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HomeMy WebLinkAbout0121 SETH PARKER ROAD - Health 21"�eth Parker Road Centerville P A = 202 193 J�aECVClfp�o UPC 12543 No. 53LOR ,o+�STCOHSJ�`o- HASTINGS, MN TOWN OF BARNSTABLE LOCATI09:1• r Ve C EWAGE Ud VILLAGE A9 ��y c ��e ASSESSOR'S MAP&PARCEL Q INSTALLER'S NAME&PHONE NO �1���19 3 C �a'�9 L SEPTIC TANK CAPACITY lo f V�1 I ,�u Use 1600 9,4/ LEACHING FACILITY.(type) 55/ C �� A r YjE c(Size) NO.OF BEDROOMS V OWNER -PERMIT DATE: 1v COMPLIANCE DATE: 5 /a- ( 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 leachin faci'ty) Feet FURNISHED BY fj� r iV Q 1 �NrI A - � A-�= ` �� (� = '76 fy .� -3 3'�C 3 �_Jo-� No. p Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Apphto.tlon for Misposal *pstrm ConstrULtlon 3dErm t Application for a Permit to Construct( ) Repair kC) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. )3 S -jo/)e -� Owner's Name,Address,and Tel.No. "�$ cla0_ 3G9 fG C�vC1• .c�= AlIx t is� � s•Ker Rd Assessor'sMap/Parcel �� /c�� �llvl. MA0�3a ��_��_��SS/ Installer's Name,Address,and Tel.No. gtfd 70 t - 1?399 Designer's Name,Address,and Tel.No. 626-349, VS�4'1 L�rkolt�'C �Cons��r l�'cr.�irx• Pv 6x�c,c/ c» in��r'! ,�rz• fib, ak93g ills, v O�lo� Type of Building: I �j Dwelling No.of Bedrooms `� Lot Size �Sa6b ,9 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1�3cj gpd Design flow provided 3 V9 gpd Plan Date /�t a0�5 Number of sheets / Revision Date n Title-1 i1 +� O x. ��/ ,afApr Ce_ 1. 7)T26C1lrll� �114 Size of Septic Tank eY,1 +-? 000 Type of S.A.S. p6aac41 &M" 616 X 19,'93I Description of Soil CPAs- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment and t to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed ✓" Date `T Application Approved by. Date Application Disapproved by Date for the following reasons Permit No. t&d 0® Date Issued (Q No. AD i O / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplicati01l for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 31 S � Pa f I1)er Owner's Name,Address,and TehrN�o'. pF �aG_ 3Co�7 x,�a/a Nl 13 ,5" dKer PU Assessor'sMap/Parcel �'�U �� a Installer's Name,Address,and Tel.No. 6bq-7 r7 I . 9 3q9 Designer's Name,Address,and Tel.No.6-Z6;3e • ( rEolc�-t _ins!r�c �'cnt Po•aK,)C / cy� �,��neerl ,i�x. lib, /3x 937 Type of Building: 1 Dwelling No.of Bedrooms 3 Lot Size j sq.ft. Garbage Grinder( ) Other Type of Building N o.of Persons Showers YP g ( ) Cafetena( � i Other Fixtures Design Flow(min.required) ,33U gpd Design flow provided 13 V 9 F gpd Plan Date a4,gM�o ( 5 Number of sheets / Revision Date y Title,iJ 5 ccSd7 P IL /8( f fLf/���) n- k-tt1iv ,C14 Size of Septic Tank Type of S.A.S. qhow Description of Soil�� '� y Nature of Repairs or Alterations(Answer when applicable) i I' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmenta Eo`de and nZot to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed - " Date ? Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ')d j -ro a� Date Issued t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(All Upgraded( ) Abandoned( )by c�r��.` � .Y,< -f ,E ��1 r;r at 131 �� 4�� �s� u' p f- has been constructed in accordance - J with the provisions of Title 5 and the{for Disposal System Construction Permit No.� (/n�o' )dated / Installers �� nnS"l lac Y Sq^� Designer y( J(11Y1(� In � 1 #bedrooms Approved design flow 3 3�_ gpd The issuance of this ermit shall not be construed as a guarantee that the system wil Ztio as designed. Date i, Inspector / --------------------------------------------------------------------------------------------------------------------------------------- No ( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction 3pPrmit Permission is hereby granted to Construct( ) Repair( I/< Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. ` f c Date l( Approved by AN-20-2016 02:52 From: To:15087906304 Pa9e:1,11 FROM : FAX NO. May 21 2010 02:56PM P1 79-1t og Barnstable r Regulatory,t y, Sera. i a Thorp m l0 cKeSIM,DirscfO Wig: �08462-464 Lius �llla 'a'y�cspre - .�tFIriti, c� ai , D�1_.,....Affinsar'" 17o �. tr�Y➢�aro �O�r-- /D � �I� �D�aA�;ei�ro �JOva � r��►9� ��y � -- — . Address: l& — ILEon �(o - :_ah _II+tss a.s5 �d a pe�mitto i_i. s11 a ( a<fe) /� culst�ew) U PA7 A a..- _- based aR i drnign&BW. ,try 9eg�spste�.at ' .��.._. . . �,�►�, p �,,.�,�� .._ wed., ,. �,'��.!S _.,.� - • I tJ i t septtiF sy :m i efer► u'cd�1i �wsg instsU.ed srah aati�3-Y s"M'dlug to the deli +, Iur nayincltir3�'.u�.inor tezoved ohfmgea such, 1�fe1a1 rc.Lc►catlo�a '�� di stribra! au bor.andltrr 8,P tc tarp.. _ r cart► y fir•tl scoc system nfetm,,ed aboVb•+S-8 uL��tal��d with.r,40Z oh s (i-e. ;ieateT fha�to,Iat::xaJ,relccati m of the SAS or any-y�ebcRl ieIOWLliclt a any coma neat of.thP:;sprit: }bud iu acct�Tduuc� twi�1�,Stachc 1 Loeamk;gulM6011a. I Levi iai�ox 0ear6'60 - c)�si�nex to fellr�ur. ,H OF 44 Vic+, DANIELCIVIL A. OJALA �(nvlaaller's 5:�. tuee No. 48502 ssiONAL G�`G �(X rin�i�t amr e) � � � ua�7 No. -20 -u5j / V� l O S Fee � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitatlon for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair X. Upgrade( ) Abandon( ) ❑Complete System 0 Individual Components X Location Address or Lot No. )a i S cTH 'P9 Z41t JeD ner's Name,Address,and Tel.No. x Assessor's Map/Parcel 0 2. SSG H� �/INIt 5-19Gr't( J_U'(20 A-) ,ijVe s Addr d Tel f C Designer's Name,Address,and Tel.No. 721 717$`39q-1 a9 'Av ;�� x S �1f�N g NLs , l2�ttc/aS Type of Building: 3 ff Yf- S Dwelling No.of Bedrooms 3 Lot Size /� 0 U 0 sq.ft. Garbage Grinder( ) Other Type of Building W)uwd No.of Persons Showers( ) Cafeteria( ) Other Fixtures ? Design Flow(min.required) > 3 U gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title SLr jfi►G S tf SM A QfPAiR. Abu Size of Septic Tank J60D &IL(c)Qsr), TypeofS.A.S. ADS Agc v C/jfimi?,A f=1LrtD Description of Soil AAD who rb 4 L)j&<Y Nature of Repairs or Alterations(Answer when applicable) 1)(C 1 X/ST)N(_ t6bn &A/c" $ rie T!r N)e tk46gr12 r-AAcN r leLO Date last inspected: Agreement: The undersigned agrees to ensure the construction and ma.imen anc o e afore described on-site sewage disposal system in accordance with the provisions of T*t10 5 of1h—e n it Code a n o place the system i ion until a Certificate f Compliance has been issued by th _ �- ed�---` Date Application Approved by —^ Date Application Disapproved by Date for the following reasons Permit No. 6 Date Issued L/ in` . � � � �• �s ., ---- ` s � :W 14 —yob ss Fee i ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH`DIVISION - TOWN O.F`�BARNSTABLE, MASSACHUSETTS Yes t 01pplicatiowfok Disposal 6pstrui Construction Permit Application for a Permit to Construct( ) Repair x Upgrade( ) Abandon( ) ❑Complete System T:1 Individual Components -Location Address or Lot No. Q 2/ StTN PAIY4A RD Arner's Name;Address,andjb.No. X Assessor'sMap/Parcel Q D 2 ! A� EvrSGHE 15AI)X 51—A4r,( J-wz'D t- ' I2staller's�y e�Addre s and Tel.N '7'� Designer's Name,Address,and Tel.No. 78/ 7'7$-31q j �►�' 7`fa� /v " ac -.—�v x -r�Prig n, R N �5 n�, 12e►t</R s ,d tl�r 0 ? y Ty e of Building 5 Dwelling No.of Bedrooms Lot Size s 000 sq.ft. Garbage Grinder( ). Other Type of Building gES 14i rjd No.of Persons Showers( ) Cafeteria( ) _ ` Other Fixtures 'T ~ ` Design Flow(min.required), 3 3�U gpd Design flow provided ?, Z, gpd Plan Date 10114' l q Number of sheets' Revision Date Title �EPiIG Sktr�M '�RE(»/11� �IA,u �\ Size of Septic Tank ()0,0 F#L l/Ek►T\1r.4,I Type of S.A.S. ADS AgL -Tt 9C F) Description of Soil D)U„/1 ?--0 `60 i tz SE_!A y— Nature of Repairs or Alterations(Answer when applicable) LqC t X/S1-INC fbb1) a fil taw St(-Ve Th ry) Am AReV Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance o e afore described on-site sewage disposal system in accordance with the provision%t0%111. itle>5-of the Eimire ental Code a o o place the system i olLeration until a Certificate of Compliance has been issued board of r3ealt _ �ig_ned Date Application Approved by —^ Date 1 U "�(-(`1 -1 Application Disapproved by ' Date for the following reasons ) Permit No. d 6 Date Issued l0 --------------------------------------------- ---------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS :. Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired) Upgraded( ) Abandoned( )by �( at 12-l ttlii giubti If has been constructed in accordance _C with the provisions of Title 5 and the for Disposal System Construction Permit No.OG/�_t(03 dated �G `4— (V .I Installer Designer 2 _ #bedrooms Approved design flo J S �--- gpd 1 The issuance of this pe' it shall not be construed as a guarantee that the system will do as designed. t Date ` 2 Inspector / ---------------- ------- -------------------------------------------------------------- -------------------------------.-------- No. P01 "l —40 Fee THE COMMONWEALTH OF MASSACHUSETTS •PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS ' Disposal *pstem Construction 3pPrm t Permission is hereby granted to Construct( ) Repair( / Upgrade( ) Abandon( ) X System located at I)L I SETP ?AJf?4R IZ IZI) 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 co feted within three years of the date of this permit Date'_t IP.�) �� 1 (t' Approved by Town of Barnstable Regulatory Services Richard V. Scali,Interim Director WANgrABM Public Health Division 1639. Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 01 Office: 508-862-4644 r, Fax: 508-790-6304 Installer&Designer Certification Form c Date: �5 Sewage Permit#a° Tr-r Assessor's Map arcel l Designer: 4&Ae A3 Installer: # ro 10 cA��o 0 ►3 Address: 1 1 r Address: q� " r On G� / �i(9 S 6 f/� issued a permit to install a (d te) �[ (installer) septic system at / i<U � �' based on a design drawn by y datedle (designer) l'/"I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils t; were found satisfactory. _ li I certify that the septic system referenced above was installed with major changes esi.e. (g greater than 10' lateral 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. Strip out(if required was inspected and the soils were found satisfactory. I certify that the sy tern referenced above was constructe ance with the terms the E rova et (if applicable) ISP&TrioFM,�s^ Q STEpflEN u B, m is Sign tune) ^'_LsOlv I � �o• 111;}, SG�S7LR� /�V 9N/TARI QA (Desi ner's Signature) (Affix Desi 1 tamp 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. Q:\Septic\Designer Certification Form Rev 8-14-13.doc ' �4 THE MOST ADVANCED NAME IN DRAINAGE SYSTEMS Alternative Soil Absorption Systems Acknowledgement Form This form is intended to ensure that the Owner is fully aware of all requirements of the Alternative Soil Absorption System as required by the Standard Conditions for Alternative Soil Absorption Systems with General Use Certification. Department of Environmental Protection Approval 1. A copy of the Standard Conditions for Alternative Soil Absorption Systems with General Use Certification Chamber Approval has been provided to the owner. 2. General Use Approval for the BioDiffuser/ARC Chamber Systems. I certify that I have been informed of all requirements of the I/A technology system proposed for my property. Signatures Date i!J 3 Owner(s) ADVANCED DRAINAGE SYSTEMS, INC. 4640 TRUEMEN BOULEVARD, HILLIARD, OH 43026 TEL: 614 / 658-0050 800 / 733-7473 ~ Town of Barnstable P# ' Department of Regulatory Services : .,rtrt Public Health Division Date J 763g r 260 Main Street,Hyannis MA 02601 rEn neat A , Date Scheduled y J f ! Time /. Fee Pd. Sail Suitability Assessmentfor Se e Ibis os , V Performed By: Witnessed By: i LOCATION& GENERAL INFORMATION Location Address i 5CT14 f Il 2leEg 91) Owner's Name PEUTSG 46_ 13ytV K Address ST�L+ C Td�Q p Assessors Map/Parcel: !-7 / J Z Engineer's Name S'Tj-Pm j 6) Nr1:�b,.-) ,f NEW CONSTRUCi'ION REPAIR �_ Telephone#(??1� 'F'7E/ Land Use Slopes Surface Stones IU U Distances from: Open Water Body >j D D ft Possible Wet Area 7l I Q b tt Drinking Water Well 1 V b ft Drainage Way >f o O ft Property Line O ft Other ft § TCII:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) ELL, lay �y2 L. CN xm aTcsT PI T 2 0 TEST PIT 1 M ku DE K 5 �P 5 C-T H Parent material(geologic) w�r1�1/}� N Depth to sedrock N! A Depth to Groundwater. Standing Water in Hole:_> 'a Weeping from Pit Nee N O Estimated Seasonal High Groundwater G ' 2 �/� M y 1[.1 wl•) DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: d k t M Q PN l G FG9ruAVr Depth Observed standing in obs.hole: e I A R 1 -(u, Depth to sell mottles: In. Depth to weeping from side of obs.hole: I�° _ __ _ in. ©roundwater Adjustment fr. Index,Well# Reading Datc: -hidex Well level Adj.factor Adj.Groundwater Level I'EItCOI,ATION TEST Date`� Thne Observation Hole# Time at h" Depth of Perc J.a-54 .. Time at G" Start Pre-soak Time @ /I /Z 3 ,1�1 Time(9"-6") End Pre-soak. Rate Min./Inch M i n' I wGlf Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conseli'vation Division at least one(1) week prior to beginning. Q:\SEPTICIPERCFORM.DOC I DEEROESERVATION HOLE LOG Mole# f Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) Soil (Munsell) Mottling (Structure,Stones,Boulders. onsistency.% ravel) FILL L L 10Y��/z tj0,-e L wJ� Lll°u1A18 t b _ 3 1j w S/)NDN ,mot Ili tf/�5�b 1� Jr- F*k1,+y31,r , Al r J�1Ft�n `7q- 122 �J L� L g-L DEEP OBSERVATION HOLE LOG Dole# 42�! _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten bum % ra bumSA�b F,t�. '� jQY2 3 z Ajd-,j.- �dLvwt,� S riD 12-3D 9w La4 N !< r i Rtz� G�twi13 30 _ S- C I ED/e CDC VLh2`{ i 7 -S n}�Nk �6 �G z G 4Vt-L DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con i to c l3 DEEP OBSERVATION DOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Cons' ten .r Flood Insurance hate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No= Yes Within 100 year flood boundary No� Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? F� If not,what is the depth of naturally occurring pervious material's Celrtii"ication I certify that on l Q �� �1 (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 CN M 15.017. Signature Date ! Q:ISEPTICkPERCPORM.DOC Town of Barnstable Barn .� Regulatory Services Department AFAmWea j SARNfffABLE, Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7014 1200 0001 0358 0130 September 8, 2014, 20.14 Deutsche Bank Trust Co Americas % Stacey Jordan 8 Sleepy Hollow Drive Plymouth, MA 02350 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 121 Seth Parker, Centerville, MA was inspected on 6/23/2014, by John Gracey,registered sanitarian and health agent for the Town of Barnstable Health Department. The inspection of the septic system showed that the system"Failed" under the guidelines of Chapter 1995 TITLE 5 (310 C,R 15.00) due to the following: • Recommend pumping septic tank now and every two years. • 1000 Gallon leach pit was full at time of inspection with solids in riser and on cover. You are ordered to replace the septic system within sixty (60) days of the date you receive of this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. (Dmaisc R OF TH BOARD OF HEALTH i can, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\121 Seth Parker Rd Cent Jul 2014.doc Commonwealth of Massachusetts r - Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when fA General Information fillingng outout forms A.orms I on the computer, use only the tab 1. Inspector: key to move your cursor-do not JOHN GRACI use the return Name of Inspector f Y GRACI SEPTIC INSPECTIONS, LLC rae Company Name PO BOX 2119 Company Address TEATICKET MA 02536 City/Town State Zip Code 508-641-6694 S1468 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this adss and tl the O # information reported below is true, accurate and complete as of the time of the-inspection. —e in ction was performed based on my training and experience in the proper function and maintenance of osite sewage disposal systems. I am a DEP approved system inspector pursuant%tA SectionA5.340tf Title 5(310 ClCIO 15.000). The system: -` �. ❑ Passe ❑ Conditionally Passes _ ® Fils ca t� ❑ Need rther Evaluation by the Local Approving Authority 06/23/2014 Inspector's Hure Date The syste i pector shall submit a copy of this inspection report to the Approving Authority (Board of Health I P)within 30 days of completing this inspection. If the system is a shared system or has a desi low of 10,000 gpd or greater, the inspector and the system owner shall submit the report to th appropriate regional office of the DEP. The original should be sent to the system owner and copies ent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. uo(j— d -1 11111y t5ins•3/13 Title 5 Official Inspection Forth:Jbsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M s 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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: NA B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantial Infiltration or exflltration 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): NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): NA ❑ 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): NA C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is CENTERVILLE MA 02632 06/23/2014 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must - be attached to this form. 3. Other. NA D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is CENTERVILLE MA 02632 06/23/2014 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ •❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ti W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK AND 1000 GALLON LEACH PIT Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® . No. Water meter readings, if available (last 2 years usage (gpd)): TOWN Detail: 201 Sump pump? ❑ Yes ® No Last date of occupancy: VACANT Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: NA Date Other(describe below): NA General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): (18) EIGHTEEN INCHES Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): GREATER THAN 10+ FEET Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO COMMENT Septic Tank(locate on site plan): Depth below grade: (12)TWELVE INCHES feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑. No Dimensions: 1000 GALLON Sludge depth: (12) TWELVE INCHES t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle (22)TWENTY-TWO INCHES Scum thickness (8) EIGHT INCHES 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 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.): SEPTIC TANK APPEARS TO BE STRUCTURLY SOUND AND FUNCTIONING PROPERLY RECOMMEND PUMPING SEPTIC TANK NOW AND EVERY TWO YEARS. UNABLE TO INSPECT UNDER NORMAL USEAGE Grease Trap(locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NAgallons per day Alarm present: ❑ Yes ❑ No Alarm level: NA — Alarm in working order: ❑ Yes ❑. No Date of last pumping: NA Date Comments(condition of alarm and float switches, etc.): NA "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA 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.): NA = 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'' 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1000 GALLON LEACH PIT WAS FULL AT TIME OF INSPECTION WITH SOLIDS IN THE RISER AND ON THE COVER. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA Privy(locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is CENTERVILLE MA 02632 06/23/2014 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately $ tE T14 PA 9,K tER RON> W I _ . Of z -as dID 3 s I D1&C0o1z cµwwEY A Q AA 55 5 45 44 4 ;LEACW�4 C �d , pit' Q.SOI-IDs) FULL/I lot OUSETL iow coveiL Q 'rime ga 12 OF IIJ srec 110ta SO ZS W 5D N0 FRkD1k AS- UMS' ON d.iNE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 .. ,, ' { _ ` . .� >.. - -._ - t .__ .0 �: :, ` S � � /� ,�. ..C7 .� i ,� f k 1 - 4. +` -• ;t f f ..r; w � ..- • 1 � � r ). 9 ,� ,. .. 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA. 02632 06/23/2014 _ _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: GREATER THE 12+ FEET 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: AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts = W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M r 121 SETH PARKER ROAD Property Address DEUTSCHE BANK TRUST CO AMERICAS Owner Owner's Name information is required for every CENTERVILLE MA 02632 06/23/2014 i page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 121 Seth Parker Road Centerville, MA 02632 Owner's Name: Dolores Stevens Owner's Address: Date of Inspection: Ma 6, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the itfformationzepott4d below is true,accurate and complete as of the time of the inspection. The inspection was perfofrt ed basec an mys, s.- training and experience in the proper function and maintenance of on site sewage disposal system. I am•a-DEP,-v approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systi in: � o -t� 7� cn ✓ Passes - + Conditionally Passes I ry co Needs Further Evaluation by the Local Approving Au ority _0 M Fails Inspector's Signature: Date: Mav 9. 2005 The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions,at the time ofjnspection 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 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 121 Seth Parker Road Centerville, MA Owner: Dolores Stevens Date of Inspection: May 6, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated,are indicated below. b Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or 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 replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 121 Seth Parker Road Centerville, MA Owner: Dolores Stevens Date of Inspection: May 6, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 121 Seth Parker Road Centerville, MA Owner: Dolores Stevens Date of Inspection: May 6. 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 r, OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 121 Seth Parker Road Centerville, MA Owner: Dolores Stevens Date of Inspection: Ma 6, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? . ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 121 Seth Parker Road Centerville, MA Owner: Dolores Stevens Date of Inspection: May 6, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: CurrenLIX occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Pumped 1 month a off-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 912186-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Seth Parker Road Centerville, MA Owner: Dolores Stevens Date of Inspection: May 6, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Seth Parker Road Centerville, AM Owner: Dolores Stevens Date of Inspection: May 6, 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were vresent. PUMP CHAMBER: None (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.): 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Seth Parker Road Centerville, MA Owner: Dolores Stevens Date of Inspection: May 6. 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1-6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach nit had]'of liguid on the bottom. The scum line was approximately 2'up from the bottom There did not appear to be any signs offailure. The bottom to grade was 9' The cover was 10"below grade CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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 i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Seth Parker Road Centerville, MA Owner: Dolores Stevens Date of Inspection: May 6, 2005 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. Li to Q 10 S� 3 30 F,3y 10 3 Page 11 of 11 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 121 Seth Parker Road Centerville, MA Owner: Dolores Stevens Date of Inspection: May 6 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- 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: topographic and water contours naps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing pproximately 30'+/-to ground water at this site This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCATION � ' JC�k PAC hLf- R�- SEWAGE # 86" ?57 �1t1i.LAGE V—ItrJik�L ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �Ujw LEACHING FACILITY: (type) (size) / 110. OF BEDROOMS BUILDER OR OWNER -1tyto S 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 Fumished by 1 r1S(�l.c.'�-gun J pola a O t 6 3 a 3� 3y 131 3 3 Z L,O CATION �i 2 SEWAGE PERMIT NO. Lug S ��r/T��o�lCe+e 7Zw E-S` rZ ,VI L AG S ASSESSORS MIAP NO: PARCEL NO.- I N S T A LLER'S NAME A ADDRESS 0.0 I L D E R OR OWNER � -N7Fe v,l/Le DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED J-Crr C� 7W i= 1-2A c-I - 30- 3 L� r *�� THE COMMONWEALTH OF MASSACHUSETTS BOARD H EA ----......- ................. OF.... ................... Appliration for Bi-qVniial Workii Ton,itrn.rtiun Pjamit Appli tion is here made for a Permit to Construct �r Repair ( ) an Individual Sewage Disposal syst __ ................ .. -------- -- ----- e ion-Ad ss b' o. .... ..... ------- -------------- ------i ....•. __.._. .................... r = Address a ......• ..... �. !' ."•............................ ...... ................. ................................................... Installer Address �. Type of Building Size Lot.��... q.Ct'?�7�..S feet Dwelling—No. of Bedrooms............................................Expansion Attic ( 00' O Garbage Grinder 04 Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixture •----••••••............... . W Design Flow___.•--��-.! _•----------------gallons per person per day. Total daily flow-------- ............gallons. R: Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth___-______..._.. Disposal Trench—No ___________________• Width.; .............. Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.--_____.--.I-______ Diameter......... ...... Depth below inlet............. Total leaching area..................sq. ft. Z Other Distribution box ()6 Dosing tank ( -ZZ `" Percolation Test Results Performed by........ "--�,_.�S_t � -•....... . Date....______..____.......______...........Test Pit No. 1__!-Z-_-minutes per inch Depth of Tit___.__.�__�_.. Depth to ground water.._.�ln°`__._..._.. GX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..-_---___-_-_---_____. ,�y� ----------------------•------------••---•-------------..........._......••-----_...--........................................................ 0 Description of Soil-•---•l!-���=--•-Ga..l��••-=-••••-•........................•-...... x W x -•--••-•--------------------••----•••---------••-••••--------------•••••----•-•••-•-•••.....--•-••--••-•-•---•--••----------••••----••••••-•-•------••---•-•--•-•-••--•-••......----••-----•---'-----••- 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 E ;of the State Sanitary Code—The undersigned further agrees not to place the system in operation until ertifi to of Compliance has been i e by the bo of lth. ^_ Signed. Y •. py� O Date Application Approved BY ... .. -..----- -------------- Date Application Disapproved for the following reasons------------------------•---.....-----------------------•----------------------------------------------•--------- ...........•--•-•--•'•-•......--•-----•---••-••---•••--•-•-•-----•--.......•'-•-•-----•--.....-•----•-•-------•------••-••-••-•---•-•••----------•--•-------------•-•--••-• ............................ Date Permit No. ......_..���__���.. Issued_-----•----------------------------•----•--------....... Date ow �t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r , ApItfiratinn for Biiiposal Works Toustrnrtinn remit Appl ation is hereb made for a Permit to Construct /_,) or Repair ( ) an Individual Sewage Disposal Sys�.t f ............................................ r �I,oc.•at on A ess rr •""j' s ? ,F No. r ......1241 ............... .. : ::...: :.._......... f a............................... _a ter �r `a A.d..d.r.e..s.s = ( ....Ow ..... Installer Address .� Type of Building - Size Lot:4-,pm_ _ _._Sq. feet 1-1 Dwelling—No. of Bedrooms.............. ._.._.._____...__._.._Expansion Attic ( ) Garbage Grinder ( P� C, aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .------•------------------------................................................................. W Design Flow..... ., ..................gallons per person per day. Total daily flow...... ..._ _. ........_____.._._gallons. n> W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No`. .................... Width. ................ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------1--------- Diameter....... ........ Depth below inlet....l�n.......... Total leaching area..................sq. ft. Z Other Distribution box " ) Dosing tank ( '-' Percolation Test Results Performed a by-------- V ------- Date._----------- ...................................... Test Pit No. 1.L-�: ___minutes per inch Depth of T st Pit.......L_ ..... Depth to ground water---------A_-____-___-. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix ---------------------------------------- ••-•--------------- •---------- -......... -------- ------- •---- ._.._.-------------------------------- --_---------------- O Description of Soil..... ��___...•............................•------------------------------------...------------------------------------•--•--..--•--- x w --- ------------------•--.........................................................................................................---------------------------------------------------------------•-- V ---Nature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------------------------------------•----------•------------------------.....-----......•--••------------•-------•----•---------.....•-----••-------•-----•-----•-••--•--•------------••---. Agreement: -,y r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with �- the provisions of r1 I-11 r ;. 5,of the State Sanitary Code—The undersigned further agrees not to place the system in operation until,a Certificate of Compliance has beenrissyed by the board of health. cJ Signed..,::::.. ------------•-..... , ................................ -- ------ _-------- F ---•�.� y,r Date Application Approved By........................... F� : Date Application Disapproved for the following reasons:-•-•--....-•----•------------------------••------•--------------•-----......---•---------•---•-----------....... ............................................................-----•---•--•-----•----------------...-------•-------------------------------------•-------•----------•----•-------•----•.----------------- Date PermitNo...... '� ^..............- --- Issued----------•-------------------------------------------- ---_-_. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........Q�..�Q.............OF........ .N S ............................................. Trrfifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( } bY........ •'� A................................................................................................ I staller at. t� C � ... == -4 �-�?h• ------•------•-•-------------------•------------------------- has been installed in accordance with the provisions of T_L j L4 j of The State Sanitary Code s described in the application for Disposal Works Construction Permit No _._._ ..... _ _ __ dated---j-- ---- --. ��.?___........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT YHE SYSTEM WILL FUN 1 N SATISFACTORY. � DATE............ . . --- Inspector....-----------•---.._!/. _f b THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................OF...... .`.f`_ 5 �-1.:.:.............................. -`� Q FEE....I.�............ �i���rs�1 nrk� ��n�#.rnr#uan rrmi# Permission is hereby granted............K L-}---•1A .... ----•.....................•---------------•-•---------•-••-------..................... to Construct (`e) or Repair ( ) an Individual Sewage Di posal System at No..� L �' == �.....----f.�-��. �'-��_�_�: s.......-•- ................... - ------ ------•---------------- Street as shown on the application for Disposal Works Construction Permi, No _ �7.Dated.._: _ __�Cj�`��...... U Board of Health DATE------- 6,..� .��:.-�--------------------•--------------------------.... FORM 12515. HOBBS & WARREN. INC.. PUBLISHERS r:" - F .._. T U.5 Ct !L L; . '_:1, _, 46 Stec 15p�FCC 2y _ 3-7 1-:5-150 � QI `I TOTA.t_=�1��IG ti 4z� �Pp• -i ��.���T��yt�: r �.� `Irl bN �—TtF I vi'p ( � ti- Ill I `t" OF �9s ISS t l I Pc TER SULLIVAN F3iCHR13D `— — � — _ ` r L c A. �. No. 29733 BARTER4,2 P{fi 24048 u �7 t 1 4 cfsTEa�O �' � d -t 4;k sS/0y A l ENG�� 3 c3�y *QLC11-IA G.o 41•6 ( - -- cco �,N b• ��.otv �tiv 4-t.o '��T1G 429 �.v . _ b OF 3i4') ,r_ N o �L _ - - j C_FI=nFY -T44A-r7�4C _._J _k3 tE4 vILI_E 4 t ���:� W.I I F1��T��- r��-'�-�� �-`j--!�•i I � CJ� t-:: VENT 20' MIN. 5' min, backfill VENT TOP OF EXISTING P��eD SAND SAND 10' min. finish grade 2" wall(min) F(ASSUMED) 00 sue'` 15 min. ,� „ * z topsoil 6 min. 6 max. J 'M1t AA S=0.02 r WAYUj i F o I j S=0.005 o- 3 ; N DUMB 1 ""a k° ! 8" _ ii water ZABEL • t tight FILTER 12" J FOUND 6" compacted N AT10 NOTES: 12" 34" crushed stone 6" compacted FA1�0t"" RD 25'-0" crushed stone 12'-0" DISTRIBUTION BOX(ES) 1. CONSTRUCT SEPTIC SYSTEM REPAIR IN ACCORDANCE WITH STATE ENVIRONMENTAL (5) BIODIFFUSER/ARC 36 CHAMBERS PER ROW EXISTING 1000 GALLON SEPTIC TANK CODE - TITLE 5, AND RULES AND REGULATIONS OF THE BARNSTABLE BOARD OF HEALTH. USE (20) INFILTRATOR CHAMBERS TYPICAL FIELD CROSS SECTION (4) ROWS TOTAL SEPTIC SYSTEM PROFILE 2. SEPTIC SYSTEM IS NOT DESIGNED FOR A GARBAGE GRINDER. LOCUS NTs NTS 3. ESTIMATED SEWAGE FLOW .EQUALS 330 GPD BASED ON 3 BEDROOMS AT 110 GPD. ELEVATION SCHEDULE 4. EXISTING SEPTIC TANK IS 1000 GALLON PER BOH RECORDS. TANK WILL BE PUMPED & INSPECTED Percolation Test* ELEVATION ELEVATION DURING SYSTEM REPAIR CONSTRUCTION. TITLE 5 INSPECTION REPORT WILL BE SUBMITTED W/AS BUILT Date: !9/18/14 PROPOSED FLOW LINE "AS-BUILT" PLAN IF TANK IS IN GOOD CONDITION. IF DEFECTIVE, TANK TO BE REPLACED W/1500 GALLON TANK Observation Hole# #1 INVERT AT FOUNDATION EXISTING 96.98 PER R"EG 15.223. CONTRACTOR TO CARRY AN "ALLOWANCE ITEM" FOR POSSIBLE TANK REPLACEMENT Depth of Perc 36 start Pre-soak 11:23 DEEP OBSERVATION HOLE LOG*#1 INVERT INTO SEPTIC TANK EXISTING 96.80 IN CONSTRUCTION COST PRICE. End Pre-Sock 11:33 Depth from Soil Texture Soil Color Soil Other {Structure, Stones, Boulders, 'time at 12„ 24 GALLONS ace(SurfInches) Soil Horizon (USDA) (Munseii) Mottling Consistency. x Gravel INVERT OUT OF SEPTIC TANK EXISTING 96.55 5. INSTALL NEW 5 OUTLET DISTRIBUTION BOX. Time at 9" - EL = 95.99 6. INSTALL ADS BIODIFFUSER/ARC 36 CHAMBERS (20) REQUIRED. 0-16 A OVER SANDY 10YR3/2 LAWN, FRIABLE INVERT INTO D-BOX 93.77 Time at 6" - FILL LOAM `time (9"-6") - 16-32 Bw SANDY 10YR5/6 FRIABLE 93.6 7. ALL PIPING SHALL BE 4" DIAMETER SCHEDULE 40• PVC UNLESS OTHERWISE NOTED. 'fate Min./Inch <2 MIN/INCH LOAM INVERT OUT OF D-BOX 32-74 C1 MEDIUM 2.5Y7/4 VERY FRIABLE INVERT INTO BIODIFFUSER/ARC36 93.32 8. BENCHMARK HAS BEEN ESTABLISHED AS TOP OF FOUNDATION AS SHOWN. TO SINGLE GRAIN TOP OF FOUNDATION ELEVATION = 100.00 (ASSUMED) COARSE 10-15% GRAVEL 92.73 SAND STRATIFIED BOTTOM LEACH FIELD TEST PIT2 74-122 C2 COARSE 2.5Y7/3 LOOSE FINISH GRADE OVER FIELD 96.0 9. SYSTEM CONSTRUCTION MUST BE INSPECTED BY THE BOARD OF HEALTH AND/OR ITS GRAVEL + EL=95.01 SAND SINGLE GRAIN WATER TABLE (BY MOTTLING) <85.82 NO MOTTLES AGENT AND THE SYSTEM DESIGNER ACCORDING TO THE FOLLOWING SCHEDULE �___. 94 STRATIFIED 94 (24 HOUR NOTICE REQUIRED)- NEW 5 OUTLET parent Material (yogic) Depth to Bedrock - NEW to anaundrater: Standing Water In the Hole: moping from pn Facet A. EXCAVATION INSPECTION PRIOR TO SYSTEM INSTALLATION D-BOX EDGE OF WOODS 9 5 Eetimaad se�,gl High Ground winter: 95 TEST PIT 1 NEW BIODIFFUSER/ARC36 B. INSPECTION OF SAND REFILL AS REQUIRED. # ' CHAMBER LEACH FIELD REMOVE EXISTING EL=95 99 N qq� hfLF?i C. FINAL CONSTRUCTION INSPECTION BEFORE BACKFILLING. LEACH .PIT ��y�-� � gd 4 ROWS 5 CHAMBERS • • 96 a3 a3 DEEP OBSERVATION HOLE LOG* #2 D. FINAL GRADING INSPECTION. ,. VENT. her STRUCTURE LOCATIONS "As-BUILT" Depth from soil Horizon Soil Texture Soil Color Soil (structure, stones, Boulders, 10. WATER SUPPLY SETBACK DISTANCES TO PROPOSED LEACH AREA... 97 Surface(inches) - (USDA) (Munsell) Mottling Consisten % Grovel 97 HOUSE CORNER "A" TO SEPTIC TANK COVER 98 EL = 95.01. 0-12 A OVER SANDY 10YR3/!2 LAWN, FRIABLE . PUBLIC WATER SUPPLY (SURFACE OR GRAVEL PACKED WELLS)- FILL LOAM 98 25' 12-30 Bw SANDY 10YR5/�6 FRIABLE HOUSE CORNER "B" TO SEPTIC TANK COVER LESS THAN 400 FEET NONE FOUND. O O , , LOAM HOUSE CORNER "A" TO DISTRIBUTION BOX COVER EXISTING 20 DECK 10 30-58 C1 MEDIUM 2.5Y7 4 VERY FRIABLE PRIVATE DRINKING WATER WELLS - LESS THAN 100 FEET - NONE FOUND. 98.8 / 1000 GALLON TO SINGLE GRAIN HOUSE CORNER B TO DISTRIBUTION BOX COVER SEPTIC TANK B A COARSE 10-15% GRAVEL 11. SITE IS NOT IN A 500 YEAR FLOOD ZONE. SAND STRATIFIED EXISTING BENCHMARK HOUSE CORNER "A TO BEGINNING OF CHAMBER 58-120 C2 COARSE 2.5Y7/3 LOOSE DWELLING TOP OF FDN " 12. SITE IS IN A ZONE II PUBLIC WELLHEAD PROTECTION AREA. SAND <5� GRAVEL #1 21 EL=1 00.00 SINGLE GRAIN HOUSE CORNER "B" TO BEGINNING OF CHAMBER 13. DESIGN CALCULATIONS- STRATI FI STRATIFIED m (ASSUMED) HOUSE CORNER "A" TO END OF CHAMBER GARAGE N : TOTAL DAILY FLOW = 330 GPD - 3 BEDROOMS parent Matertal (gsotaglc) Depth to Bedrock: 99.4 Death to am Standing Standing Water In the Hole: Wa"Ing from pit Face: HOUSE CORNER "B TO END OF CHAMBER Eafimat�seasonal High c.«,nd water: SOIL TEXTURAL CLASS I LTAR 0.74 GPD/SQ Pf = R „A" TO OBSERVATION PORT� HOUSE: CORNER LEACHING AREA = 330 GPD ;/ 0.74 GPD/SQ FT = 445.95 SQ FT REQUIRED 99 M 0 Certification HOUSE CORNER "B" TO OBSERVATION PORT BIODIFFUSER/ARC 36 EFFECTIVE LEACHING AREA = 4.80 SQ FT/ LIN FT = 92.9 LIN FT REQ'D 99 I certify that on 1��?�f 97 (date) I have passed the soil evaluator examination PAVED approved by the Department of Environmental Protection and that the above USE (20) BIODIFFUSER/ARC 36 CHAMBERS D analysis was performed by me consistent with the required training, expertise and DRIVE experience in 310 CMR 15.017. LEACHING CHAMBER AREA PROVIDED = 480.0 SQ FT = 355.2 GPD m Signature _ -- ----- Date1 f[I� 8 98 9 14. PROPERTY LINE INFORMATION TAKEN FROM TOWN OF BARNSTABLE GEOGRAPHIC INFORMATION SYSTEM 9 6za 96 ASSESSOR MAP ID 170/192 � STEPtiEP►��yGa certify that this subsurface disposal system was a inspected on and found to have been NELSCW in compliance with Title 5 of the State Environmental Code, "°'713 Board of Health requirements, LEGEND: and the approved plan. 1151 SETH PARKER ROAD SCALE . 1 - 20 PROPERTY LINE: Stephen B. Nelson Registered Sanitarian EXISTING CONTOUR: _� CL EAR WA TER RECOME.RY PROPOSED CONTOUR: 00 SEPTIC SYSTEM REPAIR PLAN TEST PIT: I certify that this subsurface disposal system was constructed DEUTSCHE BANK/STACEY JORDAN 121 SETH PARKER ROAD in compliance with Title 5 of the State Environmental Code, CENTERVILLE, MA SPOT ELEVATION: 100 Board of Health requirements, and the approved plan. DWG. NO.: BARN 121 SETHPARKER DESIGNED BY: �, STEPHEN B. NELSON SCALE: AS NOTED DRAWN BY: REGISTERED SANITARIAN ��� 175 SPRING STREET Installing Contractor DATE: 10/15/14 CHECKED BY- ROCKLAND, MA 02370 SHEET 1 OF 1 APPROVED BY: �j / (781 ) 878-3849 e SYSTEM PROFILE MARKED WITHCMAGNETICTTAPSHALLE OR BE NOTES PROVIDE MIN. 20" DIAM. WATERTIGHT COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS ASSUMED c G o` (NOT TO SCALE) ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE 2. MUNICIPAL WATER IS EXISTING o ' 2" PEASTONE OR GEOTEXTILE (` \ FILTER FABRIC OVER STONE - 3. MINIMUM PIPE PITCH TO BE 1/8„ PER FOOT. MINIMUM .75' OF COVER OVER PRECAST F2% SLOPE REQUIRED OVER SYSTEM 47.0 48.0 a9j e"rf BLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST PRECAST H-10 NOTE: MIN. WALL THICKNESS 2" PRECAST RISERS UNITS TO BE AASHO H-10 Q� RISERS (TYP.) , MORTAR ALL .a: 2'0 49.46 4"OSCH40 PVC INVERT IN 44.17' 5. PIPE JOINTS TO BE MADE WATERTIGHT. hQo COMPONENTS o .•.,• PIPES LEVEL 1ST 2' 4' (np) 4' o Locus Q �' s n ,.: ENDS 0, SIDES N ACCORDANCE 45. 6 CONSTRUCTION DETAILS TO BE I q r " 10" EXISTING 14" TEE _MSMM0�� ®®®® ®�®®- o®®® °0000a WITH 310 CMR 15.000 (TITLE 5.) TEE SEPTIC TANK** TEE ,* 00000000 D�DOO�O�®®®® �C7�®®®��®a0 ;gaoog000 �3 48.Ot s" MIN. SUMP ;o...° °0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND a 0 0 0 0 0 0 o 0 0 ° 000000000000 12" MIN. INT. DIM. °o°o°o°o ®Q�o�QoDo®Qo�QoO QC]®®®�000�� o 0 0°0 GAS BAFFLE::` °o,°o�°o°o°o° ;g °0000 , °°°°°°°° 42 17' NOT TO BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. 44.89' 44.72' } °°°°°°°° � {e 28 i L H-10 500 GAL. LEACHING CHAMBERS BY ACME PRECAST OR EQUAL 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. RoU 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. (2) UNITS REQUIRED Route 28 ALL AROUND PRECAST STRUCTURES 9. COMPONENTS NOT TO BE BACKFILLED OR OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' CONCEALED WITHOUT INSPECTION BY BOARD OF 6" CRUSHED STONE OR MECHANICAL HEALTH AND PERMISSION OBTAINED FROM BOARD COMPACTION. (15.221 (21) OF HEALTH. ( 35 7. SLOPE) ( 5 SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR 35.5' BOTTOM TH-2 CALLING DIGSAFE (1-888-344-7233) AND LEACHING NO GROUNDWATER FOUND VERIFYING THE LOCATION OF ALL UNDERGROUND & FOUNDATION- EXIST. SEPTIC TANK 9' D' BOX 13' FACILITY OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED LOCUS MAP PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE SHALL BE REMOVED 5' BENEATH AND AROUND THE CONDITIONS IF NOT SUITABLE PROPOSED LEACHING FACILITY. NOT TO SCALE 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN ASSESSORS MAP 170 PARCEL 191 L E G E N D SAND. 99 - EXISTING CONTOUR X 99.t EXIST. SPOT ELEV. -[991-- PROPOSED CONTOUR [98.4] PROPOSED SPOT EL. TH1 SYSTEM DESIGN: TEST HOLE 2% SLOPE OF GROUND 105�� GARBAGE DISPOSER IS NOT ALLOWED CC)_, UTILITY POLE DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD / LOT 661 USE A 330 GPD DESIGN FLOW Zc FIRE HYDRANT 15,250.7 Sq. F e NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING a SEPTIC TANK: 330 GPD (2) = 660 48 / `�� **RE-USE EXISTING 1000 GAL. SEPTIC TANK PAVED DRIVE LOGS TEST HOLE LEACHING:52 ��� SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD ENGINEER: DANIEL E. GONSALVES, SE #13587 F � � BOTTOM 25 x 12.83 (.74) = 237 GPD s WITNESS: DAVID STANTON, RS TOTAL: 472 S.F. 349 GPD DATE: 12/17/15 � EXISTING PERC. RATE _ < 2 MIN/INCH DWELLING // USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) \ `' BENCHMARK WITH 4' STONE ALL AROUND COR BULKHEAD CLASS I SOILS P# 14913 PORCH ON / / EL. = 52.6' ELEV. ELEV. PILINGS <'D� 5� o„ Q 47.0' o" w 46.5' / o °ECK TITLE 5 SITE PLAN � 2J S OF FILL FILL 20" 18" 131 SETH PARKER ROAD A A s� TH1 ! CENTERVILLE, MA J LS LS a, �� � PREPARED FOR 24„ 1OYR 3/2 45.0' 1OYR 3/2 J 23„ 45.1 46] BORTOLOTTI CONSTRUCTION/ � B B SHED �- MAYERS � �� LS LS DATE: DECEMBER 17, 2015 30" 1 OYR 4/6 44.5' 1 OYR 4/6 PROVIDE 46' OF 40 MIL LINER AT 5' REV: JANUARY 8, 2016 (C LAYER) 32" 43.8' OFF SAS IN AREA SHOWN. TOP AT ELEV. 45.0', BOTTOM AT EL. 41.0't PERC C C 1O5 �� 4of ^A�\�C �OFM,�s � t..:. MS M �S �� ",;ILL 'nr1 g off 508-362-4541 I �•�I O LA 2.5Y 6/4 2.5Y 6/4 r� fax 508-362-9880 �� l Jim r Pu �6562 � t 1 �: downcape.com F� V T 0- U�,% town cape engineeringi inc. 132" 36.0 132 35.5' 4:s'?NAL � =y' si �v k civil engineers NO GROUNDWATER ENCOUNTERED Scale: 1 '= 20 land surveyors 939 Main Street ( Rte 6A) 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 15-360 BORTOLOTTI_MAYERS.DWG