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HomeMy WebLinkAbout0048 SHUBAEL GORHAM ROAD - Health 48 SHUBAEL(;ORHAM RD CENTERVILLE A = 171 136 1 OWN OF BARNSTABLE LOCATION S�y A@,I G pr� AN\ SEWAGE#. VILLAGE CW l GN AL ASSESSOR'S MAP&PARCEL INSTAL.LER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 LEACHING FACILITY:(type) a' f03 (size) a'•SX S� a NO. OF BEDROOMS p 3 OWNER Iti APO PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet. Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY --Cn5pe c-r ^ =- For8 g6310 1 I 1 I O � � a a 3q 3y o 3 S8 yq TOWN OF BARNSTABBLE COCA i ION �� SEWAGE # I � ..VILLAGE L e4 m !e_ ASSESSOR'S MAP& LOT ON,3&/ 'INSTALLER'S NAME&PHONE NO. 7t/' e e,,S , SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 5�0 Ga/ rha, 4,S a size) NO.OF BEDROOMS BUILDER O R C� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility w Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) lv Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _ l 4 36' 5ql. y�/ p I O / �No. 9i Fee �a ,J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS -� 0(pprtcation for Mtoont *roem Comaructton V, eerrmit Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) El Complete System L/f Individual Components Location Address or Lot No. � C a kel ,9f ke1 Owner's Name,Add ess d Tel.No. Assessor's Map/Parcel O �a � G e19�e�g�/�/fie Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Ago_7VZv711 Goa 5l' 7;7/�93�� Type of Building: Dwelling No.of Bedrooms- Lot Size sq.ft. Garbage Grinder Other Type of Building Jre I/ eolre_No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /6V9 Type of S.A.S. /7• �X ZS~it'L� J / Description of Soil Z- _s©yy�//o�v diD;W k S Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued thi d Health. Si%�� Date Application Approved Date Application Disapproved for the following reasons Permit No. Date Issued No. F,4,7., Fee �_ #; THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppfication for 33iopozal 6pgtem (Eongtruction Permit Application for a Permit to Construct(i )Repair(/Upgrade( )Abandon( ) El Complete System P Individual Components Location Address or Lot No. //9- Owner's Name,Address and Tel.No. ,* Assessor's Map/Parcel C eh Installer's Name,Address,and Tel.No, Designer's Name,Address and Tel.No. '914f Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building. 4fe,-C No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets - Revision_Date R Title Size of Septic Tank Type of S.A.S. /7.S X Z_.5`~X Z Description of Soil Z SCSI' "�.l�a/1 C61Q,rp4-Is Nature of Repairs or Alterations(Answer when applicable) 7- T(e J7- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issued y this&a ird •f Health. Signed .. Date Application Approved b Date ? Application Disapproved for the following reasons ti Permit No. 9_ 62Z -3.?� Date Issued 7----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO C TIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( +�'�Upgraded( ) Abandoned( )by f d G�A95 at T & Qe CeA)4e14/l/e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. s dated Installer Designer _ n The issuance of this permit shall n :t be co r�} s a guarantee that the s, see-- will function as esign4M C Date ! Inspector ' i _n o 4A No. � � .� � vv ---------------- ` Fee THE COMMONWEALTH OF MASSACHUSETTS .-, : PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS. ]Digpogar *pgtem on0truction permit Permission is hereby ranted to nstruct( Repair V U ra e Abandon g L� )! P ( ) Pg � ( ) ( ) System located at �`� 5 Gt'I/�E'� �?41'f'k 1/7 1?h 717-t6l;/l1_ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. le Provided: Construction must be completed within three years of the date of this t. Date: ' Approve lY 5 Fl v J owE LA-iNL I IWA- � l 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning Qy' concerning the property located at 4ake/z meets all of the following criteria: ✓ The failed system is connected to a residential dwelling only. There are no commercial or business /uses associated with the dwelling. Y The soil is classified as CLASS I and the percolation rate is less than ore equal to 5 minutes per inch. 4here q are no wetlands within 100 feet of the proposed septic system V There are no private wells within 150 feet of the proposed septic system r There is no increase in flow and/or change in use proposed /There are no variances requested or needed. 4,1 The bottom of the proposed leaching facility will not be located less than five feet above the ma-dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the ma.,dmum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 7� B) G.W. Elevation ,�,�+the MAX.High G.W. Adjustment. �-•y= 3 ,' ` DIFFERENCE BETWEEN A and B � 2, SIGNED : DATE: G Z [Sketch proposed plan of system on back]. q:health folder.cert I COMMONWEALTH OF MASSACHUSETTS R EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS _ a r° DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 48 Shubael Gorham Road Centerville:MA 02632 Zo, Owner's Name: Paul&Melissa Rapo Owner's Address: Date of Inspection: April23, 2009 Name of Inspector: (Please Print) James.M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 026554049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that.I have personally.inspected the sewage disposal system at this address and that the information reported. below is true, accurate and complete as of the time of the inspection. The inspection was performed based'on my training and experience,in the proper function and maintenance of on site sewage disposal systems: I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes - Conditionally Passes 4this s Further Evaluation by the Local Approving Authority Inspector's Signature: Date: _ April30, 2009 The system inspector shall submi a copnspection report to the Approving Authority(Board of.Health or DEP),within 30 days of completing this `m spectton: If the system is a shared system or has:a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional:office of the DEP. The original should be sent to the system owner and copies sent:to the buyer,if applicable;and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 Shubael Gorham Road Centerville, MA Owner: Paul&Melissa Rapo Date of Inspection: April 23, 2009 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. Answer yes,no or not detennined(Y,N,ND),in the for the following statements. If"not detennined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years'old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than.4 times a year due to broken or obstructed pipe(s). The system"will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 g of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 Shubael Gorham Road Centerville. MA Owner: Paul&Melissa Rano Date of Inspection: April 23, 2009 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is.within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to deter-nine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliforn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 Shubael Gorham Road Centerville, MA' Owner: Paul&Melissa Ravo Date of Inspection: April 23, 2009 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_.. ✓ Any portion of the SAS, cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or.tributary to a surface water supply. ✓ Any portion of a cesspool or privy is mithin a Zone I of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified.laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is"equal to or less than 5 ppm,provided that no other.failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a"large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd " You must indicate either"yes"or."no".to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water.supply the system is within 200.feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone II of a"public water supply well If you have answered"yes to any question in Section E the system is considered a significant threat,or answered "yes"in.Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 48 Shubael Gorham Road Centerville, MA Owner: Paul&Melissa Rapo Date of Inspection: April 23, 2009 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ — Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 f Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 48 Shubael Gorham Road Centerville MA Owner: Paul&Melissa Ra o Date of Inspection: April 23, 2009 _ FLOW CONDITIONS RESIDENTIAL Number of bedrooms.(design): 3 Number of bedrooms(actual): 3 DESIGN flow based.on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have,a garbage grinder,(yes or no): . n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in 2008-per owner Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared.system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation.and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Date of installation 614199 per as-built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Shubael Gorham Road Centerville. MA Owner: Paul&Melissa Rapo Date of Inspection: April 23, 2009 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: S" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age; Is age confinned by a Certificate of Compliance(yes or no):certificate) (attach a copy of Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffler 6" Distance from bottom of scum to bottom of outlet tee or baffle: 101, How were dimensions detennined: Measurir g stick Comments (on pumping recommnendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). The tees were Present. The liquid level was even with the outlet invert There did not appear to be any s- ig_ns Of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOL UNT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASSESSMENTS PART C SYSTEM INFORMATION(continued) Property Address: 48 Shubael Gorham Road Centerville MA Owner: Paul&Melissa Rano Date of Inspection: April 23, 2009 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene ._other(explain): Dimensions: Capacity: gallons Design Flow: allons/day Alarm present(yes or no): Alann level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alann and float switches,etc.): E DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Corr vents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-Box was normal. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances,etc,): 8 i Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Shubael Gorham Road Centerville MA Owner: Paul&Melissa Rapo Date of Inspection: April 23, 2009 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: leaching chambers,number: 2-500 gal. chambers 12 5'x 25'x 2' Per as built 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 failur e, , level of ponding, damp soil, condition of vegetation,etc.):, i The Chambers had 6"of water on the bottom. The scum line ivas at the same level There did not appear to be any saQns of failure CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: t . Materials of construction: Indication of groundwater inflow(yes or no): Continents (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 48 Shubael Gorham Road Centerville. MA Owner:. Paul&Melissa Rapo Date of Inspection: April 23, 2009 SKETCH OF.SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least.two permanent reference landmarks or benchmarks. Locate all wells within.100 feet. Locate where.public water supply enters the building:. 1 a a 39 3y 0 3 5$ y q 10 ., Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 48 Shubael Gorham Road Centerville MA Owner: Paul&Melissa Rapo Date of Inspection: April 23, 2009 SITE EXAM Slope Surface.water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours reaps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours tnaps the maps were showing approxirnately 25'+/ to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. . 11 i - J TOWN OF BA.RNSTAB�LE y� LOCATION S l?y`il SEWAGE # �! / VILLAGE �� ASSESSOR'S MAP &LOT/Z/ 'J•3 INSTALLER'S NAME&PHONE NO. ! SEPTIC TANK CAPACITY D G LEACHING FACILITY: (type) ��Gal ��'� Glom��S (size) NO.OF BEDROOMS BUILDER O OWNER PERMITDATE: / COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) ; Edge of Wetland and Leaching Facility If any wetlands exist Feet within 300 feet of leaching facility) Furnished by I I � 1 L-t� E T ION SEWAGE PERMIT NO. "v 1.L_L AG E INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER `,�� .ram 6 ��_�:�. ....:,�./•�l"i� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7_ � �9 v2•� 1 r ,�,.. � ��a0 �, L.0 CATION S E W A G E PE RMIT NO. VIL-LACE I N S T A LLER'-S NAME i ADDRESS 9 U I L 0 E R OR OWNER DATE PERMIT ISSUED /T9 DAT E COMPLIANCE ISSUED r ire- 't (7;No. .....�.4..... Fx$.. ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® HE LTH / .........OF.......... . .......... ....... Appliratilan for Bispos al Works Tonstrnrtban Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst IS .. . Locati -Address o N0. ........ ............................ ......•.. J •. ................... Own A r s W / t-a ........ .. ................... ......................... ................ _ .... .... Installer Address Type of uilding Size Lot/$,.J_d_"0.......Sq. feet Dwelling—No. of Bedrooms._._..._............................Expansion Attic ( ) Garbage Grinder (A Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other-fixtures Design Flow----••------ .,.....................g P P P Y Y ga Wallons er person per day. Total daily flow............................................ lions. WSeptic Tank—Liquid ca.pacityAMOgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No../40_'4'0'0... Diameter.....4e.F_t. Depth below •nlet.. .... ....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosiri a ( . 69A aPercolation Test ResultV Performed by._. .. ''_._ _Q_ ___ _ ______ ____ Date.... a Test Pit No. L. minutes per inch Depth of Test Pit.................... Depth to ground water........................ .._ ___ (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ...........•---..... ............................. Description of Soil--_----_6 "z..�.�- ys--.�._..z-' - * i -s � ._ ✓ , U -------------- •--------------- -------------- -............... --........ ----------------------------------------------------------- •--- W -•---•---•----- --------------------------------•------------------••-•••••••-------•-----•-••-•-----•---•-••----.....-•-•••-•-------•-•--•-•----•----••--......----••--•-----••••......•-----.......-- UNature of Repairs or Alterations—Answer when applicable................................................................................................ --•- ------•-----•••...---•------------------------••-•------------------••--------.....-------------------•---•----•••----•-----•-------------•---•--••••--••••-•-•---•-•----•---•---...__._......--•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewa Disposal System in accordance with the provisions of�IT�.;;;. 5 of the State Sanitary Code— The undersigned rtl:er agrees not to place a system in operation until a Certificate of Compliance has been i by the boardAfl4th. Sigd —..°.. ......... ......•-------• Date Application Approved By........ ... ..2 DLYe Application Disapproved for the following reasons:............................ - -----------------------------------------------------...........----- ....................•---........--•---------•--------••------•---••--•---.........__.....--•---------••--•-----•--.......••-••-•••••--•---•-•-•---•••---•-----•-•••-•--••--•----------•-•-•------------ atPiate ermit No----------------•--..........----•-............-•------.. Issued....4'�_/ .. .. 1...-------•---- ' I •(7;.No. ...a.:(.�,_.... -- F�$.�..• ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _. et...........OF.......... . .. +�" ..... Appliration for Disposal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal Syst _ ____ ,✓ 1 ti K* Locatr " Address o No. -•----•-- ....... --........... _p ........................... `4Owner`� A Fps a ...... .r�� =.... ` ` •. .:C..................... --...:.... ....._..._. Ad re s Installer • � Address UType of uilding Size .......Sq. feet Dwelling—No. of Bedrooms.......... ...........................Expansion Attic ( ) Garbage Grinder ( A)0 Other—Type of Building ...._._ No. of persons............................ Showers a YP g ---------•-•-•------- P ( ) — Cafeteria ( ) Other,fixtures .--•-•-----------•-----------------••--•-------•--•----•----•••---••••---•••----••••--•-•-••--•-••.....,- _- :. . WDesign Flow......... ...:....5..................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity,F+.t*::*�`- 43.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width ....... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No../A _.. Diameter..... Depth below iinlet.. - Total leaching area..................sq. ft. Z I Other Distribution box ( ) Dosm to ( [�/r1C .. � '�"'' ;`•7J& a Percolation Test Resu/2-_­minutes Performed by._. .r !.... � ,.. . ._.. Date._ ..........t"`'"""'""#° "'* Test Pit No. I.. per inch Depth of. Test Pit.................... Depth to ground water... fY4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------------•... 4 O Description of Soil............ V ------------------------------- ------------------- ----------------------- •--------------------------------- ------------------- -------- -••-------•••------•---._.......-----•---•------•----------•- W U Nature of Repairs or Alterations—Answer when applicable..............................._._..... ....................... a ----------------------.................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewa Disposal System in accordance with the provisions of Ti ..m 5 of the State Sanitary Code— The undersigned _rther agrees not to plac5� he system in operation until a Certificate.of Compliance has been i by the Board of ealtli ,+'" r Sig d..:. y ..........................`": ,., ---•......•- Da te Application Approved By....." . Y ............ " _ � k D to Application Disapproved for the.following reasons:........................... ................................•-......_........----•._....................... .........................;...................•-•---'-•----•--..._...•-•-••••---•...................................•••••-•-----Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. ....... ..OF...... `� ..-:......................................... a Tntifirair of TompliFanrr $. THIS C F t the Individual Sewage Disposal System constru ed (— ) or Repaired ( ) b ,�....: y .......... ,A'Inst has been installed in accordance with the provisions of T 5 pJ_The State Sanitary Code as described in the application;for Disposal Works Construction Permit No__...... ...._7 : .--------- dated......",t_.�._ �--.............:.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE d, SYSTEM WLL FUNCTION SATISFACTORY. DATE......& .7 ............. ....... �• ••--•----•---- Inspector......... � � .f ,. THE COMMONWEALTH OF MASSACHUSETTS BOARD O.F EALTH f ..:.. .... ....OF................ ....k............................ No...............'.�... FEE... Q... Disposal, or art inn rranit Permissior>< is e y granted........ •-• ....+1------ . . -• ................................................................. .... ... ........ to Constr ( or�Re ( ) a n ]dual Sew rs osal ys Street !� as shown on the application for Disposal Works Construction Perm, ated.._.7"' """� - ..................f•........... ................ L' -----------------------> Board o Health DATE............. ( - FORM 1255 HOBBS & WARREN, INC..,PUBLISHERS ,;q;. .....•..-.- ;.SIEvtOCM "0 G,ATZ-aa<E 6,RI Q >U-� PIT t=Low = t i o V. 3 t sac) G•P•D- �E�ri Q-9 g 6.P.0. U S4E�- tc>oo Gam . .,UXWAL - AZeA = t50 IG-,v SP7 x 2.S 3'1S G.P.D. 1r F"vc>>l.i�ATtt�hl BdTrOAA AOEA t sr �� Sss. " t .a = 50 ToT,-L 'tDES16tJ = 425 6-.PatD. — z, '�/ �'•,` ,�( �; -'7 c>TA t__ l.0%4,1 = 33D CxR 1 ArC-A r�tGGOLQTIUt.I CZl�TE : l"to 2MIu ofz s .�I * 1j„ t. ,Y f J _ j + 7- T gISI16 ,E qg t .��, o-' ..., a •; iuv• "�,a LoAwy s Pv I o0o Ml• + 4'p,PB MKT IW. G,o.LG.9 ' Sv�Sa t,, -Box �fG,l. Se ric I o n z ,WV. r TAKiK t r::, 000 LAN RI T wiru •i 1 WASNEU p 5Tow.1� 10, U ��. C-C-.I.TIV-%ED PL(7'Tr PL /A.lJ L oCA T 101 1 C-CB lTE ZV 1 LL-6 Sc AL[` �1- �Cj iA--r N G WaT�a... Q L A t-.1 �l-h�:.��.►.1 C� GViZTIF= `( T►4AT T1-1G �DVtJb(1TIoIJ SN P I-Ic_IZt��rJ Gca�.«�L�<s v✓ I Tia <Slo� �t��E: LoT I-s(�, A1.JD �;LT1:;nGIG �'C4Jt�ENIi.iTy DF TNC: yaww or- 30te Pc... sl- vA•rr_ la Z'1 ��� t... �i l �, '--�- _ B/,,�,:c'C tie. �,,. W c= I c- Tt-�IS t7 f_A�..I t; L.I oTLA.•Scr� Ut•1 pN USTEtZ�/1�LL v /trCAxiJ 1�.1;f'C'tJ:✓�CiW i Maui:•/t_.� "(�a C:Ft=> i"�i 5�1GwLn A.PP�l_I <_A.ti_i-7 4 >3 r: a :L, J rC, I�r_1't;►�M►�l; tro r t_�14 —_ _