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HomeMy WebLinkAbout0036 SHEAFFER ROAD - Health -6 8 heaffer :Road Centerville A = 172 035 i I No. 42101/3 ORA I(D B, o% la ®a OEM '4 6 Commonwealth of Massachusetts P�a"- 03 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Sheaffer Road Property Address Collean Ross Owner Owner's Name - --- --- - ___ information is Centerville Ma 02632 7/30/2020 required for every _ -_ page. City/Town _ State Zip Code Date of Inspection �� Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. Inspector Information on the computer, Sean M. Jones use only the tab ---__---- ..-___.-- key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Company Address Centerville Ma 02632 CitylTown ,State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4622 lean@smjonestitle5.com license NJumber B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CHAR 15.000); I have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/30/2020 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This Inspection does not address how the system will perform in the future under the same or different conditions of use. 15insp.doc•rev.7126=18 Title 5 official Inspection Form Subsurface Sewage Disposal System-Page 1 of 1s r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4y ° a N 36 Sheaffer Road Property Address Collean Ross Owner Owner's Name information is Centerville Ma 02632 7/30/2020 required for every __ ityrTown State Zip Code Date of Inspectionpage. C C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1} Systeri Passes:.' ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15,304 exist. Any failure criteria not evaluated are indicated below. Comments:. The property located at 36 Sheaffer Rd Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 5 Hi Cap Infiltrators. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for."yes", "no"or"not determined" (Y, N. ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t8insp.doc-rev,712&20f a Title s official inspection Form.Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts W_ , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 Sheaffer Road--l-1-1-111--- Property Address Collean Ross Owner Owners Name information is required for every Centerville ma___ 02632 7/30/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): El Pump Chamber pumpsialarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. El 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): El broken pipe(s) are replaced n Y El N El ND(Explain below): ❑ obstruction is removed El Y E] N [I ND(Explain below): ❑ distribution box is leveled or replaced C] Y F] N E] 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): Ej broken pipe(s)are replaced ❑ Y El N D ND(Explain below): El obstruction is removed El Y El N El ND(Explain below): 3) Further Evaluation is Required by the Board of Health: El Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment, a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protoGt public health, safety and the environment: Lt5insp.doc-rev 712612018 Title 5 Offirial Inspection Form Subsurface Sewage Disposal Swam-Pana 3 of 16 Commonwealth of Massachusetts - � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 36 Sheaffer Road Property Address Collean Ross _ Owner Owner's Name information is Centerville Ma 02632 7/30/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil stem absorption s SAS and the SAS is within p Y (SAS) 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: . ._...___..._.._._ ................... 4)4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev 7126 018 Title 5 official Inspection Form.Subsurface Sewage Disposal System•Pap 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments as 36 Sheaffer Road r Property Address Collean Ross Owner Owner's Name information is Centerville Ma 02632 7/30/2020 required for every --_. .._..._.. _.,_�_._.._.__ �.._..__..__._. page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems: (coat.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4, 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 151nsp.doe-rev_7t2612016 Title 5 Official inspection Form.Subsurface Sewage Disposal System-Page 5 of IS Commonwealth of Massachusetts iY Title 5 official Inspection Form -: `i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .. g P Y rY z y 36 Sheaffer Road Property Address Collean Ross Owner �--______....._....._______..-...._.-__......._..-----_.__.__..__----------._........_.__.----------....__...........___...___._..............._.._._......_. __m. ..__.�.... Owner's Name information Is Centerville Ma 02632 7/30/2020 required for every __-- __._... _ ..... ..._......_.___ .�_.-.......--- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant "yes"to an question in Section CA above the large s threat, or answeredy y stem has failed. The q 9 Y owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for aH inspections: Yes No 0 ❑ 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 an of the failure criteria related® ❑ ( y c to a to Part C is at issue approximation of distance is unacceptable) 310 CMR 15.302 5 pp p }I ( )l t5insp.doc•rev,R2612018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts l T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Sheaffer Road Property Address Owner Collean Ross _ Owner's Name �. information is required for every Centerville _Ma 02632 7/30/2020 City,Town ---� - — _ per. State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): —-- Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 5 -- Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: - --- ----- —- - Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal user ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp,doc•rev 7/26P2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts -= wv Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments H yy S. - £~ 36 Sheaffer Road Property Address Collean Ross Owner Owners Name information is Centerville Ma 02632 7/30/2020 required for every - --_- page, Cityrrown State Zip Code Date of Inspection D. System Information (coot.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): - ---- —� Galllo onns per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If es discharges to: Y 9 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: -- Last date of occupancy/use: Date - - Other(describe below): ................._...,_..............._..------- - 3. Pumping Records: Source of information: Tank pumped after inspection for overdue routine maintenance Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 .. ........ ....... . gallons How was quantity pumped determined? size of tank Reason for overdue pumping: - t5insp.doc•rev.7ormte Title 5 orrrzeal inspection Forth;Suosurface Sewage Disposal System-Page 8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 36 Sheaffer Road �'- _ . Property Address ..._...._ Collean Ross Owner Owner's Flame Information meadfor every is required for Centerville Ma 02632 7/30/2020 page, Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: system repaired 11/9/2004 per town records Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 3.5 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.): Joints in good condition, no leakage, vented through roof, 15insp.dac-rev.7M/2016 Title 5 Official Inspection Form Subswiare Sewage Disposal System•Pape 9 of 18 Commonwealth of Massachusetts : _1- Title 5 Official Inspection Form Fi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . . `,. 36 Sheaffer Road ._.._ _._......__ _ Property Address C_ollean Ross Owner Owners Name information Is Centerville Ma 02632 7/30/2020 required for every __ ___._. page. City/Town State Zip Code Date or Inspection D. System Information (coat.) 6. Septic Tank(locate on site plan): 3 Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years__.__..°_._...____. Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 100..gallons Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3 Scum thickness 2'" Distance from top of scum to top of outlet tee or baffle 7" 101. Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Opened covers and took measurements m commendations inlet and outlet tee or baffle condition structural integrity, Comments(on pumping r p g e g ty, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was pumped after inspection and should be done again every 2 years for proper maintenance. Tank was structurally sound. t5insp.doc-rev.7 6011 8 Title 5 Official Inspection Fort:subsurface sewage Disposal system•Page 1 o of is Commonwealth of Massachusetts :- � =:== Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -�' 36 Sheaffer Road Property Address Collean Ross Owner Owner's Name information is Centerville Ma 02632 7/30/2020 required for every _-� _._...-.. _..w_ page. Cfty/Town State Zip Code Date of Inspection D. System Information (cant.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness --........ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle - --- ---- Dateof last pumping: _.._..-----________-___..._...___.____....__..._._._..........: .Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity. liquid levels as related to outlet invert, evidence of leakage,. etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: -- Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7126 018 TO 5 official Inspection Form:Sutlswam sewage Disposal system Page 41 of 18 Commonwealth of Massachusetts --: Title 5 Official Inspection Form "I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments K ~ 36 Sheaffer Road Property Address Collean Ross_ Owner Owner's Name information is required for every Centerville Ma 02632 7/30/2020 _._._. .._ _ .pap. Ci r—rO n State Zip~Code Date of Inspection D. System Information (cons.) 8. Tight or Holding Tank (coot.) Alarm present: ❑ Yes ❑ No _.... ...._-._.___....................._..................... Alarm in working order: ❑ Yes ❑ No Alarm level. 9 Date of last pumping: -- Comments(condition of alarm and float switches, etc.): ---.....__.......,....____..__-_.... -.... _.__.._... _— *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was functioning as intended. t5msp.doc,rev.7128018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r Commonwealth of Massachusetts - � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^ :; s 36 Sheaffer Road Property Address -- Collean Ross Owner owner's!dame information is Centerville Ma 02632 7/30/2020 required for every ,�_.._._...... _� per. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: - --® leaching chambers number: 5 Hi Cap Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: _......_.........................__._ t5insp.doc•rev,1/28t2 I8 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Pape 13 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments P. 1` 36 Sheaffer Road Property Address Collean Ross — Owner Owner's Name information is Centerville Ma 02632 7/30/2020 required for every ity/Town __...__.........__. -.______ page. C State Zip Code Date of Inspection D. System Information (cunt.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 5 Hi Cap Infiltrators in a 37'x10'1' trench. Leaching chambers were video inspected from vent and was found dry with no signs of past overloading. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — --- Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool - -- -w- — ---- 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.)-. t5ftP.40t-rev 712W2018 1010 6 official Wpeclon Fame SubSwfaw Seweae UMPUSal system•Page 14 of 18 i Commonwealth of Massachusetts #fs - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 36 Sheaffer Road Property Address Collean Ross Owner Owners Flame information Is required for every Centerville Ma 02632 7/30/2020 _... ------. page City/Town state Zip Code Date of Inspection D. System Information (coat.) 13. Privy (locate on site plan): Materials of construction: --------------- - ____ Dimensions ---- -- Depthof solids _......._._....__...................1.................... Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5hap.dm•rev 71M018 Tills 5 Qf -jal Inspedian Form Substnrace Sewage Disposal System•Pape 15 of t8 Commonwealth of Massachusetts Title 5 Official Inspection Form �R1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,n i 36 Sheaffer Road Property Address Collean Ross Owner owner's Name information is Centerville Ma 02632 7/30/2020 required for every page. Citylrawn State Zip Cade Date of InspectionD. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 1 f i 0 Z w A Z 2Y z, 30 15ftp.doc-rev.7126MIS Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments s.r . ` 36 Sheaffer Road `- Property Address _ Collean Ross Owner Owner's Name information is Centerville _ Me 02632 7/30/2020 required for every - ---------__.___.... _ page. CttylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: bat e ❑ 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 was established by accessing town of Barnstable groundwater contour maps. ..............._.._...._...... Before filing this inspection Report, please see Report Completeness Checklist on next page. tbinsp.doc-rev.712WO18 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 18 f r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 Sheaffer Road Property Address Collean Ross Owner Owner's Name information is required for®very Centerville Ma 02632 7/30/2020 -------- page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form Inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l5insp,doc•rev 712612018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 18 NL�A WN OF BARNST LE 1�XATION EWAGE # - -VILLAGE C2=6,?JZ=t,� � ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY JEEkY `7 LEACHING FACILITY: (type) (size) tG �C d j NO.OF BEDROOMS BUILDER OR OWNEP. PEP,MrrDATE: ! t) COMPLIANCE DATE: 17 L Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r n- s It U, i T No. '"i (9 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for ;MiopoaY *pgtem Con5truction der tt Application for a Permit to Construct( . j Repair(�)Upgrade( )Abandon( , ) 0 Complete System dividual Components Location Address or Lot No. W 616 5 QhOle&� T?1a Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. _gdbQ5_kS C ` 'o Ge la A°d' Yl u dCl�n(`rYzo�`�c._1U C Type of Building: Dwelling No.of Bedrooms 3 Lot Size j S I000 sq.ft. Garbage Grinder Q4J/4 Other Type of Building kkne No. of Persons Showers( + Cafeteria( v� Other Fixtures L4,,�A-R92ti'. I�"�L. oJ ► c� {\�"t� Design Flow gallons per day. Calculated daily flow gallons. Plan Date lb Number of sheets l Revision Date Title C o c�,o Se -ck-s• c� Size of Septic Tank Ei oO6 \1oh Type of S.A.S. Description of Soil �Qe� C5\ram Nature of Repairs or Alterations(Answer when applicable) '2,0_`Zp� An 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 provisi s of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by this Board lth. Sign Date 161d5l6v Application Approved by Date Application Disapproved for the following reasons Permit No. ' 9d Date Issued �D No. r Fee • THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for 30igpool Opgtem Congtruction Permit Application for a Permit to Construct( , j Repair( )Upgrade( )Abandon( ) 0 Complete System 0 Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. e of Building: �'P g• Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers,( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued Fee t� THE COMMONWEALTH OF MASSACHUSETTS Entered to computer: � Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Migpo!Ml *pgtem Congtruction Permit Application for a Permit to Construct( )Repair'KA)Upgrade( )Abandon( ) ❑Complete System Pr di-vidual Components Location Address or Lot No. �� �� >�, S, Owner's Name,Address and Tel.No. Mtn 1 tlUU G`ajtj Assessor's Map/Parcel € tw1 E. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size I!S,C:GQ sq.ft. Garbage Grinder(V/A Other Type of Building &I c-w No.of Persons Showers(✓) Cafeteria( a� Other Fixtures yN et_) 'bit-.at Design Flow a^�� gallons per day. Calculated daily flow 1 gallons. °" Plan Date M ;V ') !t 14 Number of sheets k Revision Date Cam' r•^, 11 1' Title ` c.�C c: ��\ "7_4a 4�C �a '.c�ti V'�C,cC',c�r� Size of Septic Tank FX►- CaC 11c;,> Type of S.A.S. 2 1 iJ F l L_T tZ i:NTt ?1.1 Description of Soil ' c c 0\c"N Nature of Repairs or Alterations(Answer when applicable) & Date last inspected: 1 .! .It, ( r K Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss Ued by this Board 09 Health. Sig Date Application Approved by Date Application Disapproved for the following reasons s Permit No. 'S-2:2'4 5 6 !7 Date Issued L,f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIF , that/the On-site SSe�age Disposal System Constructed( )Repaired ( ) Upgraded(�) Abandoned( )by lt'1 Pt{'f "S'r ! at 411 h/! �o f'l'�' (��� 0 >' P 11 (/' has been constructed in accordance with the prov�si�ons}f Title 5 and the for Disposa ystem Construction Permit No. ew tt - 6-7 dated Installer 1 /I�r �.� f/, Designer r..am The issuance oft thisl permit shall not be construed as a guarantee that the system will Lction as designed. Date i 1 1916.4 Inspector - . F�.•f. fr P l ( THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS migponf *pgtem Congtruction Permit Permission is hereby granted to Construct( ),Repair(;-2)Upgrade )Abandon System located at q1,0 r e ),Repair 6' and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions`. /1, / Provided:Construc ion mus be completed within three years of the ate of this\per�it. Date:_ / Approved y.=_ Town of Barnstable OFfHE rq�, Regulatory Services �O ; Thomas F. Geiler, Director * BMWSrABLE. 9�A MASS �0� Public Health Division 1 . Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 11/09/04 Designer: Shay Environmental Services, Inc. Installer: Robert Septic Services. Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street MA 02536 Yarmouth, MA On 11/5/04 Robert Septic Service was issued a permit to install a (date) (installer) septic system at 36 Schaeffer Road, Centerville, MA_based on a design drawn by (address) Shay Environmental Services, Inc. dated 11/04/04 (designer) _XX 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. I certify that the septic system referenced above was installed with major changes (i.e. 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. SN OF MgSs�c o� CARMEN Insta er re) i+ ,SMY V . g/✓� �j i ��i ( esigner's Signature) (Affix 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:Health/Septic/Designer Certification Form / TOWN OF BARNST. LE �L �/ LOCATION EWAGE # _c VILLAGE 1XILL9 ASSESSOR'S.MAP & LOT /VV INSTALLER'S NAME&PHONE NO. i2A- SEPTIC TANK CAPACITY Y C LEACHING FACILITY: (type) � (size) 16 �c d l NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE:. t c v LCOMPLIANCE DATE: h. Separation Distance Between.,the: • Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching.Facility (If any wells exist' on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by / - bra i 6 n sNrvJ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FAILED INSPECTION mAP TITLE 5 -OT OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 36 Sheaffer Road Centerville. MA 02632 Owner's Name: Paul Glynn Owner's Address: Date of Inspection: August 17, 2004 4 1--; C:"wiJ Name of Inspector: (Please Print) James M. Ford # v Company Name: James M. Fordfm Mailing Address: P.O. Box 49 CD Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 co CERTIFICATION STATEMENT CD rat I certify that I have personally inspected the sewage disposal system at this address and that the in rmation reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: August 19, 2004 The system inspector shall subm' 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 of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Sheaffer Centerville, MA Owner: Paul Glynn Date of Inspection: August 17, 2004 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: B. System Conditionally Passes: I 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 i i ' Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) i Property Address: 36 Sheaffer Centerville, MA Owner: Paul Glynn I Date of Inspection: August 17, 2004 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. i 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: i 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: I _ 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. I I The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. i 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: i i 3 ,I i Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Sheaffer Centerville, MA Owner: Paul Glynn Date of Inspection: August 17, 2004 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 '/z 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 forma i Yes (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. i I 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 I If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered I "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 I i Page 5 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 36 Sheaffer Centerville. MA Owner: Paul Glynn Date of Inspection: August 17. 2004 I Check if the following have been done: You must indicate"yes"or"no"as to each of the following: t 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? I ✓ _ Has the system received normal flows in the previous two week period ? t ✓ 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? { I � ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? i ✓ _ 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 I ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. i i i i 5 I a i Page 6 of 11 i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 Sheaffer Centerville, MA Owner: Paul Glynn Date of Inspection: August 17, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 330 Number of current residents: 2 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: Currently occupied COMMERCIALANDUSTRIAL I Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): I Grease trap present(yes or no): Industrial waste holding tank present(yes or no) I 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 in 2001 -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: i TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy I 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: No information available Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) I Property Address: 36 Sheaffer Centerville, MA Owner: Paul Glynn Date of Inspection: August 17, 2004 I BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): I Distance from private water supply well or suction line_ Comments(on condition of joints,venting,evidence of leakage,etc.): �I SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 28" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed b a Certificate of Compliance es or no g g y p (y ) (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" I Scum thickness: 2" 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: 12" How were dimensions determined: Measuring stick i Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert There did not appear to be anVsigns of leakage Recommend installing risers on the tank to the cover. I GREASE TRAP: None (locate on site plan) I Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: I 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 f as related to outlet invert,evidence of leakage,etc.): I i 7 i i I r Page 8 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Sheaffer Centerville, MA Owner: Paul Glynn Date of Inspection: August 17, 2004 I 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): i 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.): j i I DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) I Depth of liquid level above outlet invert: i 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.): I I 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.): I II f 6 I 8 I - I I • Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION (continued) i Property Address: 36 Sheaffer Centerville, MA Owner: Paul Glynn Date of Inspection: August 17, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) i If SAS not located explain why: I Type ✓ leaching pits,number: 1 - 6'x 6'(1000Qa1.) 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.): I Liquid in the pit was 4"below the pipe The scum line was above the pipe There were signs of hydraulic failure 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: I Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): i PRIVY: None (locate on site plan) Materials of construction: I Dimensions: j Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): i 9 I i i Page 10 of 11 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Sheaffer Centerville, MA Owner: Paul Glynn Date of Inspection: Aueust 17, 2004 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. fJrA � �"0 nT � B I l I i / 16 a l I a �s a36 3 i I i r 10 I I I Page 1 1 of 1 1 i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION (continued) Property Address: 36 Sheafleer Centerville, MA Owner: Paul Glynn Date of Inspection: August 17, 2004 SITE EXAM I Slope Surface water Check cellar I Shallow wells i 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 maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: I I You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps the maps were showing approximately 30'+/ to ground water at this site. I I I I I I I This report has been prepared and the system inspected and failed 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. I I I 11 � I i f ' �� t t �7f V Commonwealth of Massachusetts Executive Office of Environmental Affairs *9 Department of Environmental Protection OOT f ��fQ One Winter Street, Boston MA 02108 (61'7)2925500 r 1 T0`�oF 1g99 .;, i� y�Tl�r��TT'q&F �'� TRUDY COXE - Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 36 Sheaffer Road, Centerville, MA Name of Owner: Ruth Manchee Address of Owner: Date of Inspection: September 25, 1999 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map. 172 i Telephone Number: (508)862-9400 Parcel: 035 I 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: I ✓ Passes Conditionally Passes Needs Further Ev ion By the Local Approving Authority Fails Inspector's Signature: Date: September 28, 1999 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS ( i revised 9/2/98 Page Iof11 Primed on Recycled Paper I ' E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION (continued) Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health: _ Sewage backup'or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,-settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken Pipe(s)are replaced _ obstruction is removed _ distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass ' approval of the Board of He alth): : inspection if(with pp ) _ broken pipe(s)are replaced obstruction is removed I I revised 9/2/98 Page 2of11 1 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) I Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 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 the public health, safety and 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 THE PUBLIC HEALTH AND 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. i 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil.absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface wateusupply: I The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well'. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER I s revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 D. SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: _ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. -The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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'/z 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable I'attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant,or Board of Health. 1 C _ ✓* None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of tliis inspection. * (House is vacant.) i n/a As built plans have been obtained and examined. Note if they are not available with N/A: ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components, excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been detemuned based on: ✓ Existing information. For example, Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)]. ✓ _ The facility owner(and occupants, if different•from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. i revised 9/2/98 Page 5of11 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 3 Total DESIGN flow n/a Number of current residents: 0 Garbage grinder(yes or no): No Laundry(separate system) (yes or no): No ; If yes, separate inspection required Laundry system inspected(yes or no): No Seasonal use"(yes or no): No Water meter readings,if available(last two year's usage(gpd): 1998-30,000 gals.; 1997-30,000 gals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gW(Based on 15.203) Basis of design flow 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: - OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped on Jun 11193 and Jun 8196-per treatment plant. System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Unknown. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6ofII S ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant, or Board of Health. ✓* None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. * (House is vacant.) n/a As built plans have been obtained and examined. Note if they are not available with N/A. . ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic fank was inspected for conditions of baffles or tees,material of construction, dimensions, depth of liquid;depth of sludge,depth of scum. } The size and location of the Soil Absorption System on the site has been determined based on: ✓ Existing information. For example, Plan at B.O.H. " ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)]. ✓ _ The facility owner(and occupants, if different•from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 a ` 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 3 Total DESIGN flow n/a Number of current residents: 0 Garbage grinder(yes or no): No Laundry(separate system) (yes or no): No ; If yes, separate inspection required Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last two year's usage(gpd): 1998-30,000 gals.; 1997-30,000 gals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL: Type of establishment: Design flow: wA(Based on 15.203) Basis of design flow 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: OTHER- (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped on Jun 11193 and Jun 8196-per treatment plant System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy _ Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of-information: Unknown. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron 40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting,evidence of leakage,etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 36" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8'6"x 4'10"x 5' (1000 gal.) Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: ". 9" Distance from bottom of scum to bottom of outlet tee or baffle: 13" - How dimensions were determined: Measuring stick . Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) The baffles were present The liquid level was even with the outlet invert. Recommend installing riser to bring cover within 6"of grade 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Sheaffer Road, Centerville, MA l L Owner: Ruth Manchee Date of Inspection: September 25, 1999 ' -TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or 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: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: None (locate on site plan) Depth of liquid level above outlet invert: Continents: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) 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.) i revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number: 1 -6'x 6' leaching chambers, number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.) The pit was dry and there were no signs of failure The bottom to grade was 10'6". Recommend installing riser to bring cover within 6"of grade CESSPOOLS: None (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(cesspool must be pumped as part of inspection). 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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 Map: 172 Parcel: 035 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) G� A � 10 p 3 �33 ` 93 Ay- a� „ o y fay - 3 1 to revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Sheaffer Road, Centerville, MA Owner: Ruth Manchee Date of Inspection: September 25, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 36+/- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole,basement sump etc.) Determined from local conditions Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. Must be completed) Using the Barnstable Water Contours map and the Topographic map, the maps were showing approximately 36' +/- to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site (SDW 252, Zone C, 8/99)was 3.6'. 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. revised 9/2/98 Page 11of11 TOWN OF BARNSTABLE LO'CATIO� 3(P is of A 1' �cr R SEWAGE # ✓II,LAGE Q2^T-P KNL6. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. t SEPTIC TANK CAPACITY LEACHING FACILITY: (type) t (size) 6 X NO. OF BEDROOMS 3 BUILDER OR OWNER RO\� IMA^C, e s— x PERMITDATE: COMPLIANCE DATE: Separ lion Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by GArA E Vc% -� - a�, n oi3 (D :� AH TOWN OF BARNSTABLE LOCATiO& S } - F SEWAGE # ,VMLAGE C "'T'LI .et C.C-Sc ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACIL=: (type) (size) '~ NO.OF BEDROOMS BUILDER OR OWNER PERM:I'TDATE: 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 L a s n :� 9 ��C� �� - �i�%,2tl�Cr�1 � _ - r ._� � � ( ,vB 1 Sv�S�rL sa/L z O 71 ENE 94 7 �• Per,P C a p P p.,B, 1 - ( lOr ,/tJQ.� /J y • 73 47 2G 3�6� � �',vcvv,�r,-�'.eEu -- 67 77E57- �4QLE J ` frr 5U __K__. . ....... 0-5-7.7/ TAY r'O dti1IV V,,q T'lam' //tA,5F'. OUI;LDIhIG 5E7" 19',K RE0U/ REMrz AZ 7-5 DR'/ ,1�/;-iY All0' 8€ �C 'f T Pe DP0 ,!s E D 13 .El >R © ©rMv 3 DEs I o/V LO 9DI-IVC' /S Usa.D'° r �';E'o:�'flS�D L:�ACH.r�32Ff3 �e� �,�F•� >�' Y,s �'��.r-g+,-�v.�.,�:��_,�ct c 7-i �,•r sH�,c..�. p��c c��.�•T;��:� ���s T . - ' • ZJ -r",E D" . c>yL ' / 19 77 'F9 ./2) ,r0i.ml o �' S lJL TS 8/9,'ek . -/94 . f!. '/�.;L 7 SILL cLFV. TC ( E FT" r'� D L/�- ,�'D. j c l / 2 F A/ 0 S0A4- E7 E 1"F-ERVIOU- -OVER M iAJ140 .,Ee'COVEER 'To EX7•EN-D 70 -, -r14 I .✓ 1' OF F/11,11,:5PED GZRR E r�-ROM /Ah-//-7-,e,97-/A/,/,- » ., _. ��rY •� �pt/Ee$ ,t UJST. S. t --�� �"'CFIS7' .&!JX �,•-� �r'1"W/vE .9.L� ,�OCJND �"MrN 4" [7f�9 wrarre ` d ? /0" C 1� rTc' NfDC /a"I�fl�• !¢.. l"rfFooT r`FQ - t.._OAJ s -y /N'✓�C'7' ! r(�./ L Ff f-r STD N E �,. {� .� Q� k //�✓lrE QT �! �� ./- Chi HL_._ A/VE e?r ,j t to -+- /2 "/•-';n/ r N f/Er�r _�' - - ���j�T .� ._ ..cam •_ O/ �T S •'�s�� - �'-r,�•i of r;.-� �_ 4 1z=.D-P407- ,PLtQAJ '4+ r / r• �©' 31 L/•!-Iir _ //7 / ) til t�';�. ;"� r• RAI- N o 571,�91f6/—E C O U A.17-Y //�t F r�5 ✓ et 'y�/,9 •c �,/ t��� ,Ae �`" ��•P T/ C T'.9 ;1J it 7"[� � F-� ,r.%,/r1/_ c a 7-/ o/v rq A/T) - tp,,e? C ,r-/ C H /A/ G Pf 7-13 �1 -ro -,3 E �.� P A2 C: P F A?T Y' ! �_'� /� '7" r` .�.�' 7"N.F� 'T`. �• �' ,tw �O G/ic/O/9 / / CJ.!/'' L . ,`,. ` .� F-j Jt1 L� .5 .� r"�• Tf C' Tt=� i"v'1<: f►/ ram/1'�7 Dh,' 7"`j-,` /�` /�'/f N / S L O c/� - ,►.'�`,�t�►•�; � ?:ti O,V T_t 1,6 C )Q ,o U PJ D !ei -5 S!-I c:? 1^/N f,' =ti F=.G7)%I 7`f-/,-9 T. / 7" !>O e-5- c 0 N ;C^j ram'/`' l J A T E~ '' / T L F �' �' /'v'7`!� �!� 7...j,4, .E' `�`"" Gtit" h! Qr� 6��'.�'.c-,_ if��4G.�_ ` �'•�, _ a`.�� ,h.`(f"`w Kr!�j-'/.fi��`�/�'. Y" _,.f!^..-�_� yy i,.r'•"+.�f.•!� _ _f""C 3 rn V V r Cj/A' ; tP k ;..cn-' �'s T t: rrGr��� ,:.,,r f�/ ...Ly:. '�i �r .Ire-" �.'i.,�i'�..4' '�i r•a.., .r,'�/J+�/;+ •� r !,, r i _�E.- -. ,f..�ti._ :.R-' fes�r_- _••_.a1N�b�1i" ... y..a+wa o..rw'� - .a..o.....+w.._.�.,..._ .......w�..,..rr++ean.aw.•r....o..r<s ... �. SECTION A -A ---- OI&'%'I'Wwa u +,., /� { 10' min. from- *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. ALL OUTLET PIPES FROM THE y VENT PIPE (9 Least 24 inches tan)- PROFILE MIEN OF ADDITION TO LEACHING SYSTEM DISTR1eDTION BOX SMALL BE ^ 12' -- CONCRETE COVER ,. , Existing Foundation [house to septic tank Schedule 40 PVC w/Charcoal Odor Filter SET LEVU FOR AT LEAST 2 FT. ,Y tic, r TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Septic tank coven must be 3' of 1/8" - i/2' washed Peostone `.� within 6 in. of finished grade prods over Septic Tank - 99.00 Grade over D-Box - 99.00 ow SAS - 99.00 3/4" to t t/2 Washed Crushed Stone 3 - 5.OUTLET -a- �-'- ,p /' I KNOCKOUTS yy ? •� \P4),, 'I i OUTLET : �� I 12' INLET S - 0.02 3 HOLE H-10 Tap Load - Elev. =96.25 `•�. / I 6" e; DIST. BOX 3' Maximum Cover _ _ - z. �r •ys '. / * ' T'r lg LEXIST. 5=o.ot or Greater u� L. S- I,'I. -15.5 - 4• - SCH. a0 T ' ' / JXIST PIPE per foot. (VO 10'FROM EXIST. FDUNDATIITN ,,, r; NK o � , ,D s units a b.zs' = as PLAN SECTION CROSS-SECTION ''0) to coteCREIE tut FWNM oI� n rn 0.83' (10 inches) - 31.25' L 6 in.of 3/4'-1 1/2• ' r SYSTEM PROFILE 11 37.25' 3 HOLE H-10 DISTRIBUTION BOX compacted stone o • rn Effective Length NOT TO SCALE Not to Scale - -` ° ° 4' - 4 n SOIL ABSORPTION SYSTEM (SAS) ® wR.wst�Nse samr•;O co4rra:Teo� -` a f 2.5 > 6 in.of 3/4'-1 1/2' t0' INFII_TATR❑R HIGH CAPACITY (H-20 L❑ADING)/ GE❑RGE ❑'BRIEN GENERAL NOTES compacted stone Effective vath OR EQUIVALENT Not to Scale NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE " 0 ( ) 1. Contractor is responsible for Digsafe notification Bottom of Test Hole 1 Elev.144' m NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" EFFECTIVE HEIGHT IS 10• and protection of all underground utilities and pipes. No Groundwater Observed O 144• / P 9 P P --------------------------- - - - 2. The septic tank and distribution box shall be set level on 6 of 3/4"-1 1/2" stone. 3. Backfill should be clean sand or gravel with no -- - - -- - - - stones over 3" in size. 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance PERCOLATION TEST with Title V of the Massachusetts state code, the approved plan and Local Regulations. 6. if, during installation the contractor encounters any Date of Percolation Test: OCT. 15, 2004 --_ soil conditions or site conditions that are different Test Performed By. CARMEN E. SHAY, R.S., C.S.E. -- -- - - PL _ -- --- -- from those shown on the soil log or in our design Results Witnessed By. WAIVER ( per Barnstable B.O.H.) 100.00 - - installation must halt & immediate notification be EXCAVATOR: Shay Environmental Services, Inc. made to Carmen E. Shay - Environmental Services, Inc. Percolation Rate: Less Than 2 MPI ® 24" 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. 98 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes- Test Hole 10. All solid piping, tees & fittings shall be 4" diameter No. 1 Schedule 40 NSF PVC pipes with water tight joints. DEPTH SOILS ELEV. 11. Municipal Water is Connected to ALL OF The Residence and Abutting 0 99•00 LOT #140 Properties Within 150 Feet. LSwtdY 15,000 Square Feet +/ THE PROPERTY LINES ARE APPROXIMATE AND ` to Y 4/2 COMPILED FROM THE SURVEY PLAN GENERATED BY 0"-6• A 98.50 O BARNSTABLE SURVEY CONSULTANTS OD YARMOUTH, MA ENTITLED �--- _-`_ SUBDIVISION PLAN OF LUMBERT MILLS , CENTERVILLE, MA" Loamy Sand ANDED DOT DINMENDED TO BE AOSOURVEY PO PAGE 65 IS LOT PLAN 10 YR 5/6 6"-32' B. 96.50 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN Med.-Fine LOT # 141 LOT # 139 THE SEPTIC SYSTEM INSTALLATION. Sand al: Gravel 2.5 Y 6/4 EXISTING LEACH PIT TO BE PUMPED OUT AND 24"-32' G 92•00 O REMOVED TO FACILITATE NEW SEPTIC SYSTEM INSTALLATION Med. NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE Sand z e/e �T�Jr FROMFgW EXISTING LEACH PIT TO BE DISPOSED PROJECT BENCH MARK C, 87.00 TOP OF FOUNDATION OF AS PER BOARD OF HEALTH SPECIFICATIONS. EXISTING ELEV. = 100.00 (Assumed) NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY GARAGE 3 BEDROOM ASSESSORS MAP 172, PARCEL 135 HOUSE#36 LEGEND Perc #1 Depth to Perc: 28" to 46" l I DENOTES PROPOSED 1o4x� Perc Rate= Less Than 2 MPI } SPOT GRADE Groundwater Not Observed I No Observed ESHWT I I DENOTES EXISTING ADJUSTED H2O Elev. = None i O 23, X 104.46 SPOT GRADE I I-} O -- PL PROPERTY LINE I ASPHALT ' � F 6 PROPOSED CONTOUR DRIVEWAI' I ° , • s 4E PVC of I. _ - - -97 EXISTING CONTOUR -- --- - ------- --- ------ -- _ VENT Failed -37.25' a '/// DEEP TEST HOLE & TEST HOLE #t 2-18' DIAM. ACCESS MANHOLES I I 15 5 PERCOLATION TEST LOCATION --- - 6 - ----- ---------- -t i Leach Plt ELEV.= 99.00 • r '` i n i- - -- -- - 98 100 00' 6 FOOT STOCKADE FENCE } ;:l _ I:= � i it ------ -- ---- ------ -- --- -- INLE T - W T S.CC P L_ OT PLAN -� �- THE ACCESS COVERS FOR THE SEPTIC TANK. � CHA E'FF..�. ' R O.A I_�DISTRIBUTION BOX AND LEACHING COMPONENT (40 FOOT RIGHT OF WAY) OF PROPOSED SEPTIC SYSTEM UPGRADE SET DEEPER MAN 6 INCHES BELOW FINISHED - - GRADE SHALL BE RAISED TO WITHIN 6' Of STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. PREPARED FOR PLAN A EW INSTALL TUF-TITS GAS BAFFLES OR EQUALS P A U L 8c H E L E N G LY N N 3-24• REMO ABLE COVERS A AT -4..- !- - -. r .;:. - 36 SCHAEEEER ROAD 3' min. deoronce �,r WIET INLET C EN TERUI LSE MA 6' min.T n. islet to outlet 6' mh _ -- -L-Y m-- �- Liquid level '._ � OUTLET 5' -r Design Calculations - --- E a I "_ 4'-0• min. OF M s PREPARED BY: oa �Bo1ei Liquid depth Number of Bedrooms:3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) CAl �lll �N F. /� �1�'1 ! Garbage Grinder: No o� R E G� 1 Capacity r O I Leaching Capa ty Proposed: 330 G I./Day Minimum (Min Per Tale V) Septic Tank - 2 x 330 Gal. Da = 660 EXIST. 1,000 GAL. Septic Tank. A r" P / Y - P ENVIRONMENTAL SERVICES, INC. 8•-0• 4' -10• -- 0 20 40 50 SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch p, 1 1 P.O. BOX 627 CROSS SECTION END-SECTION Bottom Area: 0,74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons -------------- O Sidewall Area: 0.74 � �, gal./sq. ft. x 78 sq. ft. = 58 gallons FGiS-T EAST FALMOUTH, MA 02536 Providing: = 331.80 gallons SgNITAR�P� TYPICAL 1000 GALLON SEPTIC TANK TEL/FAX : 508-548-0796 NOT TO SCALE Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1 "=20' SCALE: 1 "=20' DRAWN BY: CES ATE: OCTOBER 23, 2004 TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE ON THE ENDS. NO STONE UNDER. PROJECT#SD650 FILENAME: SD650PP.DWG SHEET 1 OF 1