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HomeMy WebLinkAbout0192 SKUNKNET ROAD - Health 192 Skunknet Road Centerville P A = 171 009 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information forms o the out f r r forms on the computer,use 1. Inspector: v only the tab key to move your Matthew F..Gilfoy cursor-do not Name of Inspector use the return key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 �4Q City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number ,e B. Certification .:� I certify that I have personally inspected the sewage disposal system at this address and teat the`- information reported below is true, accurate and complete as of the time of the inspection. The rn-slection was performed based on my training and experience in the proper function and maintenanGt of 9" site sewage disposal systems. I am a DEP approved system inspector pursuant to Section:%,5.3jD�f Title 5(310 CMR 15.000). The system: CD ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-24-14 oe Inspector's Si ture 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 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. s r ****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. t5ins-3113 Title 5 Official Inspection Form:S VeSewage Disposal System-Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑. N ❑ ND (Explain below): t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):. C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the.environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or. more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No Backupof sewage into facility or stem component 9 Y Y 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 '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high groundwater elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? • ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 192 Skunknet Rd, Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is Centerville Ma. 02632 7-24-14 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): . . 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. Sludge depth: 41' l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments ,. 192 Skunknet Rd Property Address Mark& Bonnie Stanley _ Owner Owner's Name information is required for Centerville Ma 02632 7-24-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" 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.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: — gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): f . Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): At time of inspection d-box appears to in working order no sign of deteration, or carryover. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4- m gallon chambers ❑ 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.): At time of inspection leaching appears to in working order no sign of hydraulic failure. Chambers dry at time of inspection, 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 l5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments •'e 192 Skunknet Rd Property Address Mark& Bonnie Stanley _ Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. City/Town State Zip Code. Date of Inspection D. System nformation:(cont.) Sketch Of Sewage Disposal:System:.Provide'a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below Q .drawing attached separately Aq e C� 0 �j2-a�' 0 0 03- aot by- Z°B' . I t5ins•3/13 Tille.5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >10 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: COC dated 10-17-06 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Ground water is >10' in area per USGS topo maps You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r * Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 192 Skunknet Rd Property Address Mark& Bonnie Stanley Owner Owner's Name information is required for Centerville Ma. 02632 7-24-14 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 e TOWN OF BARNSTABLE 7NSTALLERS N^ �� � (1Q �� SEWAGE#0� 7 7 (O 0)4* ASSESSOR'S MAP&PARCEL NAME&PHONE NO. ANK CAPACITY LEACHING FACILITY:(type)�— .5 00 6 C ize) 7, y 10 k � NO. OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: /0,/7-04e _ 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 1 O:Lk� qll r � � Z- No. Fee= THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYicatiou for �Bigoal �§pgtem Couotructiou Permit Application for a Permit to Construct( ) Repair()O/Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. J 4ok 5 ir'a ii / Owners Namg,Address,and Tel.No. Assessor's Map/Parcel 171 0 (yq �+ Installer's Name,Address,and Tel.No. k/ • Designer's Name,Address and Tel.No. PQ Type of Building: Dwelling No.of Bedrooms 1 t Size sq. ft. Garbage Grindervo Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ry: Design Flow(min,required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title ` Size of Septic Tank Type of S.A.S. Description of Soil ) /117 e— C0a,-.$ S4,110 Nature of Re airs or Alterations(Answer when applicable) ? -11C ' V_C, 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 th. Si r o g Date ✓- J ul -Application Approved by ; OWIM�eDate Application-Disapproved by:, Date • for,the;following reasons Permit No. Date Issued Ow No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes i3plication for �Bigpogal �§p!5tem. Con.5truction Permit Application for a Permit to Construct O Repair/Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. 1 Ku < Owner's Name,,Address,and Tel.No. Assessor's Map/Parcel /-7/ 0 U q SG A M 1 'r Installer's Name,Address,and Tel.No. k/' AO lW 04 Designer's Name,Address and Tel.No. PDa� leg t Gr✓n�?tvl��� Type of Building: " Dwelling No.of Bedrooms 010t Size sq. ft. Garbage Grindervo Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd / 4 Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ) /ln e-_ GD2r'S-t_ S J�?.0 r^ Nature of Repairs or Alterations(Answer when applicable) I=J!! h r IIU ✓' d Date last inspected: Agreement: } { f �• The undersigned agrees to ensure the construction and maintenance of the afore described dri-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 Hea th. I Signe r r��/ ^ a./ ` _ r r Date/ Application Approved by , Date Application Disapproved by: Date for the following reasons i r rrs Permit No. f Date Issued l!/ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded Abandoned( )by k1. A:;_ JZ 1 dS6b`I D y s071i( /C/ // at /!7 cR Sku n At d?P A,o has been constructed in accordance +( �'V�� dated with the provisions of Title 5 and the for Disposal System Construction Permit No. 1 Ga Installer(/; � lZ411,YLV,11 !S C _ Designer �4 ZI #bedrooms Approved design flow Ll 4/1 gpd The issuance of this permit shall no 1be construed as a guarantee that the system will fu ctt•n as designed._��_�,�, Date to 4 )( Inspectors No. 'Fee /� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Bi!gpont *pgtem Con6truction Permit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at Roao 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. Provided: Cons ction` uust be completed within three years of the date of thi�pe-r'n t;-' Date l' A roved b A / � a / pp Y Town of Barnstable Regulatory Services o Thomas F.Geiler,Director ........... . NAMPublic Health Division �.. � Thomas McKean,]Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fad 508-790-6304 Installer&Designer Certification Form Date: Ao0e. Designer: ��'" nsS• Installer: Address: ?anoLg�_� Address: On was issued a permit to install a (date) (installer) septic system at F based on a design drawn by (a dress)//,a& J' dated ,��,'"r/-� ✓st E'er !? ,2b a6 (designer) certify that-the septic'system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or cerkifi as-built by designer to follow. - — - 00er' I4Iq = S Si R. ALL No.5V Q d EDS� R, EVA030 er's (Affix Desi tamp Here) PLEASE RETURN TO BARNS•TABLE PUBLIC 119ALTH DIVISION. CERTIFICATE OF COMPL ANCE WU L NOT BE ISSUED UNTEL BOA' THIS FORM'AND AS- BUILT CARD ARE RECEIiTED BY TIIE BARNSTABLE P LEC HEALTH DIVISIGN THANK YOU. Q.Health/SgWWA)esiper Certificatim Form Zil Town of Barnstable P -- Department of Regulatory Services 1 a ' Public jaealt�h Division D J sot Mam Street.Hyannis tru►ossol Fo ts' A. Fee Pd Date Scheduled Time T — • ' ' Assessment for Sewage Ds os Sod SuUabfflo � aiul Performed By: Te: o,✓ /,L � Witnessed fly. LOCATION&GENERALOR TION Location Address' 0*v, �i�6•J fit'-�/►')�� 0,9 � I Address .�a.r�t!w�ly� L Assessor's Map/P�rc �"' ,` 1 ! '_ ,°.,� � AL�•• I�S Telephone# NEW CONSIRU�PI�I� REPAIR ! ��sr,�F.Ji L — Slopes cam) sulfa stops .�-- Land Use ft ! ft Drinking Water Well Disunces from: OPcn Water Body CD ft Possible Woe Area 1. — I ft Drainage rr!o�✓c ft Propertyliaf / Other 8 locate wetlands in proximity to holes) SKETCH:(street name,dimemi—of'CA,exact locadons of tent holes&Pere tests.75 l i � y Q a � I , ) I c v Depth t0 00droek I Parent material(gcdogic) �r ! Wing from Pit Woe N Depth to Groundwater: Standing Water io Hole: ; N Grouodwata i 8sdmaled Seasonal high . DkTE.R�TION FOR SEA80�4AL HIGS WATER TABLE Used: I w01110 ip. Depth ObaervW atandiog iu ohs.hole in. Depth t0 mm . Depth toiweopiag from side o[obs.hole: � ia• �fltetot....�.--�•��Lwtl..... Index Well N Reding MIT ml Index WeU level �' ! PERCOLATION TFrST D'''91,0 °` . Observalioa -rim at Hole g Depth of Perc -- Start Pre-soak Timc. End Pre-soakL Min./lnch 11 d Rate Site Suitability Assessment Site Passed Site Failed. Additiaaal Tearing Needed(YIN) — on Back Observadon�Hole Data To Be Completed Original: Public Hetdth Division . test is to be conducted within 100,of wetland,you must first notify the ***'If nj�rcola fiion t ,.o. .,.a1...vinr to beginning- ... � . �._— , — , , �.��.,."V k. mole ��j,'��� Depth from Soii Horizon Soil%lure Soil Color Soil I Other 1 (USDA) (ManselQ Mottle g ( Stones,Boulders. D -074CO.r ��LL reel .tom o L DEEP OBSERVATION HOLE LOG Hole# Soil Hallos soil'11Uatttnre : . -: Soll(dolor soil S�faee(7a) (USDA) (Mansell) Moulin Other (Structure,Sties,Boulders. „r / sit % ravel) al I r r r r- -L3 C- — DEEP OBSERVATION BOLE LOG Hole# frrom Soil Hodwe Shc'llsttere Soil Color . Soil odor (USDA) (Mansell) Mottling (Structure,Stones,Boulders. onsl tent Oravel PEEP OBSERVATION HOLE LOG Hole# Mob from soil Horizon SoilTaft" Soil Color sell other Surfm(in.) (USDA) (Munselq Mottling (StrwmM Stares.Boulders. onsistwicy.%amyll) Flood Insar M6 Rate May: Above SAO hood bon No— Yes 1� ndery V ithio 300 year banrdnr No— Yes ' within 100 year flood boundary No Yeit.,:. Deydief Na ervi° , ateritit Does at least fo feet of naturally occurring pervio a'material exist in all areas observed throughout the area propo ed the soil absorption system? If not,what is the depth of naturally occurring pervious'material? ,� Cer ffl6don I certify that on. (date)1 have passed the soil evaluator examination approved by the Departrnettt of Vn mental Protection and that the above analysis was performed by tt�e consistent with . the required tra nd described in 310 CMR 15.017. Signs Q-%SHMIC PERCF0RM.DOC T OWN OF B LE 90� 561n CAT SEWAGE # VILLAGE ---- �J�' V ASSESSOR'S MAP & LOT/ INSTALLER'S NAME&PHONE NO. . SEPTIC TANK CAPACITY /t LEACHING FACILITY: (type) JSi (size) L� NO. OF BEDROOMS" BUILDER OR OWNER PERMITDATE: 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 �/l�/` fI p IA 5 � A 1:01 Ac- AoM '90 T5 Town of Barnstable tia* Regulatory. Services BARNSfABM Thomas.F. Geiler,Director. 9� _` •0�' Public Health Division Office: ; Fax: 508-790-6304 August 29,.2006 Mr Stephen Schmitt 192.Skunknet Road Centerville,MA 02632. ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 192 Skunknet Road, Centerville,MA,was last inspected On August 9th 2006 by,Robert J. Bortolotti,.a certified septic inspector for the State of Massachusetts.. The inspection of your septic system showed that your.system has "Failed"under the guidelines.of 1995 TITLE 5 (310 CMR 15.00) due to the following: Leach.pit#1 was.full of sewage.at time of inspection. Leaching pit#2.had 69" of water(3" from bottom of inlet pipe).. You have 2 years from the date of the of the system failure to bring the system in to. compliance.. If there.are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT Dale Saad,.Phd Agent of the.Board of Health -\ COMMONWiE_AL;TH OF NKASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. DEP_ARTME'NT OF.E3VUIRONMEiVTL PROTECTIO\T TITLE 5 OFFICIAL I111iSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSUP—RelCE SEWAGE-DISPOSAL SYSTEM FORM PART _A CERTIFICATION Property Address: I_C .r.°t;j�:✓1t'_ l_ Owner'sName: Owner's:Address: J /7", Date of.Inspection 0�P ,,,� .�t. a2� e✓ i .� Nameiof Inspector piQase print) e'",j ?(�3' � i Company Namv:, t3'7iFi: 1^sT Mailing Address:'., Telephone Number )�°"2111-_'? r CERTIFICATION STATEMENT i.cerify 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 ofon;site sewage disposal systems I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3.10 CMR 13.000). The system: Passes - Conditionally Passes ;Needs Further Evaluation by the.Local Aporov.ing Authority Fails Inspector's Signature: Date: The system.inspector shall su;: it z copy of This inspection report to the Approving Authority (Board of Health or DAP)within'DO days of completing this inspection. If the syst.em.is.a sharzd system or has a design flow of 10,000 gpd or V eater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The oriEinal should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authorit?i. 1 s Notes and Comment t } L v' y� J ) /� �J( /Cc ��LC: „ "**This report only describes conditions at the time of inspection.and under.the conditions of use at that time.;This inspection does not address'ho w the system will perform in the future under the same or different conditions of use. Title Inspection Form 6/.15122000 page 1 Pane 2 of 11 OFFICIAI INSPECTION FORM-NOT FOR VOLUNTARY A5SESS111EN I S SUBSURFACE SEWAGE`.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: r Owner; t� Date of Inspection: f' 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 '! CMR 15.303 or�in 310 CMR 15.304 exist.Anv 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 re aired.The system, upon completion of the replacement or repair-.as approved by the Board of Health;u.ill pass. Answer yes,no or not determined(`r`,N.;ND)in the for the following statements. if"not determined"oiease explain. The septic:tank is metal and over 2.0_years.oldY 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 tanl:as approved by the Board of Health. A metal septic tank.will pass inspection if it is structurally.sound;not leakins and if a Certificate of Compliance indicating that the tank is less than 20 vears old is available. V ND explain: Observation of sewage backup or break out or high static.water level in the distribution box due to broker 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 pipes) are replaced obstruction is removed dist,ibution.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 p.ipe(s).are replaced obstruc.tion is removed . ND explain: Page 3 of 11 OFFICIAL INSP CTION FORS -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 IS'/P Owner: r.�s�.a .;�� ' Date ofInspec-ion lh�w,(.,�O" r 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, safet;r 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 pry, 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 2 manner that protects the public health,safety and environment: _ The.system has aseptic tank and soil absorption system (SAS)and the SAS�is.within l00 feet ofa surfacewater supply or tributary to a surface water:supply: The system has a septic tank and SAS and the SAS is within Zone 1 of a.public water supply. The system has a septic tank and SAS and the SAS is within 50 feet ofa private watersupply 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 supoly.well"*. Method used to determine distance *"This system passes if the well water analysis;performed at a DEP certified laboratory, for coliform I acteria 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 thatno other failure criteria arc t i2zer ed. A copy of the analysis:must be attached to this form. 3. Other: 3. Page 4 of I OFFICIAL:: IN,SPECTI,OiV FORi'✓I—.NOT F.O"R VOit U TARY:ASSESSMENTS, SUBSURFACE SEWAGE DiSFOSAL SYSTEM NSPECTION FORM PART A. CERTIFICATION(continued} Property Address: GJ 1 �+ 'j Owner: Date of Inspection: D.. System Failure.Criteria applicable to all systems: You must indicate"yes" or"no"to each.of the following for all inspections: Yes No Backup of sewage into:.facility_or system component due to overioaded'or ciogged SAS or. cesspool Discharge or pondine of effluent to the surface of'the ground.or surface waters due to an overloaded or clogged SAS,or cesspool Static.li uid l.evelin the distribution b r q box above owlet invert duet overloaded Qo — o an o e.loadea or clo��ed SAS or cesspool — Liquid depth in cesspool is less than 5" below invert or available volume is 'less than %day flow . Required pumping more than 4 times in.the last year NOT due to cloQQed or obstructed pipe(s)_Number oftimes pumped Any portion of the.SAS, cesspool or privy is..below high around water elevation. Anyportion.of cesspool or privy is within 100 feet of a surface.water supply or tributary to asurface ✓ water suP_ply" Anyportion of a ces spool.or.privy is within.a Zone l of apublic well. �.Any portion of:a cesspool or privy is within 50 feet of aprivate water supply well. Any portion of:a cesspool or privyis.less than 1,00 feet but greate.r.thar..50Aeet.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 n ppni, Provided that no other failure criteria are triggered.A copy of the analysis.must be attached to this form.] � ,l�Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in310 CMR 15.303, therefore the system fails.The.sy stem owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large.Systems: To be considered a larger system the system must serve:a.facility with a design Dow of10.000 gpd to 1.5;000 gPd You must indicate either",Yes" or"no" to each cf the following: The following- criteria a( n 1 to larg., systems.in addition t criteria above) - ,. ,p y � on o the crit.,.i4 i 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—TWPA) 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 3.10 CMR 15.304.The system owner.should contact.the appropriate regional office of the Department. Page 5 of I.] OFFICIAL INSPECTION FOltMT —.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM`INSPECTIOTi FORA PART CHECKLIST Property Address:., ` A Owner: Date of Inspection: C&t4 Check if the following have been done.You must indicate`yes"or"no"'as to each of the following: Yes. No �Z__ Pumping information was.provided'oythe owner, occupant,or Board of Health. _jZWere any of the systen components pumped out in the previous two weeks ? ' as the system received normal flows in the previous two week period? Have ^rzvolumes 7 e '+ F ' ? h Imo__e of water been introduced �o the system _ ys *n recently or as par o.�this inspection . — - P P 41- Were as built plans of the system obtained and examined? (If they were not available note as N/A). {I Was the facility or dwelling Inspected for signs of sewage back up V Was the site inspected for siams of break out ? ponents, excludingthe SAS,, site Were ail system corn, — 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 cn: Yes no Existing information. For example, a plan at the Board of Health. Dete.:tined in the meld(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)1 Page 6 of]1 OFFICIAL INSPECTION'FO.RM—NOT FOR:VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART.C SYSTEM INF.ORI ATI0IN PropertyAddressc �-. , l✓t? , -tea /� {' - A-14 Owner: i �1 ��+� CNi Date:of Inspecti(fri: FLOW CONDITIONS RESIDENTIAL Number of bedrooms.(aesign)..,0 Number of bedrooms(actual).: DESIGN'flow based on 310 C Rt 15.203(for example: 11.0 Qpti x T of bedrooms): �.3 Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry.on.a.separate`sewage system (yes or no):. . if yes separate inspection required] ,��s — [ .. P q I Laundry system inspected(yes,or no)- /V Seasonal use: (yes or no): � Water meter readings, if available last 2 years usage d Sump pump (yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL./W Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sg.n,etc.): Grease trap present(yesor.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 j y Source of information: Was system pumped as part of thein PeciiC( es or no): J "' If yes, volume pumped: gallons --How was quantity up ed 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 1 > ( �x/��..�✓'f p Approximate age of all components, date installed(if known) and source of information: 4A1a Were sewage odors.detected when arriving at the site(yes or no): e) 6 Page 7 of 1 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION (continued) Property Address: _ �• � , rx Owner: . �e Date bf Inspec4 : X` d BUILDING SEWER(locate on site plan) Wo Depth below grade: Materials of construction: cast iron 40 PVC_other(explain): Distance$om private water supply well or suction line: Comments (on condition'of ioints, ventina, evidence of leakaae, etc:): f SEPTIC TANK: ;"/(locate on site Ian) Depth below arade:(A,, _3 y�- Material of cons action:. !concrete_metal fiberglass _ polyethylene _other(explain) If tank is metal list ace: Is age:confumed by a Certificate of Compliance (yes or no):'._(at tach_a copy of certificate) Dimensions: Sludae depth:L1 &Z__)iq_/^__ Distance from top of sludge to bottom of outlet tee or.baffle: Scum thickness: Distance from top of scum to top.of outlet tee or baffle:. 7 Distance from bottom of scum:to bottom of outlet tee or baffle: Li How were dimensions:dete.rmine.d: L?.z .lro�' G-1 r/�t' fJ` L �/ , Comments (on pumping recommendations;n et and outlet tee or baffle condition, structural integrity, liquid levels �relatea to outlet invert, ev a nce of leakage, etc.): a' /''xee,A Av, -Y"''i`".edtf>;y _J ate c z 401?65�e �'L �,° ✓ GREASE TRAP�I�',✓,(locate on sae plzn) Depth below grade:_ Material of cons�3uction: concrete_metal__fiberglass=rolyethylene._other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or bathe: Distance from bottom of scum to 'bottom of outlet tee or baffle: Date of last.pum_pinQ: Comments (on pumping recommendations; inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakaa6, etc.): f Page 8 of I l OFFICIAL..INSPECTION FORM=NOT FOR.OLUNT:ARY. ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAIN C. SYSTEM INFORMATION(continued) . � ° 7^, :�� Property Address: , , �e°,/,�Lt'C,; Owner:_ ?J � Date of Inspecti n: 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/day Alain present.(yes or no):. Alarm level: Alarm in working order(yes or no): Date of last pumping: ComJr ents condition o.f alarm and float switches etc.): DISTRIBUTION BOX (if present must.be opened)(locate on site plan) Depth of liquid.Ievei 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:: 'i �. Iocate 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.): �3. Paae 9 of 1 1 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBS.URFACE"SEii'/_AGE:DISPOS-,AL SYSTEM INSPECTION FORM PART.0 SYSTEM INFOR-nL A.TION(continued) .�` '�Property Address: s } J .�?lL�-� 111 Owner: r,'A ,"�.. r 1110 Date of Inspection SOIL ABSORPTION SYSTEM. (SAS): izocate on site plan, excavation not required). If SAS not located explain why: .LZ!eaching pits,number: leaching chambers,number: leaching.galleries, number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cess000l,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. c. — CEi^ �'q ,,,.' '/,.i'.;s .J.d{/> •:.,�, ;f�i' .Y 9 "%.a®' i !� '� ..1..- ez Ile CESSPOOLS (cesspool must be pumped as part of inspection)(locate on site plan) y Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cess000l: Materials of construction: Indication of.groundwater inflow (yes or no): . Comments (note oondition"of soil; signs of hydraulic failure,.level of pondin(;, condition of vegetation, etc:): PRIyI': ' , (locate or_site plar:) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, sins of hydraulic failure, Ievel of ponding, condition of vegetation, etc.):. j f 1 C u t Z' 9 Page 10 of 1.1. O'r'FICIAL 1INSPECTIOti-FORMI RIOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORiYI PART C SYSTEM.INFORMATION(continued) Property Address: 1 Owner: Date of Inspecti m.6 Al "' ' i- .. 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 1 OC feet.Locate.where public water supply enters the buildin-. 1 �a r ,_'s! 1� >, ;U s lU • Page I I of 1 1 OFFICIAL INSPECT ION FORM —NOT FOR VOLL N ARY AASESSIMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: �r . a Date of Inspe4ion: ) j 60 � SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to c ound water Meet Please indicate (check)_all methods used to deter_nine the high ground water elevation. Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site (abutting propet�/obser,�ation hole within 150 feet of SAS) Checked with Iocal Board of Health-explain: Checked with.local excavators; installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high groundwater elevation: n d 11 Permit Number: Date: Completed by: ()/,57 114 `HIG.H GROUND-WATER LEVEL .A TION. Site Location: �4 �1. t ,. ����5 Lot No. Owner: '/�_,0/,/ d/f `2 ��''r/� Address: y Contractor: /r'd%`e Address:_ Notes.: _—... .._ � � r� '.. . . STEP 1 Measure depth to water table to nearest 1/10 ft. ............. ................ .............. .Date t month/day/year STEP 2 Using Water-Level Range Zone. and Index Well Map Jocate site and determine OA .Ap.propriate_index Well ................. OB Water level range zone STEP 3 Using.monthiyreport ;Current Water::Resources>Cond�tions determine u crrent depth to waterIe.v:el for:lndex:vsreU :_[ month/year STEP 4 Using Table,of.W,ter-[eve l-Adjustments for index.vuell-=(ST I :2A)::current depth to water-level:for:index<weli (STEP 3), and water level zone (STEP 2B) determine water-level adjustment ........................................:.......................................:......... STEP 5 Estimate depth.to high water by subtracting the water' level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ................... � Figure 13.-Reproducible computation form. { 15 ' 8 Ali L7 08/27/2006 20:56 5083625151 GREAT MARSH CHIROPRC PAGE 01/03 � f v GREAT MARSH CHTROPRACTT.0 1049 MAIN STREET WEST BARNSTABLE, MA 02668 John C . Doriss , D.C . 508 362-4533 TO : FROM: � gut FAX NO. ( 508) 362-5151 No . of Pages to Follow: 2 COMMENTS : ��Sry` Q ¢— �� 1 0rh� ¢- /< j►.�/��/ V to DATE: 6 tt'�4A1 1 08/27/2006 20:56 5083625151 GREAT MARSH CHIROPRC PAGE 03/03 /ko� 711-4 77'o f.3R • �Z � 0� � Soli - o/- w 08/27/2006 20:56 5083625151 GREAT MARSH CHIROPRC PAGE 02/03 7. A- -- Pei q f r cr - - - � �=�-- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS M W DEPARTMENT OF ENVIRONMENTAL PROTECTION � d U1A/ SVOv TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 192 SKUNKNET RD CENTERVILLE, MA 02632 1-1k Owner's Name: KIMBERLY FOGARTY Owner's Address: 192 SKUNKNET RD CENTERVILLE, MA 02632 13 5 Date of Inspection: 3/21/02 RECEIVED Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS MAR 2 8 2002 Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 TOWN OF BARNSTABLE Telephone Number: 508-564-6813 FAX 508-564-7270 HEALTH KEPT. CERTIFICATION STATEMENT I certifv 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 systmis. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally P ses _ Needs Furth r valuation by the Local Approving Aullwrity Fails Inspector's Signature: Date: 3/21/02 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of l lealth 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 PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. c'I c,-)nnn I Page 2 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 192 SKUNKNET RD CENTERVILLE, MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/a The septic tank is metal and over 20 years old* or the septic tank(whether rrietal 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 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): _ broken pipe(s)are replaced _. obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).'file system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of I t OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSAJENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 192 SKUNKNET RD CENTERVILLE, MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 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)(1)) 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 I 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 n/a "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: n/a Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 192 SKUNKNET RD CENTERVILLE,MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 D. System Failure Criteria applicable to all systems: You niust indicate"yes"or"no"to each of.the following for alLinspections: 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 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 n/a. 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. IThis system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma _ (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 X the system is within 400 feet of a surface drinking water supply ` _ X the system is within 200 feet of a tributary to a surface drinking water supply i� _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped r Zone 11 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 "ves" in Section D above the large system has failed. The owner oi•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 Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT,,)' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 192 SKUNKNET RD CENTERVILLE, MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 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 or 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 been 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 or distance is unacceptable)[310 CM 15.302(3)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 192 SKUNKNET RD CENTERVILLE,MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 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: 4 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 Water meter readings, if available(last 2 years usage(gpd)):4" ZQpv_, �G1i D00 Sump pump(yes or no): NO 2-DO — Iai2t 000 Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on.310 CMR 15.203): n/agpd 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: n/a Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons-- 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 Isom system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 12 it v,1RC BY OWNF,R Were sewage odors detected when arriving at the site(yes or no): NO C, Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 192 SKUNKNET RD CENTERVILLE, MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40.PVC_other(explain): n/a Distance from private water supply well 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: 12" 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' 8"" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 15" 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 NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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 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 7 Page 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 192 SKUNK-NET RD CENTERVILLE,MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 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 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 IC;0'.;age into or out of box,etc.): D-BOX IS 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 ° 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: 192 SKUNKNET RD CENTERVILLE,MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: C a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/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 PIT3S STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. BOTTOM IS AT 9'. 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 ol'conslruction: 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 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 192 SKUNKNET RD CENTERVILLE, MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 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. C C mOb rLl up PY I 03 �13 3b Page I I of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLILINTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 192 SKUNKNET RD CENTERVILLE, MA 02632 Owner: KIMBERLY FOGARTY Date of Inspection: 3/21/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 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) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12 FT. �e Commonweafth of Massachusetts Executive Office of Environmental Affairs John Grad D.E.P. Title V Septic Inspector Department of P.O. Box 2119 .Environmental Protection yy ��! t, MA 02536 William F.WeldGovemot 15��'�J -G813 Trudy Coxs 8�crru y EOEA VIA Davidmmt Struhi e s 'Vf ionel SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �� I to CERTIFICATIONNIS `9b' Property Address: IC( c.>ar�eX� - l`U QS 1V OO Wdress of Owner: Date of Inspection: � C��ti�n (If different) Name of Inspector: Company Name, Address and Telephone Number: CERTIFICATION STATEMENT [certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems._ The system: Passes _ Conditionally Passes _ Needs Furth r Evaluation By the Local Approving Authority _ Fails / Inspector's Signature: u Date: The System Inspector shall submit a copy of this inspection report to.the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system 6vner and copie_ ser,; to the buffer, if appiicaUe and the appro.ing authority. INSPECTION SUMMARY: Chec01 C, or D: A] SYSTEM PASSES: I�hav/e not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 81 SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised B/15/95) / One Wbnta►Street a !baton,Massachusetts 02108 FAX(617)UG-1049 a Telephone(617)26.WW 10 Pnnied on Recycl l Papa SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is,failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM I5 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND,SAFETY AND THE ENVIRONMENT _ IhP >\sten) ni> a >e VUC tanK anui luii ibturpUOn sysit i and ii Niilnl', iuv feci tip o-su p:c '.-.a:ct SuPp!-' v: uw.i:a r'r to a surface water supply. _ The s\s!en� ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well.water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303, The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary.to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. t (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART A CERTIFICATION (continued) Property Address: Owner: ^\ Date of Inspection: u , D] SYSTEM FAILS (continued): 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 welt The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the.local regional office of the Department for further information. (revised 8/25/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propert ss: Ow ner: o��Inspeion:\n e Date of Check if the following have been done: _L,?Vmping information was requested of the owner, occupant, and Board of Health. -6.No6e of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or ai part of this inspection. _L.,As built plans have been obtained and examined. Note if they are not available with N/A. j--T�e facility or dwelling was inspected for signs of sewage back-up. �-�e system does not,receive non-sanitary or industrial waste flow L-:PKe site was inspected for signs of breakout. t..-Wsystem components, excluding the Soil Absorption System, have been located on the site. 1�.Zhe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _L''f1!ie size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods, if difipran( frnrn ownar1 were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAk SYSTEM INSPECTION FORM PART C Q SYSTEM INFORMATION Property s: (3 � 1 Owner: \4 e S Date of Inspection: cam\ ZZ�Qb 1 FLOW CONDITIONS RESIDENTIAL• ��\\ Design flow: 3✓�'Rall ns Number of bedrooms: Number of current residents: Garbage grinder (yes or no):,, N, j Laundry Connected to system (yes or no):�--,-,,7, Seasonal use (yes or no):,-2Dk Water meter readings, if available: Last date of occupancy: COMMERCIALANDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) - - Last date of occupancy: GENERAL INFORMATION PUMPING RE RDS and source of information: System pumped as pan of i ion: (yes or no If yes, volume pompt'd gallon� Reason for pumping: �-MLIA Q o1 'N . TYPE OF STEM 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: L..01.�� Sewage odors detected when arriving at the site: (yes or no)CYN (revised 8/15/95) 5 } f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C, SYSTEM INFORMATION (continued) Properr ess. `2Aa Owner: h� Date of Inspe cts A ��Gcp SEPTIC TANK: (locate on site plan) 1 Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: LA 61k.tl I .t 1 Sludge depth: Distance from top of s�iudge to bottom of outlet tee or baffle:w1 I Scum thickness:, Lo' T} Distance from top of scum to top of outlet tee or baffle: utj Distance from bottom of scum to bottom of outlet tee or baffle: t Comments: (recommendation for pumping, conditio of inlet and outlet tees or baffles, depth of liquid level in relations to outlet invert, stru Ural integrity, evicl nc akage, etc.) GREASE TRAP:Civ-�4� (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: Scum tiucl.ncr». Distance from top of scum to top of outlet tee or baffle: Distance from hot-ton' rn —,— M bottom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prope Address: Owner: j Date of Inspeictio : TIGHT OR HOLDING TANK.N(' (locate on site plan) Depth below grade: Material of construction: —concrete ,metal _FRP`other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_L,---' (locate on site plan) lln Depth of liquid level above outlet invert: O tk ,�Q et WtA\ Comments: (note ii leve`and dntrutwr ryu i, r,iUrI1Cr of SGi d carr);,,er, e�idence of leakage into or out of box, etc.? PUMP CHAMBER:��' (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prope ess: Owne��sp ��?S Date of Insp ton:S�a1a� SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number:vt leaching chambers, number:` leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) S1T.l �S C�ml S.A CESSPOOLS: (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 ground„atc-. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition o(.vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: O,imensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition,of vegetation, etc) (revised 8/15/95) B SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Owner:.of Inspectioe 5� ��ity SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' C � � � g 606 64 ?� �c �y gp �' C� �b DEPTH TO GROUNDWATER Depth to groundwater:__a feet. method of determination or approximation: �"'�J m �r` in' (revised 8/15/95) 9 i rT tt1l fir, r V I 1 1p�o$e i f TO$ � - r. f r 61 q® �- TCAP 4 ! C s l . In i i i I lo v Pao, CAK ci 1 — J I j � i L I i y ' f CIA 5 � 130 5 t ' a0 wF` 1 IIII, I = Li II �SroI 1-21i� 1 ilk! oj5cv� cto r ' il M j 11 _ r K YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates COST $30.00 for 4 years. A Business Certificate ONLY REGISTERS (WHICH YOU MUST DO BY M.G.L. - it does not give you permission to operate). You must first obtain thenees YOUR NAME in the Town at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1" Fl., 367 Main St., Hyannis,the necessary signatures on this form the Business Certificate that is required by law. y s, MA 02601(Town Hall) and get f 3 F x Fill in please: DATE: � a APPLICANT'S YOUR NAME: BUSINESS, YOUR HOME ADDRESS: � TELEPHONE # Home Telephone Number: U `'NAME OF NEW BUSINESS�j,.,_r,< ��� TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES Have you been given a NOk 1 g approval from the building division? YES NO ADDRESS OF BUSINESS SY CQAAc MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in Compliance Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 2 r of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits p e with the rules and regulations of the Town of town. p sand licenses required to legally operate 00 Mour business inethis I. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. COMMENTS: Authorized Signature- 2. BOARD OF HEALTH This individual h b infor eci e �m' ;- is that pertain to this type of business. Authorized Si ature" COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. COMMENTS: Authorized Signature— TOWN OF BARNSTABLE LQCATION�c Q.fJ l\9, S) Uuy KV, TW SEWAGE # R,9 " 17 S- VILLAGE ASSESSOR'S MAP & LOT4"_0 INSTALLER'S NAME & PHONE NO. (- (A)Pc SEPTIC TANK CAPACITY ,LEACHING FACILITY:(type)"TU�1C) ITS (size) cu A' W4P .NO. OF BEDROOMS _PRIVATE WELL O �LIC 'BUILDER OR OWNER•�> DATE PERMIT ISSUED: `{P 'DATE COLIPLIANCE ISSUED: 'VARIANCE GRANTED: Yes No T: Is 6bSepxvr 0 W O �{ P1zS W 3,Slb10-Q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................0 F..A6#4fij1e10 Z................................. .1A.6.Lr_ Appliration for Uhipoiial Works &nstrurtion Vanfit �orApplication is hereby made for a Permit to Construct Repair an Individual Sewage Disposal aS stein at: ... ............................... ------------------------------------------------------- Location-Address or Lotfo. ..... .............................................................. ... ......p.</.1aQ.7A Owner Address .. .......................................... -------**--------------------"------ Installer Address Type of Buildifig Size Lot.1.7, Y.310— Sq. feet U Dwelling No. of Bedrooms--- Garbage Mg'e....Grinder r'in"d"'er ..................................Expansion Attic P14 Other—Type of Building ............................ No. of persons........ ............ Showers Cafeteria 04 Other fixtures W Design Flow......%90.....1.10...........gallons per person per day. Total daily flow......Y.Y.0..........................gallons. 1:4 Septic Tank—Liquid capacity/ gallons Length................ Width__............._ Diameter.-.-_-__-__----- Depth............._.. Disposal Trench—No. .................... Width.........._.___..... Total Length___...._............ Total leaching area....................sq. f t. Seepage Pit No--------------Z-- --------- Diameter----G_---------- Depth below inlet_?,42...... Total leaching area..43Q......sq. f t. Z Other Distribution box ( &-' Dosing tank 11 Percolation Test Results Performed by t-JOIZZ4Jtrr.................................... Date..J'V�1/19�'.I-q-------96 I --- --- Test Pit No. ]G:Zn-----minutes per inch Depth of Test Pit.... ..... Depth to ground water/*6fv4F.IE.,-�PfJ'7r?tz'FLI 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._....._..___....._... 0 Description of Soil..Opi.f�d W ­------------- -------------------------------------------*--------------------------------------------------- U ......................................................................................................................................................................................................... W Z. ............... ........................................................................................................................................................................................ 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 TL I Ti LT�, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued.b theboard of health. '1 Signe . . . ..... ........... ........ ate Application Approved By......... ...... ... .....----------- ................................................. ........ Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ '? Date PermitNo.._...................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH %U G.1/N............ oF.. rqA N � -...... Appliration for Disposal Works Tonotrnrtion runtit Application is hereby made for a Permit to Construct Xl or Repair ( ) an Individual Sewage Disposal S stem at '! (:..... ............ ............ /r1.......................................................... o:anon:Address L?._..,_OI.� S --.....--•-----------------•...-------- c�?Ali ¢fr r��..1� ......��/• ! f?o r V Owner Address .................................................... Aa c........................................................... Installer Address 7 G`�a UType of Building Size Lot. .. ___/_...____'_._..Sq. feet a Dwelling No. of Bedrooms...... ...................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ____________________________ No. of persons.......Z ------- Showers-- howersCafeteria ( ) Other fixtures .. ---------------- - ------------ ..-------------"------------------------- ....... •------- W Design Flow.....`' ._......1_0............gallons per person per day. Total daily flow.....e e�0..........................gallons. WSeptic Tank—Liquid capacity?Sqqgallons 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.!�?p...... ft. Z Other Distribution box (6-) Dosing tank ( ) a Percolation Test Results Performed by..... ....................................... Date.............0 _f--•- / 7'----------------. Test Pit No. 1 -......minutes per inch Depth of Test Pit--- Depth to ground 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix ...._-•-------•-------•--•---------•---•••......... ............ •----------------- --••-------- •------ ----------------------------------- ••--------- ".--------- D Description of Soil. 'Uf/tt r-_"f °�'!> �` C011!�r V ................•---------..........--••-._..---••----.....--•-........_..._.................---------........--•----------•----------•-•-----.....-------------------•--•-----------•-------------..... W 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 TIT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issue y tthboard of liealth. i r ... . ...... -� Date Application Approved By....... Z44f , ............................................................ ......... l .,/.............. /Date Application Disapproved for the following reasons:----"-"...--""-----""-"-"-----------"""-------------------------"-----------"-------------.........---•--------. ...................•............_...-•-•----------••----......_._............------------....-------•-•----------------...----------------------------------------------•---------------------..._--•--- Date Permit No. ! y?.... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF F HEALTH - .........................................OF.......................rt' .............................................................. Trrtif iratr of TontpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V) or ,Repaired ( ) by---------------- . ........................................................................................... n Installer has been installed in accordance with the provisions of It 5 o Th�tate Sanitary Code as described in the application for Disposal Works Construction Permit No..__!�_�.'"___.__��____..._.. dated_....__.l'_"_".'�.l__"�4T��.__._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... ..__ ......................... Inspector................ ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH 1 ...................OF..... ..'... '.. "' aA ? ..........._.............. ;" No. ................ FEE_...........`'� Disposal Works Tontrurtion rrntit Permission i ereby granted.........G-A.Vzw... _1 �!�1 ..` t�( .................................................................... to Construct or Repair ( ) an Individual Sewage Disposal System at No. "!4I+GGIP/�'T'.. ��Y..C� , '�. 1 c:�1. :_./_.F.. Street as shown on the application for Disposal Works Construction Permit o "rf� Dated_._/` ----- 7...... .............................................."��- Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS D�51GN DATA TEST PI TDATA: P .58-8'7 Sw►9la Family 4. f3ccGrooms __Garbalc Grinder Date. ', �- ly 1871986 Des►3N Flow'.- *4 X 1 10 =_4- 4-0 G P l> Tc6r LDId T,_H,.IYI'i l viia Sceptic. Ta.hK t-A-40 x ISO ofa .__�(a0_._Gc.I k ov►s w + c g YY1e USE K TPA TP�Z, Le,acin Pit.--_ " cQ�z x.s.`7cf{cc+�vc. eLapl4l w +►1t� sivhe. 58,Z 5►eAewe.11 :1�1_ SF x z,5 Gpot/sF 905GP D C3oHorr+ : / 4---Sr- .. x 1.0 Gpd ! SP =.,es4G P • _3L5_ S in .0167 GP-0 X Z k Z_ /,v SF 14 GPD 13onC-y i N2 lop o AJjus+ inlcf cover' Foundnttf o.% io one -foot 6.I o w , -finish a aale, . Z Pcastonc 9 qn 'PVG.. d 1NV c �Nv yao Gz//o,► INv Box Ur A99 `q�► ,J b 7.2nk STEPHEN ALLYN fit tI v RICHARO t noffom o f sL O WILSON li r 85�I Leach P,L Clo BAXTER _ A �No.30216; i4'-- ------ S`�STEI'>7 Pr�01�'ILE C s,° ► ° �::;� M_ l iasy�� 3-Ze•89' L .CE-KTI FY -'1-IAT THC .P/ZoP..h!Qvs SEPTIC SYSTEM DESIGN SHOW HGRE-00 COMPLYS W17-H THE LOC,4Trda/:- Lor/yam SfrvgkUc IPo=a/ S1DEl.IWE AND SGTMACK ReQUI1 GME-1JTS Arrut//c O!Q TH a I-OWN O F ,3ffR/L44 T4/-44„L.- __^.N D IS NOT !-.oGA?'ED W ITNIA! A rL00zbPLAIKJ ° Z�i97�:�7lv,Q, Z8, /989 G cMC 3-26=8q LJ APPL/C/g,t/T T�ATia , THm PL,Rk.1 IS N07 '12,AZI O O►J /0rn1 C3 AXT�F2 NYE �NC, I INSTRumeNiT SURE`? AND T-r-le C FSET5 R�J >>'r�� Aana/ 5u.-veyora SHOWM HIrRt2 OIJ S►-IOUL-D NOT- Off USE-0 C/,�// F ;� rer� TO ESTAOL.I S►-► L0-r L I W L=S . d s r /2.✓/t_LC� ///R SS y06 \w i / a �' I ► r I I � I Zl ljrPAV I I I rv / i L P tq I Zo, I 1 t L R � Tom .Q/- 1 y ' � `�/c�• 1C{-L':f•.�.: • 471.I0.0'.5... 1 1A. BARTER No.2404a Aj a 9FOST Ea`�� \ N £ STEPHEN ALLYN `n WILSON No.30216 Q will LOT % 91 r I I /7 43 I I I 1 Scatc: 1%20' ;8�/2(0 SHEET 2 aF � 4ase�074--- #`7r Sc 4edv S D �l l wall i 1= ` 2'= - A-1 walls c' Den W1 A 13 1 V-o L�/F I 14 3G r0 13 —� -� UA, ed 511de ram; Ott Iity go . Rooms 8de0061 ��Vhe iy f1®dam s -r p er C�ui I INN wu-t vr►c��h 9 rQ S S^� Cy S. 7LI k� S�OWtr to// Uri Ftn1s4,o( Ff 1-�4 CAi r"ney ea Se- m-e 4 E F - wN Fern, l VV U 8&Seme 0 Ku ce/7Ie (le � - w a-rer main i Z-6% Q �k - 4 1 197— . 2' 4 �#/a .' -� _ '— -.� p � �L e�• _- �� �'I.r�d�—/7S`ti,/ys �a�9',�r_-'�'����.5", _ s.saT 9 ••,,.-. /J✓/C J4 22.y ��� /2 .�=z i9z N.- /qTTALL " / ; a o j / S ,41d�1SE' / / '4 �y ��• : o• �Z. _�' �; x t , .,.--- 9f-�n�IL—y4� r� .r(.k.'�_r�/e✓S !6� ,M S �iaLLSd4,7 �Ti�I� ,E vi�e 'o SGr••.J��- i:.T.� 2J Ip C � 577d;' •C EL TOP OF FOUNDATION! ✓F( /`off 1 en 4 CONCRETE c .COVERS I 4"CAST IRON 9' ' 'r .� ,, - . • F„J,�G � t<1G5E _ .�.?', f OR SCHEDULE 40 , 4"SCHEDULE 40 P.V.C. (ONLY) g'MIN . LEACHING TRENCH ( I)REQ. �� P•V,C.PIPE MIN. PIPE-MIN.N 1/8"-1/2" WASHED STONE 36 MAX. PITCH I/4N PER.Fi PITCH 1/4 PER.FT � '• 2" _ - - it- it �X/�//�(� .Cl i C1,J�`1Y�-�C1' Q,•C��'C!%Ci-, � „ 4 C ` EL�/• e,?.. IN�CERT . I ERT q`=I�'ca,Ci�:C7�'C1 CIa 'b 24 L C /u' SEPTIC TANK - DiST. a 'L, a / �.. INVERT EL. BOX ...... rk. ;[�a�C1,©'Cf.;CI;t�-�U•(�,jp: T � , - - ,:' ELF/.. G , / 4�,- �/2 ,••�.�Cc� GAL 1NVt _ .. . ELF• INVERT Precast 500 GaI.Leach 3/ 6°CRUSHED STONE EL':vq.... W) REQ. Chamber P34WASHED STONE , .. ' PROFILE OF 40T70_17 �T = EZ 41,Q, GROUND WATER TABLE 2--�C SEWAGE DISPOSAL SYSTEM TYPICAL •CROSS SECTION SOIL LOG No SCALE LEACHING TRENCH SITE PLAN /92 SKKUNKNET PD4, CFNTEPVILLE MA DaT � TlI�r. :�: • NOC- �3cs`tSSr i TEST HOLE 1 TEST.HOLE 2 D I G N D� ' ELEV. �G'. ES DATA : 9„1 .f' I/g':.'1�" ... WfiSHED -36`MAX. ,t„ ....} ',.,..,:,�,�.c v...,,,' NUMBER Or BEDR00FdS .!�. FOP . .. . SDNC 2n TOTAL ESTIMATED FLOW .... .,. GALLONS/DAY •� •::�%��_.� _ � � BOTTOM LEACHING AREA O S T E P HEN DE8 l�A �—� SC HMI T T �Q. /f � � T ; G t�E, 'L A G AREA . .FT/TRENCHlam('. y S N . . . .�7,3Z SQ - �' 2 r- GAR AGE DISPOSAL .,.!✓,4...(50% AREA INCREASE) i TOTAL LEACHING AREA .. ./c' SQ.FT. �r PERCOLAT .. TEi� ...... '' Yam.PER.INCH ' LEACHING _ PER T RATE� 9,U,, 50.F i.GPI tp X 7y c9.S: GROUND ar APPROVED .. . . . . . . . . .. ... BOARD OF HEALTH N icR T`.LE�.�/� .e��,WATER ENCOUNTERED DATE ,... ..: .. ... . . .. . 'l1!t#F + WITNESSED -BY . AGENT OR Ir�sPE�roR '�N..- : ''�^ BOARD OF HEALTH R. ENGINEER .,. . F _ �,� EVAL�F fi�. t PETITIONER : . '' / ,J d lJ_; ?�,�/ C:;!y soli Z-6� ED ' v✓.�-LCs�� 'e( , .. - ,r �! J••���� ��=E�G l� � �3�'�.vl�-L7%�h/r�./ n,s�aT�/9 a.,/ !�/,.�rJ , I9Z /?% L- , l.�{"�iion.�Si�F� G3.�1 c�l"crWl�L I�/�%J.✓I. 17, o ' cfil'l�r�r.<' , ? k r,/�TF : 9.,Iy p"'�:�"n�os �f T_~,- /�'�/ iiJi.JC �,/17«s lc- �r✓�/Lr� iit/C% / !%✓GiS, c- /!✓ v�i�F'� 7. /� C4rv�STtkiis //G� si�i� ►�� <I�LGiE. e.. �[. CA, ao ELF �" V �G �..�T l� 1p 1 L©/ v EL..4 I la;I.:. _ Mew✓c!`] �T/d '�ZU� .. TOP OF FOUNDATION �.E✓FC' t� ; r -.�G97S ' CANCRE c .COVERS ' ' 4"CAST IRO >m �r - ,r,rn,r ,� , Lcrv,/ ., .. - �i✓ 'C.�rjGSE _ fiS 1 , OR SCHEDULE 40 PVC.PIPE MIN. 4"SCHEDULE 40'P.V.C, (ONLY) 9'hUN . LEACHING TRENCH (I)REQ. PIPE-MIN. I/8"- I/2° WASHED STONE ��,, 3611MAX. i r r PITCH I/4"PER.FT PITCH 1/4 PER.FT. - .u�. • .<4. .r•-)Gf - -,:ev.L•:. .,o J=JTt1):!i51i�.44 Y 211 i - _ O=f.Y 1 .•p 8 �I 1 INV Ta // � .f-7� t't�:)�=rCl�f ;[�' -��' ;'d 4T ��• ✓ C� '1d / LS� ;•o EL a�I...�?��.. X/ QIST, I VERT �Cli%�1`OrC1':C7 'C�1' [:1'CI'�lr• - 24' L SEPTIC TANK y < a A INVERT ELF:. BOX ELS/.Il�, GAL:. EIN ER L -� V .. _ �...1�. EL `Ji7 INVERT �(�1 R o00 G01.LeOch 3/4"-I/2"--f 6"CRUSHED STONE Chamber P.?4WASHED STONE 7. 7�1 H PROR LE OE r GROUND WATER TABLEC SEWAGE DISPOSAL SYSTEM TYPICAL -CROSS SECTION SOIL LOG ' NO SCALE LEACH I NG TRENCH • .SI. TE PLAN 192 SKUNKNET PD,,_, CENTERVILLE, N - MA DAT�.F--•�.T:�<:�':-? Ti«�: �a:�� 0 SCAL TEST HOLE 1 ! TEST HOLE 2 � >�%r✓/fiLC�<3,�s'��`-��3,5 ELEV.- �': ... .. ELEV. ��.�f: DESIGN DATA : 9"1diN• WASHED -36"MAX. ��,�„ {•t r� tIUt.19ER OF 9EDRDOA;3 .�. STONE FOR . ,. . 2 ,��G • . 1 , �o. �_E, rlEoStib/Qy�'� moo! �� ,�v✓��C� l5 TOTAL ESTIMATED FLOW .,. ���... GALLONS/DAY _ - 8n 22 7 /a i2lo/7 BOTTOM LEACHING AREA . �f�: ?...Sa.F T./inENCH S T E P HEN DEBORAH, SCHMITT' �`�T y /y. y�xs 'G AREA . 7 Z . /TRENCH 24 G'-/ E5 g4 ? 510E LEACHING AREA A . . , c s"R.F i. 1 L y�sJ r'7 �'9 XP_ �C�7_3Z " GAREAGE DISPOSAL ...r✓.4...(50% AREA INCREASE) r ►-. " /'7 —CDF t"F �^' �t� 1 TOTAL LEACHING AREA . .lP .:z6..: Sa.ri. I,r/ E3 �tS e PERCOLATION .BATE ... :� /!?!'v ... 'PER.INCH •' � -• P� .c _.__�l� �GFs©�I� ,•�v �.1S'.. 9.r�'.3r r L°ACHING AREA PER PERCOLATION RAT c' 9. Sa.F T.6P� ' N �. ��v.ic3.�C.7`1 =-�- 93 - . ROUND 'HATER r,,BLE o`-n/� /,� EL �1.47 APPROVED .. . . . . . . . . ..... BOARD OF HEALTH ..�d.WATER ENCOUNTERED _ DATE —'—. . ... . . �� E WITNESSED -BY . AGENT OR INSPECTOR .2rW&aOARD OF HEALTH ENGINEER .•. . . . . . . ♦. . . . . . . . . . . . ��� f,� &17' PETITIONER : . �f4/�Er,l 1✓ ��/ C ,�'I�T% A4�A