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HomeMy WebLinkAbout0092 SKUNKNET ROAD - Health 92 Skunkroet Road 3 Centerville P i �x Up A = 191 111 — 7 TOWN OF BARNSTABLE `a 0),4 v 13 LOCATION �V 9,,J SEWAGE# VILLAGE C Q/� J i��p ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY e1C�3� \(too 0 LEACHING FACILITY: (type) /�J p S'TaU141 (size) NO. OF BEDROOMS OWNERV PERMIT DATE: 12 x+ �(� 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 e�� No d Fee l� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes—L� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpficatiou for -Disposal 6pstem Construction Vermit Application for a Permit to Construct( ) Repair(V�Upgrade( ) Abandon( ) ❑Complete System ®'individual Components Location Address or Lot No. �� �[nLQ,41 L� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 19j— L t �V .t _c'`��' Installer's Name Address,and Tel.No. Designer's Name,Address,and Tel.No. � trc,,Vt \L-3 6LJ Yr rMd �� �Ve-C61eG��w-o%.r S MA Type of Building: '13,0y aCj\.A 0065 AI Dwelling No.of Bedrooms Lot Size IL sq.ft. Garbage Grinder(dojo Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ��� gpd Design flow provided X?® gpd Plan Date a �� Dec) Number of sheets Revision Date Title 411 Size of Septic Tank f bco !g Type of S.A. 6 � Ta k f b t1 Description of Soil � •�'ej ,)A C,.A Nature of Repairs or Alterations(Answer when applicable) \G Q_ t 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 Boardaf Health Signe Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �, _ �� Date Issued f: '' n No l/X Fee THE COMMONWEALTW&NFASSACHUSETTS Entered in computer: Yes _t ;x PUBLIC HEALTH DIVISION � TOWN' BARNSTABLE; MASSACHUSETTS Zipplitation for -Misposal 6pstem Construction Permit Application for a Permit to Construct( ). Repair(v<Upgrade-(..) Abandon( ) ❑Complete System 'Individual Components Location Address or Lot No.. ,� `rsNk 1 C- Owner's Name,Address,and Tel.No. Assessor's Map/Parcelfit Installer's Name Address and Tel.No. Designer's Name;Address and Tel.No. C � trt"A..,,A( 1 t 3 G L J Ywr M d�'�` �J (�v{-Co u >w r eAAkai1.SXje M-, 4 44 r14 Type of Building: 5�oy `jGI,.A (30L.S r. Dwelling No.of Bedrooms Lot Size I �o sq.ft. Garbage Grinder A0 ., Other Type of Building No.of Persons Showers.( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �'S� gpd Design flow provided3 d gpd `a` } Plan Date�,�) f �U Number of sheets �•, Revision Date ' . Title Size of Septic Tank_1e'X(S&N IbM ;iAL Type of S.A. GC.1�Un f Q C L.G.rn C,.t Description of Soil MTV �C-A ►w�1yM � .�1� I r �\C .J 1. X tla h � 63qK Nature of Repairs or Alterations(Answer when applicable) \•C1 tA_, a "r' 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 Boar f Health SigneY rw. Date 10Llx Application Approved by Date Application Disapproved by . Date for the following reasons Permit No. i/ �` Date Issued t� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS eeftificatP of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by �)� M t�' ►t, at a SLc�,�nVL�t R s) C�F'ts'4\1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated? J t Installer GV� "}` {� Designer j k d CG U`I^l �s r #bedrooms IT Approved esign-flow " gpd The issuance of this permit')shay,not be c strued as a guarantee that the syste will func•on si ed. Date /-- �� Inspector No. i Feet© THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pst m Construction Permit Permission is hereby granted to Construct( ) Repair Upgrade{ ) Abandon( ) System located at C KV��•A$ �7 l� to ^ T 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/ie completed within three years of the date of this perm1 Date � �per:+ Approved byy r X Town of Barnstable Regulatory Services Richard V. Scali,Interim Director `MRN DI ' Public Health Division MA$8. iD�Foru�° Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 8/3/2020 xSewage Permit#)dab—_ 12 LI Assessor's Map\Parcel 191/111 Designer: ®tN�� �� �r`U'-�f Installer: R,,1�✓L- Address: C (� � �v Address: 1 3 c)0 �( nil �a� a(7 c iT C� ���� was issued a permit to install it (date) (installer) septic system at 92 Skunknet Road based on a design drawn by (address) David D. Coughanowr, R.S. dated 7/20/20 (designer) I\,/— I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were {'build satisfactory. 1 certify that the system referenced above was constructed in compliance with the terns ofthe I\A approval letters (if applicable) DAVIti �, � c.;" GA�l1C� (Installers Sig e jU Cf:UGHANIO CCJUC'sHA^JOtiit'iZ �> No 109 (Designer's Signature) '.t `v �' ner's Sta •`` PLEASE RETURN •TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. 'CHANK YOU. Q:lSeptiODesignerCertification Fonn Rev 8-14-13,doc f. THIS IS A t T�� T�Ee�COLOR I 3 Ra1> `°a t WATER LINE ►�■ GARB o; PLAN WATER GATE O USE COLOR PLAN ONLY; / �, �� � � � • 55 FOR INSTALLATION OAS LINE T m �' R paN v ; FULL DETAIL IS BEST OAS GATE 0 OWED 8' 00a�o VIEWED IN \ c'a oy FULL COLOR OVERHEAD WIR OH -Th UTILITYq. rr��F� LOCUS' POLE �� n CENTERVILLE. MA, * gy LOCUS MAP py ' 0 tA\ Q, ,MIN e e �* MAL GRADING LEGEND a��r���111 • PROPOSED SEPTIC COMPONENTS EXISTING r / 1000 GAL SEPTIC TANK 0 'k EXISTING % O . Q o • LEACH PIT/ CESSPOOL IL O T TEST DISTRIBUTION PIT BOX® Q � �.. � / .� Q ®p AREA = 16611 sf+4wl — �. ®gad PLAN BOOK 224 PAGE 127 k�k�� wsx, �bP,q�� ASSR MAP 191 PCL 111 STING LEACH PIT TO BE/ PUMPED AND FILLED 9% r OR REMOVED MR � . PROPOSED SOIL 55 �� ABSORPTION •. \ SYSTEM v f � ��H Of btgSs P��N OF Mass� \ 512 -SEE SONOETAIL BACK o DAVID 9�yGs o� DAVID 9 GJ \ p0 D. D. �oCOUGHANOWR H COUGHANOWR N 15 in bo O G OAK No. 1093 No. 461 30PLAN OAK 1 15 OAK SFGISTER�� Sp�pPROVE� ♦` qN AR ,P SCALE: 1 in = 20 ft 20 40 THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM _ DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING PLACEMENT OF ADDITIONS. SHEDS. FENCES OR SWIMMING POOLS. OWNER 6 0 iO ZO 6.44 fr ` �� M�' SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. PRINT ON 11 x 17 in ��! ���NstpeLE GIs oar�y` PAPER FOR PROPER SCALE ELEVATION o'o SEWAGE DISPOSAL 57.0E / \ ` ' SYSTEM PLAN -TO SERVE EXISTING DWELLING I0 ^^p FRANCI S AND A DEANA PULSIFER OWNER(S) OF RECORD 92 SKUNKNET ROAD iss Goo Ruder Rd s CENTERVILLE, MA PROPERTY ADDRESS Chatham. MA 02633 Dovidcou®Hotmoil.com IDATE: 1ULY 20, 2020 508 364-0894 PG.U2 jOa� ETE-4644 Aecoe S OO I TEST .; Oo MEN N A U A�a O N 1000 GALLON SEPTIC TANK SOIL . .ABSORPTION. . SOIL EVALUATOR: DAVID D. COUGHANOWR.•ASE 0461, _ EXISTING UNIT DIMENSIONS & DETAIL: CONSTRUCTION,,DE.TAIL DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD S Yo�TEM. 16 WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT. TANK TO BE PUMPED DRY AT T TIME OF INSTALLATION L SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS j USE SHOREY�PRECAS.T SOO��GALLON LEACHING' AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL TEST PIT 1 PERCGROUNDWATER ATO6N n - 2 MNIINCH INECED USE SOILS SOUND STIRUCTURAL 1000 GALLON SEPTIC TANK IF IN CONDITION. IF NOT. INSTALL NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. DU IIT 24.0 ft NEW 1500 GALLON SEPTIC TANK. REPLACE WITH A NEW UNIT ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER �► ISOD GALLON TANK ��" �.' m �' t " " c) 55.65 INCHES HORIZON TEXTURE (MUNSELU MOTTLES DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. 1 in ® A IF CRACKED. ROTTED M r 0-8 Ap SANDY LOAM 10 YR 3/3 NONE FRIABLE TAPER .� SOIL ABSORBTION SYSTEM: ® OR OTHERWISE cn 52.98 8-32 Bw LOAMY SAND 10 YR 4/6 NONE FRIABLE w COMPROMISED. 01 THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE Aa- 0 ,M co � 32-132 C MEDIUM SAND to YR 5l4 NONE LOOSE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES c � � ��" L 44.65 PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. 0 # F 0 N c) v, NO GROUNDWATER ENCOUNTERED I ` TEST PIT 1 THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY �'. �* '��`' � NOT "� 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DEPICTED BELOW CAN LEACH: '""" � .� STONE TO 3.5 ft 8.5 ft 8.5 ft 3.5 ft INCHES HORIZON TEXTURE (MUNSELU MOTTLES BOTTOM AREA = (24 x 12.5) =300 s + "� 55.70 q' ft. _ I b SCALE 0-10 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE SIDEWALL AREA _ +2 + 5+ =146 so. ft. _ 53.03 10-32 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE TOTAL AREA = 446 sq. ft. 500 GALLON DRYWELL 44 20 32-138 C MEDIUM SAND 10 YR 5/4 NONE LOOSE FLOW CAPACITY = 0.74 x 446 = 330.04 gal/day8 ft_6 in A {'� DIMENSIONS & DETAIL INSTALL ONE INSPECTION INSTALL A 24 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED RISER TO WITHIN THREE BELOW. FLOW CAPACITY = 330.04 gal/dog WHICH EXCEEDS INCHES OF FINAL GRADE THE 330 al/do REQUIRED FOR A THREE BEDROOM DESIGN. INLET OUTLET USE & INDICATE LOCATION g g COVER COVER H-10 ON AS-BUILT ._M UNI T ,,, IN DROP -INSTALLER TO OBTAIN DISPOSAL WORKS p -� FLOW LINE DO 33 PERMIT BEFORE STARTING WORK. ®ISTI'�IVTION .SO�Ch,"OB 3H�20Y, FROM 10 In = 14 TO a8op: in -ALL COMPONENTS INSTALLED SHALL MEET DIMENSIONS PIPES EXITING D=BOX TO RUN LEVEL BUILDING in D-BOX 0� THE MINIMUM REQUIREMENTS OF dD o AND DETAIL FOR 2 FEET BEFORE PITCHING DOWN Q8 I!1 0 $�(� MASSACHUSETTS TITLE 5 SEPTIC GAS � 5 CODE (310 CMR 15). LIQUID -INSTALLER TO VERIFY LOCATIONS OF ALL LEVEL BAFFLE 102 in UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. c 12 In CROSS SECTION VIEW -ECO-TECH RAPID RESPONSE RECOMMENDS —► 6 in STONE BASE IF NEW INSTALL AN APPROVED GEOTEXTILE THE INSTALLATION OF LOW FLOW FROM 5 = FABRIC OVER STONE FIXTURES & APPLIANCES. AND PERIODIC * N TANK 10 b TO SEPARATION BETWEEN INLET & OUTLET SAS= 4 A ,� TEES NO LESS THAN LIQUID DEPTH PUMPING OF THE SEPTIC TANK. -SYSTEM IS NOT DESIGNED TO WITHSTAND R CROSS SECTION VIEW VEHICULAR LOADING. DO NOT PARK OR rie STONEBASE 1-u2ln ONAVEL 24 �n 1-U2►n ORAVEIk.' DRIVE VEHICLES OVER SEPTIC SYSTEM. in x ,_. r xi a EFFECTIVE® 28 �� �s DEPTH e ,.... . 2� CROSS SECTION VIEWji 46 in 58 in 46 in 150 in L . . 0 . p G 0 . . : l TOP OF FOUNDATION RAISE COVERS TO WITHIN O ALL PIPE TO BE 4 in SCH. 40 PVC EL = 57.05 +- b in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN ii i + \� 7 \� \� 55.17 DUO { 3' _CASTIN USE H-20 53.15 MAX EXISTING 1000 UALLOOIIV — o Oa o° 00000g°°°0 PRECAST °00000 000a ° boo ° °° o 0000 SEPT�� T�N� 53.00 O0 0°oDRYWELL °o°oaoo 6 in 52.50 °�ooa00000 °000000ao° EXISTING REFER TO DETAIL BOX STONE S 0�L A BSOmPT ON + 52.67 BASE 52.40 �YS EM —REFER TO 4- EXISTING 6 in STONE BASE IF NEW 27 f� S ft DETAIL BOX o Ln 50.40 NO GROUNDWATER BELOW MOTTLING OBSERVED _ 44.20 L SEWAGE DISPOSAL SYSTEM_PL_AN11 92 SKUNKNET ROAD CENTERVILLE. MA DULY 20. 2t ?0 ETE-4644 PG 2/2 tPle v� Aar ? Ah3i ua 32 ® 3: .t V O � � <;�-1 i t;- COMMONWEALTH OF MASSACHUSETTS u EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A FF Q� „e MAP PARCEL TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 92 Skunknet Road Centerville MA 02632 Owner's Name: Sandra Wood Owner's Address: Same Date of Inspection: October 1,2003 :� C� Name of Inspector: PATRICK M.O'CONNELLCompany Name: SEPTIC INSPECTION SERVICES CO. �EMailing Address: 189 CAMMETT ROADMARSTONS MILLS MA 02648 �ONJ �e Telephone Number: (508)428-1779 CERTIFICATION STATEMENT 1 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature?,� a,,d Date: I0(I � 103 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: System in good condition. ****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 some or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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 determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: P Page 3 of t 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 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 determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: p Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 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 _X_ Discharge or ponding of effluent 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 1/2day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 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 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 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. 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. A a n Page 5 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health 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 ? _ _ 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 X Existing information.For example,a plan at the Board of Health. X_ e is Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distanc unacceptable)[310 CMR 15.302(3)(b)] s r Page 6ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 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: I 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): Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2001 —22,000 gal.2002—22,000 gal.=60 gpd Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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: Last pumped one year prior to inspection. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: 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 the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Original system 1973 overflow pit 1980-1985. Were sewage odors detected when arriving at the site(yes or no): No i r Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 BUILDING SEWER: X (locate on site plan) Depth below grade: I Materials of construction:_cast iron _X_40 PVC other(explain): Distance from private water supply well or suction line: 35' Comments(on condition of joints,venting,evidence of leakage,etc,): SEPTIC TANK: X (locate on site plan) Depth below grade: 8" Material of construction:—X—concrete_metal__fiberglass__polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8'long x 5.2' wide—1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:29" Scum thickness: trace Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank is structurally good,baffles intact and clear. Liquid level at bottom of outlet pipe GREASE TRAP: No (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.): v M Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: No (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: - Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: No (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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: Two 6x6 block pits in series. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Observed two feet standing water in primary pit with a high stain four inches above current level. Liouid level in pit has not been high enough to flow to overflow in many-years. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): n f r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 . 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 5�> 5W 1 in r ,- 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: 92 Skunknet Road,Centerville Owner: Sandra Wood Date of Inspection: October 1,2003 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 15 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: Checked with local excavators, installers-(attach documentation) _X Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water elevation below el.35 and USGS topo map shows property elevation above el.50. Bottom of SAS 7 feet below grade leaving more than 7 feet separation to groundwater. j 1 +� CECTERVILLE-OSTERVILLE-MARST013S MILLS FIRE DISTRICT 1875 ROUTE 28 CEATERVILLE, MA 02632 (508) 790-23801FAXO(508) 790-2385 OILMAZARDOUS MATERIAL RELEASE FORM F.A.# !;d aA ('4 -- LOCATION: ADDRESS OF RELEASE: J 2_�{E a>a a.+k .►�,} d—t � c 'A 4 4 Hai' i I.g DATE OF RELEASE: 10 li//S,15 f PRODUCT RELE ASED: ESTIMATED ItJANTITY: E,2�a(F!. o,0 wo Move -� k --j 2 S4leo-ji CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY: 4 to 61 4.,w� o eSf�H r- I/� 4 e - Y NOTIFICATIONS: FIREDEPARTMENT: YES( I>-NO( ) DATE ,[.,L 5"-SS TIME:-i z T_ NATIONAL RESPONSE CENTER YES( ) NO(-;�= DATE: TIME: DEPT.OF ENVIRONMENTAL PROTECTION YES( ) NO(,)--DATE: TIME: OIL SPILL COORDINATOR: YES( ) NO( DATE: TIME TOWN BOARD OF HEALTH: YES( ) NO( DATE:—TIME: TOWN HARBORMASTER: YES( ) NO(.�)- DATE TIME: OTHER AGENCIES: COMMENTS: nn �e,�e I I o2 Ir / -g t ate oa 10 �!-fytf►r �-.@ iTsa� Jt- k v REPORTED BY T,' 1:4 d>� 6.�-- a i a,—t/ D ATE: WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.F. PINK COPY-BOARD OF HEALTH C-O-MM FORM #S$ No. ..............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �s ✓'i--------------OF........ .�� sys / .'................ Appliratiuu for 43iupu, al Works Cnuustrurtiuu Pprutit Application is hereby made for a Permit to Construct (_k�'or Repair ( ) an Individual Sewage Disposal System t Locat' -Address, �. � "' or Lot o. /1j �/` •"�"'�"-' - r::Tye':�2✓ {"�� =•----®----------- - =-Y' sue'_ '.ESL. `ht=-- -- --------------------- ..__....__ �6 _..._ ...._ Owner Address W ----- •----------------•-----------__________-----•-------•---__--•-----•------•----------_-••----•-- nstaller Address Q Type of Building . Size Lot--- } q. feet U Dwelling-E . of Bedrooms...._.._...----------------------Expansion Attic ( ) Gauge Grinder ( ) aOther—Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................................................... Design Flow_______________________6-4.....____ Mons per person per day. Total daily flow______.__.___ .__.gallons. WSeptic Tank�Liquid capacity c?/i Ilons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No_____________________ Wid h_________ _._____ L ng �._r_.._____ ___- otal leaching area------- -----------sq. ft. Seepage Pit No. Diameter �_. I pt#ee —��! Total leaching area � � ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed bY.......................................................................... Date------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground Water______________________.- f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... D th to ground water........._______.__--._. P ------------------ --- --- --- - - ------------------------------------------------------- O Description of Soil...........................!Tr %✓ _ M x ,-va• ' ------------------------------------------------------------------- w x -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee .issue by the oard of lfealth. �J Signed...••• ------- ---- ---------------•-------- ` Date Application Approved BY z A my- -fir" ---------------- ¢ i�- to Application Disapproved for the following reasons:............--••---------------------------------------------------------------------------------------------- •------------•---------------------------•--•-------------------------------------------•---------------•..-------------•-------------------------------------------------- -----------------------•--•- Date PermitNo......................................................... Issu - -_3- - --•------- 60 No.--- •••... FEs.. .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD DE HEALTH Appliration for Dispwiaf Worko Cnowi rurfioat r.eranit Application is hereby made for a Permit to Construct (P'`or Repair ( ) an Individual Sewage Disposal System at y` r - +' •Loc/at'i'o�n-Addressor Lot o. : ""� d s:....... �+ �a�=a ----•------------------ IL 6-, er d ` ,v4' „y A dress sfaller Address Q Type of Building,.' Size Lot__- feet V Dwelling o. of Bedrooms.............. ------------------------Expansion Attic ( ) Garage Grinder ( ) P-4-, Other—Type of Building ____________________________ No. of persons-._-._________.________-____ Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow.........:.......:....... c ......_.gallons per person per day. Total daily flow.................. :Xf- ..__.gallons. WSeptic Tank- Liquid capacity �:*allons Length................ Width---------------- Diameter..._____________ Depth__.____._____--- x Disposal Trench—No.............:....... width... _.____r tal Len gt tal leaching area____ ---sq. ft. Seepage Pit No..._ ------____-- Diameter �A°; __. il � P$,, otal leaching area. _. ft. z Other Distribution box ( ) hosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_____________________._. w Test Pit No. 2................minutes per inch Depth of Test Pit................... D nth to ground water____-___--__.--___-__. a ----- - l :.. .._. ._. .____. ...... J -.•--------------••--------•----•-------------------- - D Description of Soil........................... -14. I ,; � V -•------••--•--•-----------------------•••------------------•-••-•-•---•--•---------•......-----•......------------•...-------------- (4 -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been,issued* by the board-of health. s ,.i'y Signed__.... w", ) - F =te ------- ------------- Date 0 Application Approved By..... Application Disapproved for the following reasons:---•----•-----------•--•---. .................................................. ........................--•----------------•--•--•-•-----------•------------------•••••--------••-•---•---•-•----•-----•----•-•-----------••-----••-----------....---•----------•---------------------. Date PermitNo......................................................... Issued - !- �a� ate .N"P-`". THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH k 1 , k- OF.... i ° w........................................ Trdif iratr of Tomphattrr ' THIS IgS TO CE, IFY, Tl therIndividual Sewage Disposal System constructed ( 4-o-KRepairea ( ) by ``�;t � '1 - `i � _- +.. = ;1 ------------------------------ C/ a '^ I 1:11 has been installed' in acc4dance.with the provisions of Article XI of The State Sanitary Code as described. in the application for Disposal Works Construction Permit No---------------- _ __. ............ dated.-------- _. ... ..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU 14ANTEE FIAT THE SYSTEM WILL FUNCTION SAT SFACTORY. . _ p U,4�_ DATE---------- = ........... .. Inspector...... . THE COMMONWEALTH OF MASSACHUSETTS a BOARD OF HEALTH a No'.._.... °.... FED•................... li,q lint vp Cn�tt # ttr i�tt pr i ,Permission is her. by granted__._. ,'._._ 4 .. .___ __ , a �. . ___ �w-............................................................. to Con str�uu ( )4rr Repaircl}vldual,. wage pts s�lrSystem f --Street ----------- '� as shown on the application for Disposal Works Construction. Permit T ------ Dated_ _ ,a, �....7 Boar of Health DATE.... ................... . .. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS.