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0521 SHOOTFLYING HILL RD - Health
521 Shoofting Hill Rd Centerville P A = 193 019 i No. 4210 1/3 ORA Ips (Jo 43 07== 10% (o O p G pff 6,�� 2 e No. `�� ` 36� r � r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS es 2ppYicatiou for Vsposal *pstem Construction Permit Application for a Permit to Construct( ) Repair/Upgrade( ) Abandon( ) ❑Complete System Individual Components LiNonAddrressorLL�ot�1o.�Zl � ®�� p � Owner's Name,Address,and Tel.No. Assessor's'Map/Pazce1 . %V� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. fiV/-/r/ Type of Building: Dwelling No.of Bedrooms Lot Size Z Z` < sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requtf ed) J gpd Design flow provided 13- gpd Plan Date g 1P Number of sheets Revision Date Title 5cs ae Size of Septic Tank I55�29 Type of S.A.S. r} 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 He 1 . V Signed Date Application Approved by Date 2—.7 —.2o(0 Application Disapproved by Date for the following reasons Permit No. ,, �D og Date Issued No. o�G 3G - `is" a`a F Feet [ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Misposal ,*pste Construction Permit i Application for a Permit to Construct( ) Repair(V�Upgrade( ;) Abandon( j .;❑Complete System Individual Components 1 Lo on ddress or Lot�lo.s�Zr ,5 0� y�wrp��� Owner's Name,Address,and Tel.No. fq�3--©y, Assessors ap/Parc G ee t t--lvl l/e Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: y Dwelling No.of Bedroom's Lot Size Z / sq.ft. Garbage Grinder( Q Other Type of Building `j €'�_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets ! Revision Date ~ Title $ lalalo e // f/ f 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 Certificate of Compliance has been issued by this Board of He 1 . �.�-----_. Signed Date c Application Approved by Date to Application Disapproved by Date for the following reasons Permit No. ova O ' 36g Date Issued 9` THE COMMONWEALTH OF MASSACHUSETTS , BARNSTABLE,MASSACHUSETTS � '¢a Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewa a Disposal system Constructed( ) Repaired(J Upgraded( ) Abandoned( )b, at ,Z-1 / has been constructed in accordance M with the prAll- ' ions of Title 5 and the for /D a D Disposal System Construction Permit No. AD - 36pq I `a-10 dated I ��/® / ( �6�3' Designer nstaller #bedrooms 3 Approved design flowA _37_ 40n gpd The issuance of thi pe t shall not be construed as a guarantee that the system wil fimc io as designed. Date 9 Inspector s . ------------------- No. polo —3 6 _ Fee /61) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal �*pstpm Construction permit Permission is hereby granted to Construct ) Re air( V lUpgrade( ) ,Abandon( ) System located at � F/ ed! Ur.l and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permii� Date ( —a �r Approved by %�j U J✓�/�j,/ 1 TOWN OF BARNSTABLE 00CATIONL21 Z2L"V hell AJ SEWAGE# V LLAGE� �ff ASSESSOR'S MAP&PARCEL O�,J INSTALLER'S NAME&PHONE NO.; d,j SEPTIC TANK CAPACITY /J^lsfi Cl ��riJ�%r LEACHING FACILITY:(type)Alc X CI d.J td ,(size) /L K;e f//J X W" NO.OF BEDROOMS OWNER PERMIT DATE: /fit COMPLIANCE DATE: D 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) j Feet FURNISHED BY C' .O.Oe ,. 11S vc�1 • J Massachusetts ` 93-- o�/ Commonwealth of as achusetts �d 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker " Owner Owners Name information is required for every Centerville MA 02632 7/7/20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information 614 L4l01&+ Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspectors UhatEre Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7126J2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f •� 521 Shootflying Hill Rd. Property Address Baker Owner Owner's Name information is required for every Centerville MA 02632 7/7/20 page. CityTrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exMtration 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owners Name information is required for every Centerville MA 02632 7/7/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owner's Name information is required for every Centerville MA 02632 7/7/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Shootflying HIII Rd. Property Address Baker Owner Owner's Name information is required for every Centerville MA 02632 7/7/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owners Name information is required for every Centerville MA 02632 7/7/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owners Name information is required for every Centerville MA 02632 7/7/20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 Description: Engineered plan on file Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 501 gpd 9 ( Y 9 (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l� 521 Shootflying Hill Rd. Property Address Baker Owner Owner's Name information is required for every Centerville .MA 02632 7/7/20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2018 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owners Name information is required for every Centerville MA 02632 7/7/20 page. Cityfrown 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: Existing septic tank, new d-box and infiltrators 2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owners Name information is required for every Centerville MA 02632 7/7/20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2'6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, inlet cover raised to 12" of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 6 Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace-1/2" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �d ,�3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owner's Name information is required for every Centerville MA 02632 7/7/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 11 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owners Name information is required for every Centerville MA 02632 7/7/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is TT below grade, poly cover raised to 4"of grade, no adverse conditions t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owner's Name information is required for every Centerville MA 02632 7/7/20 page. Cityrrown 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: 10 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts '. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owner's Name information is required for every Centerville MA 02632 7/7/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 10 infiltrators per as built, infiltrators were video inspected and are damp at this time, no indication of past hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top.of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owner's Name information is required for every Centerville MA 02632 7/7/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �. ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owner's Name information is required for every Centerville MA 02632 7/7/20 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 TOWN OF BARNSTABLE LOCATIONra?/.J4aes'' /Iil�// SEWAGE# dJO— d( VILLAGE /� ASSESSOR'S MAP&PARCEL /9l INSTALLER'S NAME&PHONE NO.a,ir1r�,- %„, Ky'ft 4 SEPTIC TANK CAPACITY /f 00<( it r(Uxre j LEACHING FACILITY:(type))D cAwj.j ld (size)/ j--;e /.-17- NO.OF BEDROOMS 3 OWNER PERMIT DATE: 9 -✓a COMPLIANCE DATE: b 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) i Feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility) Feet FURHISiIE•D BY/ e.�a • r Y f#'b r.,en 'tr fl ` v..+r Commonwealth of Massachusetts ,,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Shoottlying Hill Rd. Property Address Baker Owner Owners Name information is required for every Centerville MA 02632 7/7/20 page. City/Town 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: >138" 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: 2010 NGW 138" Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 5'+ seperation per compliance on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 521 Shootflying Hill Rd. Property Address Baker Owner Owners Name information is required for every Centerville MA 02632 7/7/20 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 i For 15: Explanation of estimated depth to high groundwater included r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 OCT-06-2010 09:47 From:BARNST HEALTH 15087906304 To:5084289399 P.1.1 FROM :down Cape engineering inc FAX NO. :150BM29880 Oct. 04 2012 10*21AM P2 r ('Y�Ly.3rt. x`7�:'G� °tae-".�>3.�'.4:�r'•ikT'Ty� �i+G'.T<t'}�€'':� < <1 Thomrtr; F. GcA)er. Bil actor • n�3twsrAtan�, } - `S,Qi4E�ll;ni� �tdr-neL.,f-U�;x�r�;A.,lb1l.� d9�'6Ib1 Off-w 5C$-['tfiJ.4(Tel4 Fax: 50S-J9C-'r:3i14 3AitagIle.' 1fPvai!l mer Ctralfrecul on Form M. ,%gC Per Tan't# �/0 J 3� �Q mk adAr"&Alfa-rT;Arc:el �1 vj // � 9�►staoiIl.e�re �JD�" 0 �� E7n ll d/3640 ` �. _ watt iivauc��l a):;t>>,T[sit to install a in..4-1:4ler) septic ty�:trm.rd�'� a ;J�1 UG �aaed on x.design drawn by �4a fl(t Tcortily 1,hat fhe Sept c syr,Lmm refei-time;i ahmm.was =11,MU lrxl LbSta 16ally according to tlic c1csig4, wll.is,h may include minor, aiTp-roved c.han?es such �tS i�ii tl.TWI C tiuu Of t1n.t ;listrihufi(m box aud/or scptic:tank. 1 Certify tllut. _he jnptic 3�fsl=l rAi. mccd abovm was iustalled w4li .major changes (i.e, kw.'at:r tlo-n 10' latrTUJ OTt r.f i31n SA S t>r any 4ert3.eal r0location of a,qv com-polient. r,;l:le septle, system) but in acumdurce with rt;r.e,t Tmeal Regulatleus. Plaa iovisloll Or C:estilied cis lAJ.lt by des;gner to fnlimv. �? DANIELA. rk - (Tnst'ailcr's SlIA life)' � OJALA � CIVIL .� Na 4GW2 RTE �. �SfONA6 (Dt:s Fl(.,r' agil•Jh7[t') - (.A.9 ix D&iis{Tlt-••r's ,a€aulp FTTYA-S-E- jibTUR TO RArvT-iS ABLE..,.Pu-BLT1';_ HEALTIM LSim1ISION. OF _ __ v�ax,i., '�tT't' Eit; G`i.R31ICE �!f`j f`.!'l, f�tA'4'FT '('fi'f:� P43YtM rLb1D i-;AltD A-RE &Pl_4:��.T'Vlydp Qt2N9T,1BL)EPl1nUi,i _ IFILYAIVI�'�'ICbAI. 'a'.tAA T11�.;vwJ. t):71ea1117/�rpPlrr!}ruN-,er CmillefftloaYOTM i-�.Gl•)n,.cigr, s 1-� Dy THE P Departrnont of Regulatory Services � �Ae e Public He�ItPIl Division Date rbBEL 200 Main Street,Hyanuis MA 02601 s Date Scheduled Time D vL lee Pd. y `oil Sz,ti ability Assessyne tfor SeMage isposal '/ s Performed4 1 BY: •q wC ' Witnessed By: ✓!` `�^ LOCATI GENERA Location Address p�1.[ �h VO /Y y'- �l f!W. O4vner's Name /�' a C e+ '[-Le l/1 l�� 7 Address w Assessor's Map/Parcel EugioeerIs Na"nc NEW CONSTRUCTION REPAllt Telephone It �7J �d, Land Use' Slopes(%) " Surface Stones Distances from: Open Water Body ft Possible Wet Aregfl Drinking Water Well ft Drainage Way ft Property Line ft Other " It SKIL'7['iCJH, (Street name,dimensions of lot,exact locations of lest holes&perc tests,locate wctlanda'iu proxinuly to holes) I AVv _ N lZ } V fj 4_(�L Parent material(geologic) �'� Depth I.Q R ock Depth to Groundwater: Standing Water in Mole:_ Weeplhg I'10111 Pit Pllt.0 Estimated Seasonal High Groundwater lot i L "'9 ]D�ICTERN[ NATION FOR SEASONAL HIGH WATER TABLE Method Used: ' Depth Observed standing in obs.hole: _ In, Deptll to loll IJlgt[LSf: �„ lu, Depth to weeping from side of obs.hole: _ 111, arouadwitter,Ad,JushTlent,_ _._fr. Index Well 8 Reading Date: ��y rIn�d-pex�'W�ehlt]e/vnrylr+�r�/�} ? TEA fnetdr— A41.OrMindwutdr UVel _e AAuJI\tl.�l'9.�YA1lJlu..N.l'�t JlESrA �.Dlll�. `A'llilfl,.1 Observation vet Hole It " 'Circe at 9" �!re9 _`- v �1 Depth of Pare Timp at 6" ' Start Pre-soak Time @ F�r�f✓ l _ Time(9"-6") End Prc-soak � 0`� -` fir ' Rate MinAneli Site Suitability Assessment: Site passed Sit.G Failed: Additional sting Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- *-**If percolation test is to l)e conducted }within TOO' of wedlaiid,you niaist first notify UIC. Barnstable ConSell yat]oIl Division at least one (1) vweel5 prior to begil'uQ-R& i Q:\S EPTIC\PEIZCfORM.DOC IDl.�+]EI( OBSIERVATI®N HO L,' + �,OG Depth Prom l Horizon Hole # Surface(in.) SoifTexlure Soil Color. Soil (USDA), (Munsell) MottlingOther (Structure,Stones;Boulders, Con istenc % . ravel 4 I y I w S DERP OpSFRVATION HOLE LOG Depth from Soil Horizon HoleSurface(in.) Soil Texture Soil Color (USDA) Soil Other (Mansell) Mottling (Structure,Stones,Boulders v C_QrjRiS ene %Oravel Co �15 . DEEIEI�OBS RV TIGN HO LE ]LOG ' Depth from Soil Horizo n S I�®]�# Surface(in.) 011 Tcxhire Soil Color. (USDA) Soil (Mansell) Mottling (Structuree,tStones,E �a oulders. ® T� to Co SiStrticy, t7 vet r D]Er-lp O-BSlEIRVA TIGN� OLE, LOG Depth from Soil Horizon Hole* ,#•- Surface(in.) Soil Texture Soil Color Sall (USDA) Other (Munsell) Mottling (S'tructura,Stpnr$' Boulders, Consi ten � a I —_ Flood ns¢aa-gincc daat�Id�a�p. Above 500 year flood boundary No_ Yes Within 500 year boundary No _ Yes,,...._�...._ / Within 100 year flood boundary Na Yes ll�e>n�9>I o�1�Tfatan>ra9�y___ ccnse�un�Ine�vaous l+�aLe ia8 Does at least four feet of naturally occurring pervious material e a xist in all areas observed throughout the area proposed for the soil absorption system It not, what is the depth of naturally occur ing lervious mat®rial? C�e�t— fracnkuon qL • I certify that on 6 (date)I have passed the soil ev,lluator examination approved by the Department of Environmental.Protection`and that the above analysjs•was performed by me consistent with dlae required trai ing, expertis d cperienee des t d in �10 CMR 15.017. Signature Date 4 r Q:SSEP'TIC\PERCP'ORM.DOC s. 7 RFrre` r-t. ... AUG 1 4 2002 COMMONWEALTH OF MASSACHUSETTS N OF BARNSTABLE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS TH DEPT. DEPARTMENT OF ENVIRONMENTAL PROTECTION IC � 4 A UG 1 TOWN OFu.,, `v ` EALTH • DEP1. TITLE 5 OFFICIAL INSPECTIOI i FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 521 SHOOTFLYING MILL RD CENTERVILLE,MA 02632 b Owner's Name: MARY D'ALESSANDRO w-- o3 Owner's Address: 78 SOUTH ST NORWELL MA 02061 A` Date of Inspection: 8/8/02 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS�t�C Mailing Address: " =1P 0.GOX'2119 TEATICKET,MA.02536 Telephone Number: 508-564-6843;FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspecied'tl:e sewage disposal system at this address aad 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 Ttle'5(310 CMR 15.000). The system: X Passes _ Conditionally,! ,ses _ Needs Furth daluation by the Local Approving Auttwi ity _ Fails f Inspector's Signature: Date: 8/8/02 The system inspector shall submit 1copy of!his 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 approN ing authority. Notes and Comments t-;s;,. SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY YEAR TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND=MOVING SPRINKLER LINE OF OFF SEPTIC"TANK. RECOMMEND RAISING COVERS TO LEACI I PITS. •r ****This report only describes con i'tions at the time of inspection and under the conditions of use at that time.This inspection does not address how thelsysiem will perform in the future under the same or different conditions of use. x_�A1 ff < Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ,ry Property Address: 521 SHOOTFLYING HILL RD CENTERVILLE,MA 02632 Owner: MARY D'ALESSANDRO Date of Inspection: 8/8/02 Inspection Summary: Check A,B,C,D-"o'r E/A LWAYS complete all of Section D A. System Passes: °. E X 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. 4' � Comments: SYSTEM PASSED TITLE V INSP,ECTION. RECOMMEND PUMPING EVERY YEAR TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND MOVING SPRINKLER LINE OF OFF SEPTIC TANK. RECOMMEND RAISING COVERS TO LEACH PITS. B. System Conditionally Passes:";, _ One or more system components tas;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. 4 f Answer yes,no or not determined(Y,N,.ND) ip the for the following statements. If"not determined"please explain. n/a 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: n/a 21, n/a 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): E i9brok'eni pipe(s)are replaced _.oSb truction is removed _ dist'ribution box is leveled or replaced ND explain: n/a n/a The system required pumping rriore'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: n/a s '4 .. 1 f _ t ; -Page 3 of I E.� OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A }; CERTIFICATION(continued) Property Address: 521 SHOOT,FLYING HILL RD CENTERVILLE,MA 02632 Owner: MARY WALESSANDRO Date of Inspection: 8/8/02 T. C. Further Evaluation is Requ ire d'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 wlii'ch will protect public health,safety and the environment: =: , _ Cesspool or privy is within 50;-eek of a'surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septicjank and soil-absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surfa'"`�e`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. 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 l. r,' supply well".Method used to'tdetermine distance n/a "This system passes if the weil'.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 eEqual 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: n/a Et Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUN TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 521 SHOOTFLYING HILL RD CENTERVILLE,MA 02632 Owner: MARY D'ALESSANDRO Date of Inspection: 8/8/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No ,,,, , -{ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool wf'. _ X Discharge or ponding o sj f ffluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4.times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped APRIL OF1000 BY OWNER. _ X Any portion of the SAS,,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy i within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspoo"I.or privy-is;within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or p_-ivy is,less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality:analys S. 1This 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 th'at,facili fy 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 (Yes/No)The system fails. f have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system'fails.IThe system owner should contact the Board of Health to determine what will be necessary to correct the failure. ,P. E. Large Systems: To be considered a large system?the system must serve a facility with a design now 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.iii addition to the criteria above) yes no ,r _ X the system is within 40.Otfeet of a surface drinking water supply X the system is within 200 feet of a`tributary to a surface drinking water supply (s. ,,, 01 X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone If of a public water{sup.p!y well If you have answered"yes' gto`any question in Section E the system is considered a significant threat,or answered eyes" in section D above the large systci'iis hots failed. The owner Or Operator of illy Iarge gygterll ctmriidered 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. ,;I l d r - - Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 521 SHOOTFLYING'HILL RD CENTERVILLE,MA 02632 Owner: MARY WALESSANDRO Date of Inspection: 8/8/02 Check if the following have been done:You must indicate"yes"or"no"as to each of the following: Yes No ,h X _ Pumping information was'provided by the owner,occupant,or Board of I lealth X Were any of the system components pumped out in the previous two weeks`? X _ Has the system received normal flows in the previous two week period'? _ X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site'? X _ 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? X _ 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 teen determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ 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)], S y lip" ip iPage6 of I I OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION Property Address: 521 SHOOTFLYING HILL RD CENTERVILLE,MA 02632 Owner: MARY WALESSANDRO Date of Inspection: 8/8/02 I t FLOW CONDITIONS RESIDENTIAL 1.0 ,,. Number of bedrooms(design): 3 Nu'mber of Bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 I it Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO ';', .0. Water meter readings, if available,(last 2 years usage(gpd)): W* O1 12—U,000 Sump pump(yes or no): NO ` _?2-1 o00 Last date of occupancy: 4/30/02 COMMERCIAL/INDUSTRIAL'` Type of establishment: n/a ` Design flow(based on 310 CMR(15.203)':'n/agp.d Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes.or no): NO Non-sanitary waste discharged to the`Title 5 system(yes or no): NO Water meter readings, if available: n/a`'` Last date of occupancy/use: n/a OTHER(describe): n/a 'GENERAL INFORMATION Pumping Records Source of information: APRIL OF 2000 BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallor s--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,�soil absorption system _Single cesspool _Overflow cesspool _Privy , _Shared system(yes or no)(if yes;attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of k l�e'DEP approval Other(describe): n/a ; Approximate age of all components,date installed(if known)and source of information: 26 YEARS BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO i f 41 L;. ;'a. Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) r Property Address: 521 SHO.OTFLYING HILL RD CENTERVILLE,MA 02632 Owner: MARY WALESSANDRO Date of Inspection: 8/8/02 , BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast.iron -40 PVC Xother(explain): 20 PVC Distance from private water supplyswell or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H 5',"6" W 5' 811" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: n/a ° Distance from top of scum to,top of outlet tee for baffle: 6" Distance from bottom of scum�to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EV9RY YEAR TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND MOVING SPRINKLER LINE OFF OF SEPTIC TANK. GREASE TRAP:_(locate on site plan) ' Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a �s Comments(on pumping recommendations,,,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage',etc.): n/a : vial€'i. `'t � 7 Page 8 of 1 I i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 521 SHOOTFLYING HILL RD CENTERVILLE,MA 02632 Owner: MARY D'ALESSANDRO,,, . . Date of Inspection: 8/8/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a " a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no):NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a (t t R Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 521 SHOOTFLYING HILL RD CENTERVILLE,MA 02632 Owner: MARY D'ALESSANDRO Date of Inspection: 8/8/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) 4 If SAS not located explain why: n/a e Type 1000 GAL 6' X 6' leaching pits, number: 2 n/a leaching chambers, number: n/a n/a !eaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a o rerflow cesspool, number: n/a n/a 'r,novative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of Hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. PIT WAS EMPTY AT TIME OF INSPECTION. PIT HAS 6" OF EFFECTIVE LEACHING LEFT IN IT. RECOMMEND RAISING COVERS. CESSPOOLS: (cesspool must"be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a N 4 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C +' SYSTEM INFORMATION(continued) Property Address: 521 SHOOTFLYING HILL RD CENTERVILLE,MA 02632 Owner: MARY D'ALESSANDRO ' Date of Inspection: 8/8/02 SKETCH OF SEWAGE DISPOSAUSYSTEM 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. E G t'k 4 sit- r U .I in . Page I 1 of I l ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 521 SHOOTFLYING HILL RD CENTERVILLE,MA 02632 Owner: MARY D'ALESSANDRO Date of Inspection: 8/8/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Y Estimated depth to ground water 15+.feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain:,n/a You must describe how you established ilie high ground water elevation: HAND AUGER- 15+ FT. t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i -. h ,fir I --- .��.�..�.1..............OF.....�E.►�&c,-- A6�a .._......---------...................... App iration for Diapas ai Works Tnnstrnriinn ramit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at - ••••. ocation-Address or Lot • Q...--...&,k .�ZIQ.................... » Quo Owner Address Installer Address U Type of Building Size Lot..... - CM!I-Sq. feet �--� Dwelling—No. of Bedrooms..........I..............................Expansion Attic ( ) Garbage Grinder We.) aOther—Type of Building ---R!r.5 i.t*N9A?No. of persons_______2.................. Showers (5O — Cafeteria ( ) Otherfixtures ................ ..•---------......-•--•-------...---•-•-•----------------•-••••••----....-----------------------._.....---•-•---------•-•-•----•----- W Design Flow......... .....1'10...........gallons per person per day. Total daily flow____._- .....33P........gallons. WSeptic Tank—Liquid capacity..0Q gallons Length................ Width................ Diameter--------------.. Depth................ x Disposal Trench—No. .................... Width_ ....... Total Length................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter... Depth belo�� inlet....... _........ Total leaching area...Z4;?$6....sq. ft. Z Other Distribution box (/ ) Dosin to ( )) �'�l% /e /Y-7 P. Percolation Test Results Performed by.: s.. !�" rl= Date../._d..�_/-_l`. fr":.._... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . - "e. ......... -�---...- - ------••----•---.----- O Description of Soil.... •-- � ` �= -�� I` ..2� �� = = � ��� �- �,3 �r�--------------------- x •-••-------•-------- ..................................... ....................................................... ---------------------------------•----•---------------------•--••--•--------........_ U Nature of Repairs or Alterations—Answer when applicable._.._........................................................................................... -------------------•----------------------------------------------•-•-------••-•--•----------•-•-----------------------------------•-----------------------•-------------------•--------•....-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned furthe rees not to place the system in operation until a Certificate of Compliance has been issu the ar of�alt . Si ` su•------------------ ':Z f 7� �/� '� ^ V•- Date Application Approved BY---•-- --- -�G•.. ....... . .. . . . .�`�.y.......-•-----........._.....--- --------'�--`�-`��'-'------ �� Date Application Disapproved for the following reasons:........................-------••-•....................................................•--.. _ ......._.__._. ......--•-•---------------------------------•------•-----------•---------------••-------....------......-----------------••----•---------------------------------------------------•-•--------•-------- Permit No. .. Issued " -------..Date -- Date — S -- Fizz 2.r�..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Works Tonstrn.rtiun rumit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at ................ _........ ...... gaL ......................... ........................................." . •...........------•-•_..... ._......--- q ovation-Address or Lot No. ..�.......`� __........ �t i ?��11 .......... -`�� � fS._ 1� ;.�re...�.1�?t�h........05,T e l�i&t L .. ........................................ Owner Address -- ------•--------•-- a Installer Address �! al ...Type of Building Size Lot..__...Z_10.Sq. feet aDwelling—No. of Bedrooms---------- ------------------------------Expansion Attic ( ) Garbage Grinder (/t©,) p, AW Other—Type of Building ___ 5t ?^�1..:-! No. of persons.......2................. Showers (`tl') — Cafeteria ( ) Qi Otherfixtures d - ---------------------•------------------------------. ------.._------------------------ -- ---...._----•------------ % W Design Flow........... __ ____;�:: gallons per person per day. Total daily flow........ ___:..... ! .......gallons. WSeptic Tank—Liquid capacity.10 gallons .Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.......... _.._... Total leaching area...-------..........sq. ft. Seepage Pit No..................... Diameter... Depth below inlet.......a .._..... Total leaching area...XP? .___sq. ft. Z Other Distribution box (/ ) Dosingl tar* ( ) Ae, Id"r/�--7 P`- a Percolation Test Results Performed by._ '�... 1 . ... ........... Date../A.x.1!_tY" �............. Test Pit No. 1................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ (r, Test Pit No, 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ........ ....................................•• ••.................f....... ---••-----•-----.........-- Descri Description of S 1 "•... r" '----•-. . .-- x P W VNature 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 TIT1E . 5 of the.State Sanitary Code—The undersigned furthep-agrees not to place the system.in operation until:a,Certificate of .Compliance has been issue the,, �ar of Health. .� - 7 S i gnefl........ �"" :. _. Application Approved By___:r:.t _ yl-t aI Dat^ey r -- Date Application Disapproved for the following reasons__________________________________________________________________________......-----•---•--. ........:.___ -----...••---••••---•-••.............•--••-•-•----....------••--•-••-------••--•-•--•--•- Date PermitNo.......................................................... Issued-----•-•-•---------•-------------•--------------------• Date 4 THE, COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ',f10.. 311..............OF........t I `"d ............................. f�rrtif irtt� laf f�unt�li�nrr � . THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired ( ) by.................. .Q_6 6.••.... ? •'•t-! •• .........•---• ......•-• ••--•..•-_. ....._.....•--•- ------- Installer at............. . 1 } Sg(?a !!I- ----- - '°'*� Zras � # f` 1g_ has been installed in accordance with the provisions of TTq��P j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._W..: _:_d................... ....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........J `,/�.�_...7 ........... .......................... Inspector......' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... o.1 .!S1...........OF.....:.. . i€e- t#$KIL........---•- .... v� No. ........... FEE...�:.:.....!;,.,._........ t rya tt1 s#r ion rrmit Permission is hereby granted..-.... { - ----------------------------••---------------•--------......-----••--•--........--------...... to Construct ( ') or Repair ( ) an Individual Sewage Disposal S Est at No._••---•�-. 'ca .. 4 , rt ,, Fy-?.� l f - 1 Street . as shown on the application for Disposal Works Construction�rrffi t Noe: .....it!...... Dated.... .............. DATE.....................--/------/--`/--•---•-0----................................... Board of Health FORM 1255 HOSES & WARREN, INC., PUBLISHERS Dee L O C A T 10 NU v�P�%�-s-C� :�Q SEW GEPERMIT NO. v 14A c E /93 - 0�19 �TL R'S NA E 8 ADDRESS B UI'LDE R OR OWNER DA T E P E R M I T IS SV ED DATE COMPLIANCE. ISSUED 9 �� �` �� n ��� ��. _►os �� �, �. ;1; � y.. ,.. '^a,_ice•-Y.�:.,.,--.-. : .� -' -. V• _ s i •.ice _ - ,.._ . • .. _. -.- :..: '� :. a •sr �`f b ' ,,ytc•4.yw-' f'{ �- _ J '.l �a�. ,'Y: :^• ..+�r�,� + l.s ':9.. - 'ra i �.(. - v, r r - tit Ftg ` } •m�"' : - J- x ., - R • 7 .874�£ �?. ice. ri . .. .. :, .lr a .4• ., S� .. ;!t'a t, , 77. 16 ��. J ,I,1•:"Li 1 v J. - w� ""t fl._�',i Tk .;1: 1 _. _ .:. _....,: , { - ne r r r _ • r z . ..• ._. :. ::- - + ':..'r- -,-_—_ _s_ r., �.wr,r.rr.r�r�.. MST.., AD p N It n. COST _ _ fit LL' t f1 _ t r A , ! ,§ ufit .ROOM ..a94. ; :. TT ' t �} r it 1 ; .a. s,� O 't so to y t { M I � � 4 ,-7, � ( • p������tif31.r Fr' �iJ f'•t 1 1 DIM- i r x n x u: _ rho 3' " iLVL. kFA..C- yy 1 1Yr// • �ll " 8I� �F1 , : s ti a•, n as 2b Fe'1 • ' •r"� - "ems: -' ,e . V Tow", T1112046' 1llP2B�4t9 x. . .. .r. .. LI } dill ' `f ' BAR I ► MA TER �, = SINK I BATH 4 1 WALK-IN I f _ I CLOSET CLOSET x I r 21-2„ g1$1411 4 N FIREPLACE DI 14 WALL VENT W� I PED. SINK , P.D. 2'-6"x 6'-$° P.D. FAMILY ROOM j 4 DOWN +� I I I I 23'-O° 2'-5�'i° 21'-101k" 4'-0" a Opp ¢� _ f i o I M4STER BEDROOM � o FWN3168S FWI460obAPLR I FWl-131b S 6-'O" x 6'-8" j r I ( Q FRENCH DOORS a _ tt I COVERED FOR A21 i TW3046 TW3046 TW3046 i ( I � Q R.O. 2'-036" x 2'-0%" R.O. 3'-24" x 4'-914" Q - - - - - - - - - - n - - - - - - m 6-0.. At b,-0„ f b,-0„ „ 2'-0„ 4,�, b'-6�" 3'-54b" 3-Sys„ 'f'$ „ 4'-0„ t 4'-01' J #� i r`t r� ` n Y - t� sD 3:-0" X 3.�D 14 MT Ao 12 1*4,44- ;.l „y f • rk . . a y � 1 , — — — ?fit"'x f f' I M I F ,. 1 3- -t tr s f � s it I L r. at i , n .Y a 2 k111 a R k :,r M x. 1• . • 1 TOa46 TiUl4 1 r .61k Kea F1486: i ..+ x 4'-94" 44 or • n "1'-0" 3'.;4g" t3','?ta4a 3'-11" 2t . .. _ 2=93>Sr: ot lo 1 ti i I _ rA►-1 = , I -195 isP� ii I • _ l.'tip � s[..,./r lU I TI-1 1 Clt `"f`"Z� v, A,arti to L-C,(AJ NO c «, /{ J ` \ ` `�..... -� 41 rAl s6'va��,.•, � U; 57 / tD7 i 48.0 w ` IAJ Q # 11 1 t 1 0 { ro •. � WNJOi< tG=.fie!'(, �.._.% � � ''"---: '�-,a' i � �-'°J � .7:.e:.:" j� L-,.;, � .,..�.`'p 7Z �TAizT 11G E?+-i� a AAA,_.k. 34 Lh � PL1�►J ?� �' `'SI�'J pG �� 5�. T I4 19-17 40 __----.— — , j CLOG tlV AlAe, ; t►W _ - 47.E dG.p (p '` i<i[,;?tp,f?cJ k 4e. L 7,� �r —-- Au, , r^ f t"• . v . SYSTEM DESIGN. SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES` LEGEND MARKED WITH MAGNETIC TAPE OR PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS WEQ• LAKE DATUM SYSTEM Rou{e 6 99 - EXISTING CONTOUR GARBAGE DISPOSER IS NOT ALLOWED ACCESS COVERS TO WITHIN 6" OF FIN. GRADE vice Rd X 99•7 EXIST. SPOT ELEV. \ TOP FOUND. EL. 52.5' PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE 2. MUNICIPAL WATER IS EXISTING Ser DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 99 PROPOSED CONTOUR USE A 330 GPD DESIGN FLOW MINIMUM .75' OF COVER OVER PRECAST 2� SLOPE REQUIRED OVE SYSTEM 51.5' 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS Locus [98.41 PROPOSED SPOT EL. PRECAST H-�o ' TO BE AASHO H-LQ RISERS (TYP.) " TH1 4bSCH40 PVC SEPTIC TANK: 330 GPD (2) = 660 2'0 51.3 2" DOUBLE WASHED PEASTONE TEST HOLE RE-USE EXISTING SEPTIC TANK** PIPES LEVEL 1ST 2' I 5. PIPE JOINTS TO BE MADE WATERTIGHT. OR GEOTEXTILE FLABRIC 46.2' 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH 2� SLOPE OF GROUND a TECE TEE * - 000 000 LEACHING: ExIsrlNc 310 CMR 15.000 (TITLE 5.) SEPTIC TANK** 49 9 f o 0 0 0 0 0 0 0° oo V Z Wequaquet 6" MIN SUMP o 45.7 0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO ° Lake �Q, UTILITY POLE SIDES: 2 (41.5 + 10.25) 1.85 (.74) = 141 GPD GAS BAFFLE ..; 0 00000000000 o° 12" MIN. INT. DIM. 0 000000000000 0° o BE USED FOR LOT LINE STAKING OR ANY OTHER o a BOTTOM 41.5 x 10.25(.74) = 314 GPD 45.89' 45.72' o�go 2 oo�g 43.7' PURPOSE. o FIRE HYDRANT o000 0000 0 H-20 3050 INFILTRATORS 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. o 0 NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING TOTAL: 615 S.F. 455 GPD �okev+lt 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED oz USE (5) INFILTRATOR 3050'S WITH 3' STONE 6" CRUSHED STONE OR MECHANICAL 3/4" TO 1 1/2" DOUBLE WASHED STONE WITHOUT INSPECTION BY BOARD OF HEALTH AND oo COMPACTION. (15.221 2]) PERMISSION OBTAINED FROM BOARD OF HEALTH. ALL AROUND � OVERALL DIMENSIONS TO OUTSIDE OF STONE: 41.5' X 10.25' 4' 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND VERIFYING THE $.9'f LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES LOCUS MAP PRIOR TO COMMENCEMENT OF WORK. *THE INSTALLER SHALL VERIFY THE ( 6'4% SLOPE) (_1_7. SLOPE) NOT TO SCALE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE LOCATIONS OF ALL UTILITIES AND ALL MA LEACHING BOTTOM TH-1 & TH-2 39.7' REMOVED 5' BENEATH AND AROUND THE PROPOSED BUILDING SEWER OUTLETS AND APPROVED DATE BOARD OF HEALTH FOUNDATION- EXIST. SEPTIC TANK 63 D' BOX 4' No GROUNDWATER FOUND LEACHING FACILITY. ASSESSORS MAP 193 PARCEL 49 ELEVATIONS PRIOR TO INSTALLING ANY FACILITY PORTION OF SEPTIC SYSTEM HIGH WATER LAKE ELEV. PER BOH 34.8' 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WITH 1500 GALLON H-10 SEPTIC TANK IF NOT SUITABLE (OR H-20 SEPTIC TANK IF IT WILL BE SUBJECT TO VEHICLE LOADING). TEST HOLE LOGS ENGINEER: ARNE H. OJALA, PE, SE WITNESS: DAVID W. STANTON, RS DATE: AUGUST 25, 2010 c %. 87 PERC. RATE = < 5 MIN INCH VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE / D IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR / \ CLASS I SOILS P# 12933 �.40.71 BY HEALTH INSPECTOR / •/ \'PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED B /' \. 4 4 , BY THE BOARD OF HEALTH REVISED DURING A PUBLIC x 39.09 \ 0" ELEV. 51.2 ELEV. 0" 51 .2 HEARING HELD ON AUG. 4, 2009 3) FAILED SYSTEMS ONLY : SOIL ABSORPTION SYSTEM y FILL FILL INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW 50" 52" GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) g00% A/E A/E AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS LS BE LOCATED MORE THAN SIX FEET BELOW GRADE. / LOT AREA '�� A 22,91 t SF 10YRR 2/1 10YRR 2/1 /41.10 , 53 10YR 7/1 55 10YR 7/1 B _ B 50.73 1 9 LS• LS x 51.64 10YR 6/6 10YR 6/6 66" 45.7' 66" 45.7' / x .73 51.52 - #1 /19 I1'88 x 5 0 x 2 1. 52 C C �x5 X 1 1 PERC / /• x 1.93 UG ELEC. / x .94 0 FS FS 1.48 2 ---42.43 51.8 .01 86 10YR 7/4 10YR 7/4 2.02 5 88 33 EXISTING 3 SR DWELLING C 138 39.7 13$ 1 1 39.7' x G1 TOP FNDN. = 52.5' X 1.36 NO GROUNDWATER ENCOUNTERED �Do 1.1 4 O 1.9 7 GONG 6V 6 / L�51.80 2.09 9� 46.88 F N LRG KS>. v OA 4 ✓ Ji x 51. 4 s� g X 2 1.74 TITLE 5 SITE PLAN x 51.2 47.63 S2 2.15 O 4 �y0 4)7.69 F .23 50.7 / 88 51.59 8" P 1 5 .75 2.14 52 51.29 x 53 9f, S RUCE x 5o Z% 51. 50.91 521 SHOOT FLYING HILL ROAD X TH O 51.72 PAVED DRIVE 4 48.38 CENTERVILLE x 0.76 51.61 � 97 1 7�0 LRG. x 7 51.32 1.04 51 R� $ �O x 49.5 48.83' PREPARED FOR / x 5 .31 OAKS 1 51.10 5� 51.0 22' 4 50.85 P,1 g.82 BORTOLOTTI CONSTRUCTION/ PROP. VENT WITH CHARCOAL FILTER f"f AND RE (FINAL PLACEMENT BY 49.18 0�O BAKER CONTRACTORACTO WITH 5�R WITH HOMEOWNER �. 50.7 � CONSULTATION) L 50. 49.32 '�/ a0500 x 49.90 X .28 9.50 tic AUGUST 25, 2010 y 5o 50.15 O.r�10 REV. 9/1 /10 (4 BR TO 3 BR) BENCH MARK - HYDRANT ON �O TAG BOLT #570 ELEV. = 52.3 c 49.66 7 Scale: 1"= 20' 9.66 0 10 20 30 40 50 FEET .62 .57 4? PiT��N OF Mqs\. off 508-362-4541 �L qs� v sy1 fax 508-362-9880 C ,I`IIEL cy�'� �°? DANIELA, yam ,m downcope.com OA CIVIL rr, dONn cape en ineern No.48502 F, Inc, civil engineers �G/ST@ q 10�oq ? "' land surveyors 1 / 939 Main Street ( Rto 6A) DATE DANIEL A. OJALA, P.E., P.LS.� YARMOUTHPORT MA 02675 > 0-099 10-099.DWG(SBO)