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0381 SHOOTFLYING HILL RD - Health
381 Shootflying Hill Rd Centerville P A = 214 060 OD SIII ��RECYC`��C O z UPC 12534 No. 2153LCLR g°OSi.CON`Ja� HASTINGS, MN l No. Z//� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS fftplitation for BispoBAr 6pstm Cunstruttion Permit Application for a Permit to Construct(Repair( ) Upgrade( ) Abandon( ) omplete System ❑Individual Components Location Address or Lot No. /./�oa��l /� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel — �O G In�staller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms •S Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �! trJ' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) - gpd Design flow provided J, gpd Plan Date /0—, Ir— �/ Number of sheets Revision Date Title Size of Septic Tank��4't_j4'- 5- 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 Certificate of Compliance has been issued by this Board ofA4Valth. ne Q Date O � Application Approved by O Date Application Disapproved by Date for the following reasons Permit No. Date Issued t 5 9 l N. ..s / ' // / {�', ..,...++.�� � i Jam/ �—f' /yv—J ate`"" Fee L*/ 21 No. / THE COMMONWEALTH\OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE, MASSACHUSETTS Yes U l ,3y/ Zipplication for bisposaY 6pstetn Construction Permit I Application for a Permit to Construct 01'/Repair( ) Upgrade( ) Abandon( ) Zteomplete System [I Individual Components Location Address or Lot No: f�/po�y�ly/� � Owner's Name,Address,and Tel.No. 1 Assessor's Map/ParcelGa,ai�T- Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No./a Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building J' /' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) c+ gpd Design flow provided "i',S's e� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tankw ct�"GG So Q./ 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 Certificate of Compliance has been issued by this Board of alth. f \ ell�_71 o DateApplication Approved by , % Date ; - t Application Disapproved b Date 4 for the following reasons Permit No. Date Issued / TI1 E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(� Repaired( ) Upgraded( ) Abandoned( )by l�'-�Jy� �dP¢�0 my/ ,OKO,> G at �/ ,l'�coT �"L'y/r y/l has been con09� with the provisions of Title 5 and the for Disposal System Construction Permit No. Installer 057'o J ,L��o��l/�� Designer,�y/d �,�pl�-fir✓ ✓r„�' #bedrooms 3 Approved de ' ow ) gpd �Qv The issuance of this permit all not77!� strued as a guarantee that the system vw' �n&io a designed. Date Ins ector (/'S/ p , %___ - -f - 1 - - --------------------- `=- x- - ------- No. ..� � Fee U HE COMMONWEALTH F MA CO ON O MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal bpstem Construction Permit `Permission is hereby granted to Construct(1,1-' Repair( ) Upgrade( ) Abandon( ) System located at .s eFt-, .-P_006-f ��L yl j' (� /illl Z 4,F�7 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust a �Omple ed within three years of the date of this permit. Date Approved by U ' OCT/29/2013/TUE 09:01 AM FAX No, PAN Town of Barnstable �t, ,4,y Regulatory Services ti Thomas F.Geiler,Director i 1 Public Health Division 16 9. ` Thomas McKean Director 200 Main Street, Hyannis,MA, 02601 Office: 508 862 644 Fax: 508-790-6304 Date: 10) 7D� Sewage Perznit0o�/3 Assessor's Map/Parcel Installer&Designer Certification Form Designer: Installer: l� Address: 6fr C:55JH0bUYL0'1 Address: 41 7& �&W Onto _CV ,, � was issued a permit to install a (date) M (installer) (�{� septic system at L ' / based on a design drawn by �. (ad ess)_ ��A 1Qt�� f c'r/• �"1ortD4,Q�7 dated (designer) ertify 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 boat and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local R^ "°tions. Plan revision or certified as-built by designer to follow. Stripout(if ri- Feted and the soils re found satisfactory, �N OF M,gss DAVI D 9c�Y TT. b B. MASON (Installers Signature) 9 No.1066 R J3 WHe er s Signature) PLEASE RETURaN TO BARNSTABLE PUBL., _,, fE OF COMPLIANCE WILL NOT BE ISSUED UN i ii tsv i UILtYI AND_AS- BUILT CARD ARM RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:lotfice[onnsWesionercertiFcation ronn.doc TOWN OF BARNSTABLE LOCATION `p �/` oa� '�y�����SEWAGE# VILLAGE ASSESSOR'S MAP.&PARCEL i� INSTALLER'S NAME&PHONE NO. .� �o�`�✓� ��s"v7o� SEPTIC TANK CAPACITY.,O---"/e- �"o ���• p LEACHING FACILITY: (size) NO.OF BEDROOMS � OWNER PERMIT DATE: P_ COMPLIANCE DATE: —a `P/`s Separation Distance Between the: 000-® lwA�tp- Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �'� Feet Private Water Supply Well and Leaching Facility(If any wells exist orr" 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 kjr> � '� d '� ,. �� s8. 7 �� . � _ o �- � f � � �'- � s � ,y.� a .b-��AX �,; THE of Barnstable / ?C�7 oa nv�, Department of Regulatory Services M r� Public Health Division Date m n'699 ��� 200 Main Street,Hyannis MA 02601 _ �UUU y' Date Scheduled1 -`� Time Fee Prl. oD " Soil Suitability Assess ent for S''e. ,fie asp®sal Performed By: r �`i® �j �V�/ I S r Witnessed By: 1 w. n . 1� -4 LOCATION& GENERAL INFORMATION Location Address gJJ ��jl �,� / Owner's Name C'�a-s,.J; Address �y/��/��?//d'�r�i.��/L Assessor's Map/Parcel: Engineer's NameG,tt fj)��Q,� f. NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(R5) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line f[ Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) I yyy l CD Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Flloe UJ Estimated Seasonal High Groundwater C.'D 171 DETE ATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soil mottles: Itt, Depth to weeping from side of obs,hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Acjl,f'actor- Adj.C roundwaterLevel PEI RCOLATION TEST Date � Thna Observation Hole# 4*A Time at h" Depth of Perc �67 u_ Tlttte at 6" Start Pre-soak Time @ Time(9"-6") _ End Pre-soak N) N Rate Min./Inch Site Suitability Assessment Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observatibn'Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conseirvation Division at least one (1) week prior to beginning. Q:\.sEiric\PE1RcFORM.D0C DE EP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onsistency,%Oravel) e 5 �S 16(4 Am DE]CAP OBSERVATION HOLE, LOG Mole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ravel DEEP OBSERVATION HOLE LOG Mole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(iu_) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consis tencv.%Gravel) ( i ]DEEP OBSERVATION HOLE LOG Bole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consi ten a Flood Insurance hate Map: Above 500 year.flood boundary No_ Yes Within 500 year boundary No& ' Yes . .� Within 100 year flood boundary No f Yes Depth of Naturally Occurring Pervious Material � 1 Does at least four feet of naturally occurring perv'ous material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of' turally occurring per ious mat®fial? �' - Certification a ' I certify that on 1 (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was performed by a consistent with . the required training,expertise and xpe ie ce described in 10 CUR 15.017. Signature Date 08t� ZO� Q:WEVTIC�PFRCPORM.DOC r -- J +' -� Town ®f Barnstable Barnstable Regulatory Services Department AFfte'caC j BARNSfABLE, MASSPublic Health Division i63Q ti�� m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 0763 September 26, 2013 Daphine Philos 381 Shootflying Hill Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 381 Shootflying Hill Road, Centerville, MA was last inspected on 8/30/2013, by David B. Mason, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • The structural integrity of the septic tank is questionable. There is evidence that effluent has been above distribution-box cover • There is obvious age decay and the majority of the tank is under a deck. • Distribution box is in crumbling decay condition, must be replaced. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH s c ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\381 Shootflying Hill rd Cent Sept 26 2013.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=15312 R---owe�w-fon /eo' Logged In As: Parcel Detail Thursday, September 2013 Parcel Lookup Parcel Info Parcel214-060 "_ _._.._ — ( Developer SLOT 2 ID Lot' Pri Location 381 SHOOTFLYING HILL RD 1125 Frontage Sec _ �.. _ _ Sec; Road Frontage _ __._,__ Fire District r� Village rCENTERVILLE _ IC-O-MM Town sewer exists at this Road ---� 1484 address;No Index Asbuilt Septic Scan: Interactive , ', 214060 1 MapI; . Owner Info _ Owner[P ILOS, DAPHNE A Co- Owner Streets i�381 SHOOTFLYING HILL RD Street2 City!CENTERVILLE State EA j Zip -02632 __.__ Country Land Info Acres 10.48 Use Single Fam 146L-01 Zoning SPLIT RD-1;RC Nghbd 0105 Topography LLevel Road Paved Utilities 1PulicWaCer,Gas,Septic Location Construction Info Building 1 of 1 Year#;g�g Roof�Gable/Hip Ext!Clapboard Built I Struct Wall Living I; Roof� -- AC —_...-_ ,_ Area I i 524 Cover I~'ph/F GIs/Cmp Type None � h .. Int Bed Style Ranch Drywall 13 Bedrooms r Wall Rooms cnR Int ._____..__._._ _� ____ Bath,,-- ( __. ModelResidential � � Floor!Carpet Rooms 12 Full sMr piaxq _____ — Heat Total �� Grade Average { Type Hot Water Rooms 16 Rooms } Stories Story I Heat I-`s I Found-,Typii� cal"'m" + Fuel I"a ation Gross http://issg12/intranet/propdata/ParceIDetai1.aspx?ID=15312 9/26/2013 Commonwealth of Massachusetts W Title 5 Official Inspection Form ®Q� _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y ry c�M 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner. Owner's Name information is Centerville MA 02632 August 30, 2013 required for every g 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return key. Name of Inspector David Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification j 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 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Is Q ❑ Needs Further Evaluation by the Local Approving Authority U :° r9 -n; _ • August 30, 2013 = Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Appdoving Authority Gard 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. A q 9 1 � t5ins-11/10 Title 5 Official In Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 381 Shoot Flying Hill Road, Centerville Property Address . Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30, 2013 required for every g 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: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30, 2013 required for every g page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30 2013 required for every 9 page. City/Town 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 '/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 4\ Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30 2013 required for every g , page. CitylTown 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: ❑ z 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30, 2013 required for every g page. Citylrown 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30, 2013 required for every g page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: 2011; 10,000 gallons and 2012; 15,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30 2013 required for every 9 , page. Cityrrown 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: Board of Health 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30 2013 required for every 9 , 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: September 25, 1979 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 25"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Observable components appear in working condition Septic Tank(locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Majority of tank inlcuding the inlet are under a wooden deck. The tank structural capacity is . questionable due to decay and a new tank is recommended. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Typical 1000 GST Sludge depth: 4" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30, 2013 required for every 9 page. Cityrrown 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 38" Scum thickness 2° Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The structural integrity of the septic tank is questionable. There is obvious age decay and the majority of the tank is under a deck. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30, 2013 required for every 9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30, 2013 required for every 9 page. City/Town 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 Above outlet tee 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.): The dbox was packed with solids carryover above the outlet pip Evidence that effluent has been above dbox cover. Dbox is in crumbling decay condition. / 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Leaching pit location not identified because Town as-built card is incorrect. Did not identify leach pit since failure exists at the distribution box. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30 2013 required for every g , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding in supposed location of leaching pit. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts . v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is August 30, 2013 Centerville MA 02632 Au required for every g 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.): 1 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30, 2013 required for every 9 page. City/Town 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 t5ins•11/10 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 GSM 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos Owner Owner's Name information is Centerville MA 02632 August 30 2013 required for every g , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check'Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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: Ground water contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: gourndwater contour map and septic designs in the area Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts • W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments °M 381 Shoot Flying Hill Road, Centerville Property Address Daphne Philos- Owner Owner's Name information is Centerville MA 02632 August 30, 2013 required for every 9 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 Lt&n. 1/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS � i1as 'EXECUTIVE OFFICE OF ENVIRONN `' AL AFFAIRS VI DEPARTMENT OF ENRONMENTAL r r ` ` E �ROTECTI� 20005APR211 18. 38 TITLE 5 OFFICIAL INSPECTION FORM OR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A M CERTIFICATION 39�P_j A Prnne`ty Address: ° �� � .� /�,Y/ Re/Z Owner's Name: F e 63d1 Owner's Address: Po V X , 6 6 Date of Inspection: ✓'v� � �a',6� : Name of Inspector:(please print) Company Name.- _ 7—EC Mating Address: pa as 9 aL6�fl, Telephone Nnmher� _ CERTIFICATION STATEMENT I certify that I have below is true, have PMMMY inspected e te the smge�S� at this address and that the W rout rite off reported g and experience in the proper functi�and mspecaon.The inspection was performed based on my approvedenaace of on site sewage disposal system I am a DEP s3' m�Pector pnrsaaut to ' n 15.340 of ale S(310 CMR 110W0 The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ' Inspector's Signature: ��/`O Date: The system inspector shall submit a copy of this inspection report to the DEP)within 30 days of completing this inspection'hf the system is a shared$Authority Board w Health or 1�or g�ter,the inspector and the system owner shall submit the system or has a design flow of 10,000 DEP The original should be sent to the system ownrity. er and copies sent to the buyerthe , and the a of the Pl�ng Notes and Comments This report only describes conditions at the time of in time.This inspection does not address how the system will spection and under the Conditions of use at that conditions of use. perform fa in the ture under the game or different Page 2ofII OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOMENTS PART A FORM 3YICERTIFICATION(continued)property Address: S�JAo/ r Owner. �t� Date of Inspecdo : inspection Summary: Check A^C,D or E/ALWAYS complete all of Section D A. Sy : I Lave not found any information which indicates that 15.303 or in 310 C1�Ilt 15.304 exist Arty failure criteria not even of the failure criteria described in 310 CAM anted are indicated below. Comments; ------------ B. System Conditionally passes: ,"One or more system components as described in �•The system,upon completion of the neplaoeme> or Conditional pass"section need to be replaced or repairepair,as approved by the Board of HealtL,will passAnswer . yes,no or not determined(yexplaim ,N.ND)in the for the Poll $statements If not determined»plea c tank Is���20 yew old*or the septic tank w substantial infiltration ar exrdtration or tank fail ( hether metal or not)is MUcturally unsound,exhibits edsting tank is replaced with a complying septic tank as approved System will Pas inspection if the `�metal septic tank will Pass inspection if it is �' Board of Health. indicating that the tank is less than 20 years old is avail* ,sound,not leaking and if a Certificate of Compliance ND explain; Observation of sewage backup Or break out or hi gh obstructed Pipes)or due to a broken,settled or uneven static water level in the distribution box due to broken or approval of Board of Health) Won box System will pass inspection if(with men Pq*s)are replaced obstruction is removed distribution box is leveled or replacedND explain; P system Ping more than 4 times a year�to Woken m (with approval of the Board of Health). pipe(s).The system will broken pipe(s)are replaced obstruction is removed ND explain; Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of lnspection: C Further Evaluation is Required by the Board of Health: Z(Candifions exist which require further evaluation Is failing to protect public health,safety or the enviromnent. Board of Health in order to determine, 1• System will pass unless Board of Health date system is not function. rmines in aecordanee with 310 CMR 1&303(ixb)that the 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 Z. System will fail unless the Board of Health system is functioning in a manner that (and Public Water Supplier,if any)determines that the protects the public health,safety and environment: _ The system has a septic tank and soil absorption system surface water supply or tributary to a (SAS)and the SAS is within 100 feet of a _ Supply The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Private water has�c.Method u and the SAS is less than 100 feet but 50 feet or more from a * o detamine distance *Tim ristem passes if the well bacteria and volatile o water 'performed at a DEP oerrified Labor for conform the ice ccompounds indicates that the well is free iiompollution from that failure sensecriteria are triggered,A trogen and Irate nitrogen is equal to or less than 5 f ty other and copy of the analysis must be attached to this f lam, that no 3. Other: t Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION(moutinaed) Property Address; ih Owner: ✓v� ��d-Date of Inspection: CA o D. System Failure Criteria appficable to all systems: You must indicate"yes"or"ao"to each of the following for all inspections: Yes No Y — of sewage into facility or system component due to overloaded of dogged po of effluent to the surface of the ground or surface waters due to Dischargeor cesspool — SAS , Static liquid level in distribution overloaded or bution box above outlet invert due to an overloaded l ceded or clogged SAS or depthin Cesspool Bless than 6"below invert or available volume is less than times pad Pumping more than 4 times in the last year 1V_OT due to clogged or obstructer flow pipe(s).Number A.portion f the SAS,cesspool or prig,is below high ground water elevatio supplPortiony pal or 1 q is within 100 feet of a surface water supply or tributary to a surface v IMY portionof a cesspool or privy is within a Zone 1 of a public well.poman of a cesspool or Pi'Y is within 50 feet of a —LeAnyportion of a cesspool or privy is less than 100 feet but water 'well. supply well with no acceptable water quality analysa than fi om a private water performed at a DEP certified y� ry,for coliform bacteria and vem �o d�well water analysis, indicates that the weD is free from pollution from that facility and the prey organic compounds nitrogen and nce of ammonia nitrate nitrogen is equal to or lees than s Pp�provided that other failure criteria are triggered.A copy of the analysis must be attached to this foruLl (Yes/No)The system fah I have determined dw one or more of the dcacribed in 310 CUR 15.303,therefore the �o� �criteria exist as Health to determine what will be necessary to Correa m fails.Th the failur+�e system owner should contact the Board of L Large Systems: To be considered a large system the system most serve a f gpd. aplity with a design flow of 1000 gpd to 15,000 You must mdicate either " of the (The following criteria V to�systems m addition t following:crime above) Yes no system is within 400 feet of a surface drinlong water snp�y the system is within 200 feet of a tributary to a surface ddnidng water supply the system is located in a w���(Ind Wellhead�ewon Area—IWpA)or a ne 11 of a public water mapped if you ha "ye�any question in Section E the "ryes"!Lj tion system is considered a significant or answered signifi threat under SectionE or failedunder S�ecfian Ile owner O1 operator of any large system considered a 15.304.The system owner should contact the appr+opr,�regional f �` �with 314-0 Pam Sof11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM k PART B CIIEC3CL ST Property Address: �O !'lOp� n� p Owner. Date of Check if the folio have been done.you must indicate es"or"no"as to each of the foilowin ; Yes o v g informatim was provided by the owner,occupard,or Board of Health T Were any of the system cow pumped out in the previous two weeks `—/. —1�s the System received normal flows in the previous two week penod Have large volumes of water been intirodvCed to the system recently or as part of this inspection Were as built plans of the system_obtained and exa>runad?(If they were not available note as N/A) T Was the facility or dwdhng i d for signs of Sewage back up Was the site inspected for signs of brrak out C/�eae ailWslem c'ono g the SAS,locked on site of the or teen material of� ms,& of " of the tank inspected for the condition ct d*th of sludge and depth of scum WU the facility ow=(=d oc if difl'exent fi gym e ofge oM1vDef)provided with Wwmatitm on the praW The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no ✓ Existing information.For example,a plan at the Board of Health Deftmdwd in fie) �5.field (if any of the failnre criteria related to Fart C is at issue approximation of ' )) dcstanoe Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSES SSMENn UBSURFACE SEWAGE DISPOSAL SYSTEM:INSPE PART C C1'ION'FORM SYSTEM 1''ORMATION Property Address: ,48,: Owner: fe Date of rnspeo6f� _-�5— os RE3IDIPNTIAi, FLOW CONDITi pft Numb of bo&oom(design): 3 N, �(ate DESIGN flow l�ased.aa:310 CNR•15.203(for- 7 Number of�r�ent resiaeNs:L_ : 11a gpd.x d.Of ��D Does residence bave a garbage grim 6 or no):kip is la ndty on a separate sewap system(y_� Laundry system,inspected(v UD) _/� or•,l no):/iJ [if yes separate inspo d.required]. Seasonal user:(yes or no): Water meterma&W if mailable(last 2 years usap Last dSump�(yes or no): (/f0 �)' occupancy: COMMERCIAL/MUSTRIAL Type of Design flow(based on 310 Basis of design now(seats/persons/sgft,etc•). Gmw hap present(yes or no):Industrialwaste holding tank Pit(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no Water meter readings,if available: ) — Last date of occvpancybse. OTHER(describe): ---------------- Pumper Records GENERAL EU ORMATION Source of information Was system pumped as part of the inspecKian(yes or no pL If yes,vohm�e pumped: )� Reason for porn �`"—'�—How was quantity Pumped determined? SYSTEM Milk distribution box,soil absorption system —Single cesspool —Overflow cesspool —pziw —Shard system(yes or no)(if yes,attach previous inspeW0n if any) obtai '•Attach a Dopy of the c operatron andmamtenav= contra(to be —Tight tank _Attach a copy of the DEP apprmxi —Other(describe): Approximate age of all oanponen%date (f se �j�nd source ofinb Were wage odors detected when arriving at the site(yes or no):� Page 7 of I l OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORMTS PART C � SYSTEM INI''ORMATION(continue Property Add Owner, I-11ti ii t Date of { BUILDING SEWER(locate on site) ' Depth below grade; Materialsof Di ce from prn �� — ' '"_°�( ): Comments (an co�nditian of '��sucbm Vie' �°�: evidence ofl et). SEPTIC TANX- on site pit) Depth below grade: (7 ,j Material of constitrctiorx —°�'(e ) —metal _polYethYlene If tank is metal ft age:_ Is ague cerdficate) confirmed by a Certificate of Cmapfiance'(ves or no):_(attach a copy of Dimendww Sc C. to bottom Of°utlet tee`orbaffle: oZ' Distance from top of scum to tap ofonft tee or baffle.- Distance from bottom of scum,to bottom of i How were moons detera�d: 4 / outlet tee or batHe:��i Comma(On ping recommendati�s,inlet and�9 o/®v, �to outlet invert,evidence Of.1 etc. tee or baffle condition,gructufal � ,; 1 ): liquid levels CO✓1 t h q7 ,4=:: 6 11<]00 0 GREASE TRAP'�&'cate on site Plan) Depth below gra&. Material of CORStructiox.—concrete meta! (explain): —fl=rjass--polYeth3'ke_other Dimensions: Scum thidoaess:_ Bistaice from top of scam to top of outlet tee or bate: Distance from bottom of scum to bottom of outlet tee or be ft _ Date of last puapitng: Comments (on pumping recommendations,inlet and oullet,tee as related to Outlet invert,evWMM of leakage,etc.): or braffie conditions�, Y, d levels Page 8 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSME SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORMNTS PART C SYSTEM INFORMATION(continued) Property Addr+esa; /���/ Owner r� � Date of Inspection;� � o TIGHT or HOLDING T kW. (tank most be pumped at time of 0n)0o«ate on site Plan) Depth below grade: Material of construction: concrete—metal fiber onSS: glam—p°lyeklene other(explain): Design Flow: aallans&y Alarm Pent(yes or no): Alarm level: Alarm in wo Date of last puniping: ff$order(Yes or no): Comments(condition of alarm and float switches,etc.): DISTMUTION BOX:v of Present must be OPCD40ocale on site plan) Depth of hwd level above outlet invert:fda/✓yr 4 Z_ Comments(note if box is level and d*ftt m to outlets 1 or wrt of N, e9ual,my evidence solids carryover b x •my evidence of �tiv /f PUW CHAM (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 e • Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYST.EM.paPEC,,MN FORM ?,o SYSTEM INFORMATION Property Add m Owner. r, o� 24 641— Date of InspectWw p s SOIL ABSO q$ygT Off: (tame m s C Pbul,eac vatic.eat.ro ae� N SAS not locaW why: C Ty leaching gfiaim n : �� 1'a o rn ffxnber,lei: _S overflow cesspool,mmnber: . System T3'Pdham of tecmwww. Commas(mle condition of soih,sips of hydraulic failure,level of pondiag,damp soil,conon of etc. vegetation, � / I� CE h ( mm be pumped as part of inspectiionVocate on site plan) Depth-tWof h@AdID inlet iavx& Depthof solids lamDepth of mm byw Dbmsjow o€o£ : Matetiahs afco ; Indication aft ,(YO oenD):. Comm Oft of soil,sips of hy&mk fmWM L-wd a fp canditi=a€veFWfiM ems.). PRICY:/�� an e she pine) Mate�ls afeaa�tructiam Dimes Depth of sow Commem*6o - ofs*ago of kdrat*c bffiffe,level of pandi, of vet etc.): .• Page 10 of I I OFFICIAL INSPECTION FORAM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oo Property Address: Date of bVft'I;W-. SKETCH OF SEWAGE DISPOSAL,SYSTEM Provide a sketch of the sewage disposal system mchxhng ties to at least two permaaet reference lam of benchmarks.Locate all wells within 100 feet.borate where public water supply enters the bonding. J ll/ Ake a9 ' 23 �_ a9 ' • Page 11 of I1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cow Property Address: ,.3!5;1/ 5 0n Owner.. Date of Inspection: SITE EXAM Slope Surface water x GS Check cellar �— Shallow wells �� 3 Estimated depth to growW water feet 3 � Please indicate(check)all methods used to determine the highgr amd water elevabom from system design Plans on record-If chedmA date of design p1m reviewed: site(fig Propeity/observatim hole within 150 feet of SAS) Checked with local Board of Health- explain: li"1L►/� f Checked with local excavators,installers-(attach documentation} To-F Aid USGS database explain: YOU must describebpw ypu established the NO ground water elevation: . O AN'1 O -ZetiG . 0000 , •� Oho o ��� lad p too 0 /fin J 06 0 Z No.............. Fimic... .. .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD ........... 01.........OF. R--------------------------------- Appliratiou� for Disposal Works Tunstrurtion rrrm* it Application is hereby mad for a Permit to struct or Repa* an Individual Sewage Disposal Sys at ,2. .&..�O....07- mw. ......dZ1111. ........................ ............7.............. Loc dress or Lot ---------- ............................................. ...................................................I............................................ Owner. , Address . . ............. .................................................................................................. Installer Address U Type,. . Bul ding Size Lot............................Sq. feet Dwelling-PNo. of Bedrooms.`.......2...................... Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons____________.____._.___.____ Showers Cafeteria Otherfixtures ..................................................)................................... ............................................................. Design Flow . ..............gallons per person per day. Total daily flow..__._.__. ..................gallons. 9 Septic Tank_Z71L'"iq'u"id capacit"Y/S__ gallons Length________________ Width................ Diameter..._.__..______. Depth_._.__.____.._-. Disposal Trench—No_ ................... Width................... Total Length._____.___.____.___. Total leaching area....................sq. f t. Seepage Pit No--------/----------- Diameter..401/6.,.. Depth below inlet_________ Total I thing area..................sq. f t. Z Other Distribution box Dosing tanJ4 0-4 Percolation Test Results Performed by.__._ --- Date..... Test Pit No. 1...bl....minutes per inch Depth of Test'Pit.................... Depth to ground water_____d............. . 0-4 04 Test Pit No. 2................minutes per inch Depth of Test Pit_____._.________._._ Depth to ground water........................ 04 .......... --------Y---------ri........ ................. 0 - - -- ------�v— X;L ...0----_/------------------------7------ -------- ...................... ........ .......... Description ?9 Soil.....'..A.._ 4 - - ------------- ......... .......... .... .......... ... ----------- ............................................ U - I - r4 ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T-I TILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee lL issued by t e board of health. Signed07. .......... ................................ 4 —Date Application Approved By...... 6ate 1-77 Application Disapproved for the following reasons:............................. ........................................................................ ...................................................................................................................................................I..................................................... Date PermitNo......................................................... Issued...... ........................ Date -7 No....................... FEic.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD .......... ---------- ......----OF..Y&411.1000-le............................................. Appliration for 11ispaiial Works (famitrartion Frratit Application is hereby ma r a Permit to struct or Repw an Individual Sewage Disposal Systeipat -4 ...... ..... ....I./............................................................ A. . ........ ... ........... .Lo dressor Lot No. ... ... .. .. ......... ... ............. ................................................................................................. 0 n rF Address (C4, . ..... ............ .... .. .7.....17. ..... ......I........................................................................................... Installer Address Type of Bqildira Size Lot............................Sq. feet U ,,Dwellln'g No. of Bedrooms. ......... . ...........................Expansion Attic Garbage Grinder Other-Type of Buildin ..........A............__ No of.persons_ _______:__.__________ Showers Cafeteria P-1 ...... Other fixtures ..........................................Vt------------------------------------------------------------------------ ............................... ......................... rallons. Design Flow .......X.y gallons per p6fson per day. Total daily flow________ capaci Y/5........gallons Length______.......... Width.___________.___ Diameter..._._.__.______ Depth. V4 Septic Tankk�Li Disposal treridi o6 -------.............. Wi4hk, Total�'Length____________________ Total leaching area....................sq. f t. 0- 1 ... Diameter._ ....De ' lm�d h- ..........sq. f t. Seepage Pit N ........ pth- ow inlet....... Total leach- ing ajga.,=,.... .Other Distribution.box..(.' 004'. 4�c Z Dosingtan4;� A at T 7s, Performed Percol 16ft Test Res by.... .4 Date.... ... Test Pit No. I...............mitfutesperinch Depth of Test Pit____________________ Depth to ground water----_-40............. fX4 Test Pit No. 2________________niinut, er inch Depth of Test Pit.................... Depth to ground water........................ ... .... ......................... -------- .......I..................................---------- -r' ......... .4 wr,4 0 DI.-scriptiorypT$oil.............................. ------- ............ ....... .....i.,.......2.............. t...................... -- ------- .. ... .. ... .... ...... ............ ... ..................... ......................................................................... ........................... .................... ........................................................................... --------------------------------------------------- ----------- .. U Nature of Repairs or Alterations Answer when app lica ble.....-------................................................................................... .................................................................;----------------7----t............................................................................................................... Agreement: The undersigned lagfees to install the aforedescribed Individual'Sewage Disposal System in accordance With the provisions of TIT 2 5 of the State Sanitary Code— The undersigned further agrees not to'place the system in operation until a Cerlificate of Compliance has bee issued by t)e board of health. issi r Signe '0 . . . ... ............ ............................. A 1* &'oved By...... 0 a pp ication Apl:,,, ... .................. Application Disapproved for the following reasons:...1 /100" .............................................................------....................................... ...................................................................................................................................................................................................... Date PermitNo.......................................................... Issued........................................... ........... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ..........r.. ........... OF ......................................... Trrfifirab of Tampliaurr IS TO C. FY, That the Ind' ual age Di posal System constructed or Repaired by...... ....... ..... ... .... .......49.1...... .... sta le -----------111.;a .........s-o/- ................ at....... .... . ... . .... ... .. .... has been installed.in accor nce with the provisions of _..l. too-' /State Sanitary Code as described in the application for Disposal Works Construction Permit N .............Vk.f............ dated ----- ...... THE ISSUANCE OF THIS CERTIFICATE SH NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ ........................................... Inspector......11�...................... ................... ..................................................... THE-COMMONWEALTH'OF MASSACHUSETTS A BOARD OF HEALT .....-7 .........OF............ ------------------ ..... ...... No................. FEE.... .............. litritetwit. rnfit 'Permission hereby granted_`""..... ....................................... .......... ..... ............ ........ ... to.Construc A 0 or fijppair i1ndividu aq, is os st E I I . at No..- .... .. ........ ........ .... ... ...... ..... ......... .... ............................. o S reet. as'shown on the application for Disposal Works Construction P 0. gpated..A��,pr9it N ............... ........ Board of Health ........DATE........�- .2 1-...7 . .......... .... ........................................ FORM 1285 HOBBS & WARREN, INC., PUBLISHERS .a ...ib41' 1R;ev t54 . v IP ------------- u't 1 •J 1 s/ .r } 7 L'.. 19, f `` RpBERT r o BUNIKIS N No.22162 S IONA\= LEGEND EMSYING SPOT EL'O=VATION ®„0 CERTIFIED PLOT. P LAN • ETt0STONG CONTOUR - 0 - - - 07 -2 sr?aort.y!IV Hict Ala; FINISHED SPOT ELEVATION LO _ FINTS.HE-v-%ON-TO-UR — L -- APPROVED : BOARD OF HEALTH 9 � d��J ��s1� ddo "BAT E AGENT SCALE / 40.�, DATE /7 s T 9 ' �®�(�®GE EiVGIAlEE'RlRIG CO. IN e_ CLIENIT __-- - - -_..-- I CERTIFY THAT PROPOSED , REGISTER EGISYERE - JOB No. l_9OSS-- BUILDING SHOWN ON ' THIS PLAN ED . , CIVIL LAND CONFORMS TO JHE ZONING LAWS...' Ei�ICIbEER SURVEYORS) OF BARfdST BLE , FAA S { . 33 NO. MAIN ST 712 MAIN ST CH. BY:: /� S0. 'YARMOUTH MASS. HYANNIS MASS. ;, ' ' SHEET L_ OF DATE REG. LAND SURVEVOR"t -e?O FT. /�Al//V /\:07"E iLII :>>, �`i4C1r//tlCr �/..7 .q/4E. �t�ePE.;.TNAs"✓ 01�/ : Y k,µ A�•L ,.6'I� I�R�UGIh�� �'"� A6d�A®E' -%`�1✓ ,EJ1`T�s4 NG�l E E,gvy CA 5-r/A,oN CO v.4 R -TI'AL e' bFL_E✓. -t 0 O O COf/ .S "� T /f�//N 0R1 V.—,VA Y { t�I '® a�Tel Co ✓ER C'L Ef4N -5-AN� ' •'•e: _-_r� L/qa/e®LEVEL - _ - •• T� - 2 LAYFR t® /ROCS P 0 0 o e o ... OF el'8 -318 .61 MIN.P/TC/e F.�I L. a p ® o o © o 0 o n a� WA 5 HE0 570NE %'Pz/� � SEPTIC TANK o/sT � o 0 0 0 0 0 000 o � � q.l Bay mE�FEC�/VE ° 4 m v 1 a c o © o Dz�/,� ® o a ° a o� WASHED STONE 0 oIf P n�IN.__ °, ®o , PRECAST SEEPAGE 1h1VLOe� L��L[��A�/®a�S �, a 0 0 0 0 'a o 0 0 0 �� o P/T DR EQU/V. p P + m IMYZRT AT ffUil-®/No 97. o FTJ INLET aSEI®T/�' Tf$MK 6 .S .FT, —AP ®/i4�9. 1• (e SEE TABULATION, oCOTLET sEPT/C TA v.,< 96 -3 FT. BOX d. J '7 GR®UNO D�dIYEIr TA®L iF ourLzT®/STR/..®a/!7 oN SON 9 S, 9 F7 �oT 2�.S FT .�E1��-0c�i� �O�'G� �41� �A�.��'�M -SCALE Y4 0- ,DO'S16,V C'R/TER/A ®/A9EMS0®/d 's�_��. NUMBER OF 46EDMOOMS 3 DIAlleNS/ON GA ROAOE®/SPOSAJ-Uq//T sou- L®G TaT�L ES"P//di.�TED �LOtii/ 3 O SO/4 TEST 4'-1 Son- TES7-02 : IYuMWER OP ,40AeaeVa P/T577 _f /-F4&rV .. 2.v -���ai , 7,E a?P So/L TESL- fl yG . y S/OE LEAiCH!/V6 PE/�P/7• 1 _SQ FT. , : — �. l✓1�iS . O _ e� "' I�ESaJ�l.TS �/!T/ieESSe�® dY_-_--- ®oT`TOM 44S4C'N/NG AP-MR 7 �. 6T a s? ^1 PERC®LI�7'/OJV IgATO*/ LESS l�lN�/iNCK Z-6 fo ATe®/V RATE#�2 %'r,—AW TOTA9L J-eAC/ 1WC- AREA m5'Q, FT ®7 .2 MJIv.�/NCH RE3ER!/E L Es�CP/!/VG AREA z U � SQ.' F7� 4 - - T Syr0O7 ��✓� \ZH OF A,S� A W /r ; 3 q� FiAl46 s o ROSERT, ` Q. N F a P. rn BUfYlKl.9 No'221 i 9� ���r r✓c 7/2 l�lD.MAl7!!.Sr.- 90 "Jig�4`' �� ; x r ry H„YANN/B, MASS: �A:Y,Ye SOW> Rly/Ot✓7AO PI. <; y - LNo <, ,. .. :.;T� ..' _ `�• t a�:. r,�. c's:i- Y �+`.sx +z '•f` `,:.+' }"' r.1��,<'� 'S:F lb' ... `y � _ ,.,�_. .s.. _ -, '. ;;�• �, :. � :, :•. .....? ...,`v....��,.r,-."f its-.;zr.�.'-,�L,=c'� :_'--»c.x.K. ,.,_w ._'-1'_?.s...ea`�-. s.7 p d-•.r .�.X` �''.: .: A...._ ,.�., -.. .. - - !,,0 CAT ION SEWAGE PERMIT NO. VILLAGE C9 o(v INSTALLER a ADDIt NAME ESS 42 0 UILDE R OR OWNER (A) � w� S DATE P R IT ISSUED DATE COMPLIANCE ISSUED -25-_ 7 /�J,6 r #., L Olt- pv�S - i i I ASSESSORS MAP : Z/ TEST HOLE LOGS PARCEL : 1 1} The installation shall cor,ii.d, with Title V a:3:1 Town ofigQ. oard ok - 94? FLOOD ZONE: �� �G-/ SOIL EVALUATOR : l�'I,. (. , Health Regulations. .. . WITNESS - '6"17 2) The installer shall verify the location of utilities, sewer inverts and septic REFERENCE ® `U`�'Z DATE: 7.A1 components prior to installation and setting base elevations. _ . 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first PERCOLATION RATE,: U , 1 G�7 FI PZ'0T � � two feet out of the d-box to the leaching shall be level. 4) This plan is not to be utilized for property line determination nor any other _— .._ TH- 1 TH-2 purpose other than the proposed system installation. 0� i )Lb 5) All septic components must meet Title V specifications. _ a 6) Parking shall not be constructed over H10 septic components. 7) The property is bounded by property corners and property lines. �i1 8) The property owner shall review design considerations to approve of total LOCATION MAP �I i/ design flow and number of bedrooms to be considered for design. Receipt 5ti of payment for the plan and installation based on the plan shall be deemed M' approval of the design flow by the owner. I�t� 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall I / I be removed along with contaminated soil and replaced with clean sand per Title V specs. �,1� 10)System components to be 10 feet from water line. Sewer lines crossing the � 91 ( `� water line shall be sleeved with 4 inch SC14 40 PVC with ends grouted if '� applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. CO SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the � owner to ensure such. 12)The installer is to take caution in excavation around the gas line if such FLOW ESTIMATE exists. 13)The installer shall verify the location, quantity and elevation of the sewer BEDROOMS AT GAL/DAY/BEDROOM ��D GAL/DAY lines exiting the dwellin"rior to the installation. 14)This plan is representative only that a system can fit on a property meeting SEPTIC TANK Title V requirements. .3aO GAL/DAY x 2 DAYS • ( /GAL USE I GALLON SE TIC TANK(gR C i F*A[a)1 MAS{ON S I DE AREA: 21� P k � j e� �� = V�k . 0 BOTTOM AREA. 2-4 X I� L:>I-7 N �rj 0 0 p P do �,,,�j, .� PTIC SYSTEM SECTION o . _ :1VWK, J b_, tic. OR GUMS �G D-BO I 16-00 GAL lP ►�� � " I��. � � �9� SEPTIC TANK I r °on _ _ SITE AND SEWAGE PLAN — LOCATION : Jed �Hg2r kLf Hu, Pblr PREPARED FOR : Hq ,,._.I�,,� 1� o SCALE: % 2D DAV ID B . MASON 94 DATE : z DBC ENVIRONMENTAL DESIGNS Z DATE HEALTH AGENT EAST SANDWICH .` MA W z ( 508 ) 833- 2177