALTH USE q OH Ki ©c AT LOCATED D ST , NAIAt �a ✓ I I V t Y fiM I->A1.�, fir, �A!K1 �I_� APPROVED BY. a, A_V I P� I C'U ,- 0 �- 1)9 NI � �C� ,� I D ' � � ,,, ' SCALE. DATE: IU LY 1� , 1 fU I rev 17 "'INEE INC* f5`5__ r_�rrw_'K liv rrr;;�- rF,40H 15 T A 0 A- K G Fo ENKU K NU l vI V5 I PROFESSIONAL ENGINEERS & .AND SURVEYORS SI TE PLAN 266 MAIN STREET - WAREHAM, MA 02571 (508)-- 5-6600 PLAN SCALE: 1" eY: cxcv: