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HomeMy WebLinkAbout0020 SHANNON WAY - Health 20 SHANNON WAY, CENTERVILLE A = r i I ® � 2 UPC 12534 � No. 2� 153LOFt HASTINGS. UN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Shannon Way c Property Address Torcoletti Owner Owner's Name 4i information is required for every Centerville Ma 02632 10/18/2016 x page. City/Town State Zip Code Date of Inspection ,ry G] Inspection results must be submitted on this form. Inspection forms may not be altered in any 4711 way. Please see completeness checklist at the end of the form. Important:When A. General Information C filling out forms 614 /a of o on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/18/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "'"`This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �Coe r's Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 20 Shannon Way Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 leach trenches, 55'total . The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 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): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-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 y 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Shannon Way Property Address Torcoletti Owner Owners Name information is required for every Centerville Ma 02632 10/18/2016 page. Cityfrown 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 't 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not _available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the 1/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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed 10/24/1999 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. Cityfrown 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 3" Scum thickness 3" 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? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank should be cleaned soon and again every 2 years for proper maintenance. Tankl was structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 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 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.): Distribution box was video inspected and found to be in good condition, no rot, water level was even with outlet invert. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 55' ❑ 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.): s.a.s. consists of 2 leach trenches totalling 55'. No sign of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 20 Shannon Way Property Address Torcoletti Owner Owners Name information is Centerville Ma 02632 10/18/2016 required for every page. C4/rown 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 f i d + l A-D_17 V C-5z Sol 47l` lI -4 II r I L44 i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Shannon Way Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. 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 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 20 Shannon Way 4 M Property Address Torcoletti Owner Owner's Name information is required for every Centerville Ma 02632 10/18/2016 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 forth:Subsurface Sewage Disposal System-Page 17 of 17 �- Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments t�! Subsurface Sewage Disposal System Form ,._,,.� W � ^: Llt Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611512000.Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Pro pe Informati 1-7AA) 1vo&) forms on theOAV computer,use only the tab key Prope y dress to move your MA S cursor-do not oWners e use the return ,,� ` ,�f key. ,V 'V 0 C O e dress Owner's d m o .o/ 'IS cityrroNvn State Zip Code Date of Inspection: Auq 27 Jos—' Date 2. In pe or: '(�') A Nam of Inspect' Compan Name/ Comp Address ,-J kn N'l S l t f2 b City/rowrp►— State Zip Code /- r /--j I�i�S1 Telephone>Rber / � Sod Y Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector-pbrsuant to Section 15.340 of Title 5(310 CMR 15.000).The system: *—Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furthe valuati n y the Local Approving Authority ` A �s> d- 7 AS- in?pedoesignature Date The system inspector shall sub 7acopy of.this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. *'This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 P Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) C� .0 -/hJa-IJ 6-3 - t. Property A, ess ff J City/T n State 7- Tap Code h1� _Qn ev �e 7i J a? Owner's Name Date of Inspedfion Inspection Summary: Check A,B,C,D or E I always complete all of Section D :�l yPasses: 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. Com ts: _ O A 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: t5insp.doc.11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Clo ficatlon Cont.) �a YJ jb Property Address �� _ . I ss A( ,0 �IQ �'h 20 S� A J - � e Owners Name Q .,t '_i I—C>.41 ^O ate of Inspection B) System Conditionally Passes(coat.): ❑ 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: _ `IA C) Further Evaluation is Required by the Board of Health: Imo_) ❑ 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 t5insp.doc-11/2004 Title 5 Official InspecUon Form:Subsurface Sewage D's aaI Sy stem Page 3 of 16 r -- %an anassacnusetts Title 5 Official Inspection Not for Voluntary Assessment., Form Subsurface Sewage Disposal System Form A. Certificate n (cont.) Pro Address City wn state,----, r lipCod Oxmer's N�-an►e JsojtJ- uate of In t�ecBon C) Further Evaluation is Required by the Board of Health(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, #/A safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is 100 feet of a surface water supply or tributary to a surface water supply. wrthtn ❑ 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 b more from a private water supply well-. but 50 feet or Method used to determine distance: This system passes if the well water analysis,coliform bacteria and volatile organic Compounds pndicatethat the well is free from pollution from certified laboratory,for that facility and the presence of ammonia nitrogen and nitrate nitrogen PPm.Provided that no other failure criteria are triggered.A trogen is equal to or less than 5 to this form. copy of the analysis must be attached 3. Other. ------------ t5insp.doc-11/2004 Title 5 Oltioal Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certificatio (cont.) Sh j Jjj o-,j I Al PropQty -d1 CiWrown � / Tw State,/ y y ZpCode Owner's Name Date of Ins ion 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 ❑ f� Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow ❑ Required pumping more than 4 times in the last year NOT 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. ❑ Eg Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ p� 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.] 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. 15insp.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) P Address YO11 C //✓✓ /� �S CX�E7 �/ Ci Qwn � le-� d 7 State Zip Code co Owners Name Date of insp6cuon 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 i� 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. t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist o A .o--rJ r!a.-J Propesti Address "V� i� �/Q A � C cityrr n State Zip Code dV/1/ ►Z C a 1 Owners Name " Date of Ins on 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? El available 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(3)(b)] t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Infor ation Pr erty dress AP �l s -44 m, �� sl D'? 6 o� City/r — Sta a Zip Code f ,�h1 Voil Co J e-7T" v Owner's Name Date of In ction Residential Flow Conditions: Number of bedrooms(design): -12 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes to No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes V No Laundry system inspected? Yes ❑ No Seasonal use? ❑ Yes No Water meter readings,if available(last 2 years usage(gpd)): Ve Sump pump? ❑ Yes [ No Last date of occupancy: .-1 C eery Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq. . etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 sys m? ❑ Yes ❑ No Water meter readings,if available: Last date of occupancy/use: Date Other(describe): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection. Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Info mation (cont.) D , 07-3 Prope"dress 1 City/Tow /i �; to old 7 ��_Zip Code ®dl Ca e r of Own is Name Date of Inspebtion General Information Pumping Records: Source of information: A00-4 Was system pumped as part of the inspection? es ❑ No If yes,volume pumped: gallons How was quantity pumped determined? C'% 11-2 ' 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/Altemative 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 compo ents,date installed T kn wn)and source of information: � e Were sewage odors detected when arriving at the site? IV (D ❑ Yes ❑ No tSnsp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection_ Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Info mation (cont.) Property ddress Chown State Zip Code 4 ^v'W: �Qc&' X 0 G a y v--- Owners Flame ' Date of Insp tion Building Sewer(locate on site plan): Depth below grade: feet — Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Septic Tank(locate on site plan): /Nt!� Depth below grade: feet INAJ C Material of construction: 61 concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of Yes ❑ No certificate) Dimensions: 45,0 a Sludge depth: f� Distance from top of sludge to bottom of outlet tee or baffle 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 0 How were dimensions determined? .,At C"7 S t5insp.doc.11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System 1 formation,,(cont.) OS ��r�v� (mac) Prope ddress �n V. P Lj ) 6 Cityfrown , State t J Zip Code Ownifr's'Name Dat of Ins on Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 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.): 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): t5insp.doc.I U2004 Tile 5 Official Inspection form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. SysteU"--)VVj"yp formation (cunt.) Prop;Ahldress �� &Al C a /e �, ,t State^J Zap Code Owners Name / Date of In pectin Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Distribution Box(if present must be opened)(locate on site Ian): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): on 4 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No t5insp.doc.11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Inf rmation (con .) c7 S ���IJ�yJ �� �- ProperVffidress it Cityfrown �-�- State J Zip Code —4'IV �c�n Co le // ,- �J��17/o Jf Owner's Name Date of Insp ction Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number: leaching trenches number,length: n❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovativelalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): S t5insp.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Info ation (cont.) Prope � Cityrro State �op Code Zri r✓�� Co le- /t �0 �t Owners Name Date of Ins ection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Privy(locate on site plan): )" Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc.11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Info ation (cont.) dr Prop e ess /r �'�� City a �- 42�/ State Zip Code Owner's Name Date of InspdEfion 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. L /7 r� )3 D v c� �if w► E 7 t5insp.doc•1112004 Title 5 official Inspection Form:Subsurface� Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Inf rmation (cont.) Prope ss A0 JAV (2 14h S-5 V .2 1 0 CitylTown 7-- State Trp Code 'tj er's Name Date of Insp6cdon Site Exam: Slope Surface water Check cellar L----- Shallow wells 1.. Estimated depth to ground water. 7 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) Q/ Checked with I Board of Health-Pplain: CAI �Y Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: /6 V r--7-JQ 1 i4j -mot Vl- co c lvv e t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 ;'O`;1VN OF BARIINSTAi3LE LOCATION LO—i a lie. *'�-aQ 1L�..,: i"' SEWAGE # VILLAGE r'�Yi�6`TZLv-Cz �,Nt�. ASSESSOR'S MAP & LOT -�o INSTALLER'S NAME&PHONF NO.,(?Ot- r TlfJ� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUELDER OR OWNER PERMIT DATE: Rf- S''y COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any:wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by o >EZ set 1 � le i N THE COMMONWEALTH OF MASSACHIJSETTS FEE q BOARP OF HEALTH f OF —bAX61�� APPLICATION FORISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components `va l � Luc Ilion ners Name �o �l Map/Parcel# Address Lot# Tcle one# Installers Name Designer's N Address Address Telephone# Telephone# Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons (a Showers ( ), Cafeteria ( ) Other fixtures Design Flow(Tim.required) 65 gpd Calculated design flow3 3C---? gpd Design flow providedj3t0 gpd Plan: Date umber of sheets Revision Date Title t ( " f of Soil(s) SDescrip f cL Soil Evaluator Form No. ame of Soil Evaluator' Q Date of Evaluation -��- DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date lo( z yf1 Inspections —-Z FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM S/96 77 N THE-COMMONWEALTH OF MASSACHUSETTS FEE q3 t BOAR OF HEALTH ` OF Y APPLICATION FOR : ISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - /Cmplete System ❑Individual Components me—A Localioi ncr's Name Map/Parcei# m"» Address - Lot# Tel� !_Installers Name Designer's Na j Address Address Telephone# Telephone# Type of Building: Lot Size 'J Sq.feet !. Dwelling—,No.of Bedrooms Garbage Grinder-(' ) Other—Type of Building No.of persons (10 Showers,,( ); Cafeteria ( ) Other fixtures Design Flow (min required) gpd Calculated design flow 3 30 gpd Design flow provided3A gpd Plan: Date - NumbeTJA sheets Revision Date Title. - 1 . Descriptio of Soil(s) Q� `' " LO �� Z3 V' n�5eta�. Soil Evaluator Form No. Name of Soil Evaluator -S6AM t AZ Date of Evaluation-If DESCRIPTION OF REPAIRS OR ALTERATIONS i The undersigned agrees to install the above.described Individual Sewage.Disposal System in accordance with the provisions of ,.TITLE S and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date /a/7,Z - Inspections i FORM I. - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 j No. W-2A THE COMMONWEALTH OF MASSACHUSETTS FEE /0 tv -r/Xi�,� .tiww _BOARD OF HEALTH CERTIFICATE OF COMPLIANCE k r.; Description of Work: ❑ Individual Component(s) Complete System S. . The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) has been installed in accordance with the rovisions of 310 CMR J5.00 Titl 5) and the approved design la s/as-built plans relating to application No. 9�Z�S"dated Approved Design Flow ( pd) Installer , f -� Designer: Inspector /�%l A ate - Yr 4 The issuance of this certificate shall not be construed as a guarantee that the system will unction as designe . �. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 - ,t No. THE COMMONWEALTH OF MASSACHUSETTS FEE " BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( -7+) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at :2C2 � . .g N-c-R L-m as described in the application for Disposal System Construction Permit No. dated y- Z Jq" / J i - Provided: Construction shall be completed within three years of the date of this pe ' All locate o itions ust be et I Date Board of Health F FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON i TO`�(N OF BARNSTABLE LOCATION SEWAGE # _ 9q+ 7 '. VILLAGE C'7i�„�NSTI�-►�i.J : L;s:©f� ASSESSOR'S MAP & LOT - .do. INSTALLER'S NAME&PHONE NO. o SEPTIC TANK CAPACITY 100 LEACHING FACILITY: (type) (size) -6-S"1 NO.OF BEDROOMS 3 BUILDER OR OWNER ,�(�, .1 PERMITDATE: - -h' COMPLIANCE DATE: fQ -2 �9,9 Separation Distance Between the: - Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well 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 e 1 ' S YS TEM PROFILE NO To SCALE TOP FNDN. FINISH GRADE EL . ��- S FINISH GRADE T-�•• FINISH GRADE OVER FINISH GRADE OVER DIST. BOX y- �' OVER TRENCHES SEPTIC TANK o..a.p0 , 12" MAX.o �`' C o,44. wo •,:;�,a• 0�..a4.D�.?0'..Q•o7D0.o'.v. oP�dp�i�'•i•'. � .S'b•9.•.r l� r _ - a v TOTAL TRENCH LENGTH a -� i OUTLET PIPE L EVEL 3„ FOR 2 FT. MIN. 2 7 /�y 9' OF 118"-112, DOUBLE XASh�E'D PEA STGWE , 6' •l �, .:• 0 727a o' a - Q, C. I. OR PVC TEES :° 7z y� ,07 7a 90 cR�E�ro o h p �� i //VL,ETs CAp E GAL L ON °o: DISTRIBUTION BOX tic :i�. 3/4" 1-1/2" DOUBLE WASHED ,oit' BSMT FL . o,'o a - . O.o w�� �.>>m CRUSHED STONE i , EL . G9- © 'o o INSTALL ON LEVEL BASE ���; Gx PRECA S T CONCPE TE .o,vp....oe•i•.. ob H- 10- f AEI NFORCED TRENCH SIDE SECTION o p bo 4►:O.p�Pri —� SEP TIC TANK ``TRENCH END SECTION i INSTALL ON LEVEL BASE NO TE.' EXCA VA TE TO EL E V. �'/� OR LOWER TO REMOVE ALL IMPERVIOUS MA TERIAL BENEA TH THE LEACHING AREA i �i -•.v.;r,.� _ �_ _ - sir • 3 REPLACE EXCA VA TED MA TERIAL WI TH s• MrN.Dram. 3" 3" OF 1/8"-1/2" Q9 e 16 CLEAN, CLAY FREE SAND ;� a;,�c,t•• s N so :.•,.. �: �,• -� DOUBLE WASHED ° PEASTONE , ¢ 3/4" - 1-1/2" oo a s- DOUBLE WASHED CRUSHED S TONE - GENERA L NOTES 1 . AL L EL EVA TICKS SHOWN ARE BASED ON ASSUMED TRENCH WIDTH 2. A L L PIPES I'�' THE S YS TEM MUS T BE CA S T IRON vl r e Y .+ OR SCHEDULE 40 PVC. OBSE R V; TIO'Pv PIT - 3. TH,:- a0Ar`yu r J.'� it�iL TH-f�f ST BE NOTIFIED WHEN CONS Ttl:: CTION IS COMPLETE PRIOR P-9381 TO BA CKFIL L 1 VG PERCOL A'TION RA TE.' MIN./IN. @� __ � . 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED <2 2 ° WI TNESSED 'S Y.• �o C� BY THE BOARS OF HEALTH AND CAPE 6 ISLANDS ____.__.... SURVEYING CG, . INC. DONNA MJ•ORAND T 5. MATERIALS ANJ INSTALLATION SHALL BE IN COMPLIANCE '.T TH THE STATE SANITARY RAB�• BRO. OF HEALTH DESIGN DA TA CODE - TITLE, V - AND LOCAL APPLICABLE DATE.' -AP-B 2•Z. 1939 RULES AND RE,9UL A TIONS W 6. NORTH ARROW . S FROM RECORD PLANS AND &,v,G> o Te-s•� N p/fs (7y�� NUMBER OF BEDROOMS °� ? IS NOT TO BE USED FOR SOLAR PURPOSES GARBAGE DISPOSAL O y GAL . 7. .FLOOD HAZARD ZONE C (NL11y—HAZ�DRL�) B ` DAILY FLOW 330 8. WA TER SUPPL Y TOWN WA TER • e?N e-1 L o, � !°y rZ 'rfG GAL . r SEPTIC TANK REO D. 1500 3� „ SEPTIC TANK PROVIDED 1500 GAL . °°ry0h PROPERTY° IS L OCA TED IN A � �� LEACHING REOUIRED 330 GPD. GROUNDNATER PROTECTION DISTRICT `�,a 1�cct v SIDEWALL AREA = �S. F. _.23£S.F.X 0. .ZgG/S. F. _ f 7e GPD. BOTTOM AREA = 22CLS. F. � LEGEND S61 H i 220 S. F. X 0 G/S. F. = 162 GPD C�'/ LEACHING PROVIDED = _ GPD F ROPOSED EL EVA TION 7� —— LISTING CONTOUR SINGLE FA MIL Y RESIDENCE G 69SERVA TION PIT i Z / ❑ CiTSTRIBUTION BOX b PROPOSED SEi✓A GE DISPOSAL SYSTEM° STEM o TREtVCH PRE D FOR PARE o o G._PTIC TANK S IPENE PEA L T Y TRUS T L O T 2 (HSE NO. 20 SHA NNON `✓ !—.! R.aSERVE AREA i� k / A Y / 216.37 _ ,F._ 'o r! "G i " T al y S 66.44'15 w BARNS TABLE - CENTERVILLE — MASS. �•Z !o P.,�PE INVERT ELEVATION i�nv rsP C� S4t1ir '�' �I : DA TE.' CAPE 6 ISLANDS ENGINEERING 333a.� PLOT PLAN N _ _ /, � 2yy-z 2 20 �,;�, �''`T:t t� t : ' SCALE AS NOTED 800 FALMOUTH ROAD — SUITE 301 SCALE.• tO 1AP SEC PCL LOT HSE i �; f • ; ^ t,�" ; ': PLAN NO, MASHPEE, .MASS. �2