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HomeMy WebLinkAbout0307 SKUNKNET ROAD - Health 307 Skunknet Road Centerville P A = 170 258 TO i (J�BAR NSTABLE LocA-Loot 3 y 7 ;S ku P? k mG T 1 SEWAGE# VJLLAGF,.—(:f--eo co!y -Ile - A.SSESSt3 S MAY&LOT INSTALLI ER`S KAW&PHZ3N NC .:: SEPTIC T'ANK`CAPACITX l LEACFrfNG FACtlh (ty ) :'°", s (sue) � y S NO.( FBEF3fl0C3S 13tTTLDER.OR G�lt�EfZ. PhRAJ nDATE. Cf3fi!€FT t iN i?ATE . Sepuatron Mtance'Betvreeti�e Maximum Adjusted.Gro04 water Table to the B�ttom':of Leaching Fa it�ty Fee€ Private Water.Suppty Wett andLeatc}isug Faciliey {€€auy r lfs exist cinsxta orvfitfuit?ASf feet'm€fesittg facility) :Fcet : andnd wEdgvfWel ad feet wittan 3{#U feet hitt�facility) Y o � � a Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy _ Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation A. the Local Approving Authority 12-2-14 Inspector's Signature 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. ****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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the.Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form 'a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M ,0 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) l 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 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 ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �qM 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3t13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts m W Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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: 2014 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 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 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: N/A 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-3/13 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 ,M 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 48"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 40"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: 12" t5ins-3113 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 �M 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 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 20" Scum thickness 1" 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 1511 e How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•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 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. CitylTown 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.): Good condition with water at working level and no sign of back-up from field. 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 System Absorption S p y m (SAS) (locate on site plan, excavation not required): q ) 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 W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Leach chambers in good condition and empty at inspection with stain lines at 4" off bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 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 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 40 �yyy :. �. i .. �. -. ' a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 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: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VA ,M 307 Skunknet Rd Property Address Nancy Richard Owner Owner's Name information is required for every Centerville MA 02632 12-2-14 page. City/Town 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 m CO 0 F F . 0 Postage $ C,dSn r=1 Certified Fee ru Postmark p Return Receipt Fee C] (Endorsement Required) Y C3 Restricted Delivery Fee r, `C Q (Endorsement Required)LrI r.q Total Postage&Fees $ CEO b CJ`` ru Sent To —(pan C3 Stieef,Apt"No.?--------t---�-------------�I-nn----I-/-�•/--1•-•- C3 or PO Box No. . ✓ r___S1/ !1�Y!l IDV' .... � City,State;ZIP+4 `/' C,QMt' VIIle 0 1 Certified Mail Provides: o A mailing receipt a A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mall®or Priority Maile. n Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service;please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. e For an additional fee, delivery may be restricted to the addressee or. addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. It a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 a� ram, Town of Barnstable Barnstable AlAm °* Regulatory Services Department er`Ce j Ate.16I4 Public Health Division �� m °M 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70062150000210418634 4/14/09 Jean &Maria Bias 307 Skunknet Road Centerville,MA 02632 ;l ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 307 Skunknet Road Centerville,MA was last inspected on February 13, 2009,by Ricky Wright, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component-due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION Vey Ricky L.Wright- Certified Title V Inspector,508477-0653 r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 307 Skuqknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 bate of Inspection: February 13,2009 Name of Inspector:Ricky Wright -License#S14595 !� Company Name:B&B Excavation,Inc. Mailing Address: 14 Teaberry Lane Forestdale.MA_ 02644 Telephone Number: 508-477-0653 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes _Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority X Fails Inspector's Signature: Date: cZ 1 1 d The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: The information as identified represents only the condition of the system on February 13, 2009 9:00 a.m. ****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. S/� I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS Page 4 of 11 PART A CERTIFICATION(continued) Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _Yes The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 "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. /IT7W1Fd-11r 1 T TATO"TTA"VT/\AT'Vd%%"Xff IkT!\T T/lil T7l%7 TT1kTT 1"%7 A V4VWV01k K1r1kTT4V Page 5 of 11 PART B CHECKLIST Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X_ Pumping information was provided by the owner,occupant,or Board of Health X_ Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X_ _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X_ _ Were all system components,excluding the SAS,located on site. _X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _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. _ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 6 of 11 PART C SYSTEM INFORMATION Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x 3 of bedrooms): 330 gpd Number of current residents:_3 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]Per owner Laundry system inspected(yes or no):yes Seasonal use:(yes or no):no Water meter readings,if available. Sump pump(yes or no):no Last date of occupancy: currently occupied COMMERCIALANDUSTRUL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): no If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: . TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system(6'pit with 2' stone) _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:Approx. Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line:_NA Comments(on condition ofjoints,venting,evidence of leakage,etc.): SEPTIC TANK:N.A.(locate on site plan) Depth below grade: 12" Material of construction:_X_concrete_metal_fiberglass_polyethylene_other(explain)_ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 5.5 X 5.5 Sludge depth: 1' Distance from top of sludge to bottom of outlet tee or battle: 4' Scum thickness: 6" 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: 8" How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) TANK IN GOOD CONDITION—T'S AND BAFFLES IN PLACE NO SIGNS OF EFFLUENT OR BACK UP GREASE TRAP: N.A. Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined? D ate of last pumping:_unknown Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 TIGHT or HOLDING TANK: N.A._(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): STAINING AND EFFLUENT DISTRIBUTION BOX:_x_(if present must be opened) (locate on site plan) Depth of liquid level even with outlet invert: liquid level is above the 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.): STAINING IS EVIDENT—AT TIME OF INSPECTION,WATER LEVELS WERE EQUAL WITH INVERT PUMP CHAMBER:N/A_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type X_leaching pits,number 1 1000 GAL _leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.)- STATIC WATER LEVEL 10"DOWN FROM INLET CESSPOOLS:_N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_N/A_(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.): Page 10 of I I PART C SYSTEM INFORMATION(continued) Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. C,a rG o z9 �ea r o �o v SQ- U / 30'4" z � nIPIWICIAT. TNCPV1-T[0NJ V"D]%A_NOT TYIT? Vnl.TTNTAUV ACCFCCMRNTC I Page 11 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 307 Skunknet Road,Centerville,MA 02632 Owner's: Jean&Maria Biase Owner's Address: 307 Skunknet Road,Centerville,MA 02632 Date of Inspection: February 13,2009 SITE EXAM Slope 1 % Surface water NONE Check cellar (crawl space) OK Shallow wells NONE Estimated depth to ground water>15'feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: N/A Town of Barnstable Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 DEADLINES TO REPAIR FAILED SYSTEMS 60 DAY DEADLINE CRITERIA - Discharge or'ponding of effluent to the surface of the ground - Required pumping more than 4 times during the last year NOT due to clogged or obstructed pipe. -Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA - Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool -Any portion of the SAS, cesspool, or privy below high groundwater elevation - Any portion of the cesspool within a Zone 1 to a public well - Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. [This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA - Single Cesspool - Any"conditionally passed systems" (broken cover, relocation of a pipe, driveway needs to be located, etc) C:\cache\Temporary Internet Files\OLK13\FAILED SYSTEMS DEALINES FOR REPAIRS1.doc J .ram TOWN OF BARR�NSTABLE LOCATION Cd-7 S �9J� � /< I� • SEWAGE# vOq- ©4/1 FJILLAGE£ Nn,'YLt/l(/LO //ASSESSOR'S MAP&PARCEL /7O/3-,�j ~INSTALLERS NAME&PHONE NO.C.6e e0A -r90C,7701J JIV(— • 6zP 3yQ/b/I SEPTIC TANK CAPACITY 1 U O 6 . 6AfJ_ LEACHING FACILITY:(type) 500 CA-t- t6A-r_1•f size) 25 '1C_l2.1, i� � NO.OF BEDROOMS OWNER �/A'Sun/ -��i✓1��72cS PERMIT DATE: /c.>^01 COMPLIANCE DATE:°1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /�/� • Feet Private Water Supply Well and ng Facility(If any wel exit on site or within 200 feet leachin• facility) 141A Feet Edge of Wetland and Leac in 3�.aatl�nd / within 300 feet o IV/� Feet FURNISHED BY ,, I� nx- � — 2 — 33' S `' - No. .. Fee j THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZPPficatiou for Mi,5ponl 4vgtem CCou5tructiou i3ermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ®Individual Components Location Address or Lot No. 307 SKuNKnIET ROPw Owner's Name,Address,and Tell.N . Assessor's Map/Parcel D/2,5-8 Installer's Name Ad ss.a T 0 �/ Designer's Name,Address and Tel.No. $QXee,-, Me_L bC"-- NJ 42-4-674s -o a9,1 E. St�N ew 1�N N�4 0 37 Type of Building: Dwelling No.of Bedrooms �_ Lot Size S _ sq. ft. Garbage Grinder (/ Other Type of Building �lG(G+�'ha,� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 342._ gpd Plan Date 3Ict'o g Number of sheets -2-- Revision Date A//+= Title �R�i�• SEQnI� 5YSMM VI0 6,C+V6: /t-4-P) Size of Septic Tank laT /UOl) 159 Type of S.A.S. - g-oo 6*&&�f/20)ekAM&rc Description of Soil ; t,082M. `�p,�,p $ 1-0A4kt,,SA-,VJ w/4t SrvAX E�S� 3. l'h,Stci__p G /�'zbl�✓M SA>jr Nature of Repairs or Alterations(Answer when applicable) 'PC j9AR Q_ O G F-A�i L L4-7+C4 A 7— Date last inspected:_ Agreement: The undersigned agrees to ensure he onstructio and mai enance of the afore described on-site sewage disposal system in accordance with the provisions of Title of he Envir mental de and not place-the-systern-in operation until a Certificate of Compliance has been issued by this Bo r of ealt: Signed -�" Date 3 Application Approved by _- Date Application Disapproved by: Date for the following reasons Permit No. a(Z Date Issued L r .•. F.ee y.No. L r:fm THE COMMONWEALTH OF MASSACHUSETTS ),.. Entered in computer: t, Y-s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ` pplicati'on for Digpont *pgtem Congtruction permit ' f I Application for a Permit to Construct( ) Repair.( ) Upgrade( ) Abandon( ) ❑ Complete System N Individual Components Location Address or Lot No. 307 s KUN KN ET-.ROA C) Owner's Name,Address,and Tel.No. r AM Assessor's Map/Parcel 7U S 8 x,. i k Installer's amen Ad ess and Tel.No. 'j Designer's Name,Address and Tel.No. DA e✓e✓'t M 2 L,e r CP �_ � % Smv dw l c�( Mq o 3 7 Type of Building: LfW5 Dwelling No.of Bedrooms $, Lot Size I S 1- 7 sq. ft. Garbage Grinder (tile Other Type of Building �IWe kd1�l No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date �j�cj'U J Number of sheets 2— Revision Date Aj14 Title (:-R2u to . SeP I IL 5Y S rT_-M UP69-A126 Ot-6 Size of Septic Tank 5e15 ° /UUU er, Type of S.A.S. Description of Soil A CA,,i3O 8 [D� �, SI�� y"� 415nti6 4:4,95, 3.�5 GnSidrl Nature of Repairs or Alterations(Answer when applicable) P&_PPr-1,_ O G L&4cl-f r Date last inspected: Agreement: , The undersigned agrees to ensure he constructio and ma��i�n.enance of the afore described on-site sewage disposal system in accordance with the provisions of Title of he Envir,, mental C�'ode and not to-place-the system in operation until a Certificate of P d, t P Y P Compliance has been issued by this Bo . of ealt :. ° Signed � � a 1_ _ Date Application Approved by x �. _ Date. -;i- Application Disapproved by: ? Date for the following reasons .- v i " + Permit No. � Date Issued y � �.—ec-,s:,,,ra�.� �aG- _ _._,_. ��iS.�: -...,..,-.�.._� •,�4r�rr?�""'o ar !� '�" 21 THE COMMONWEALTH OF MASSACHLtSETTS BARNSTABLE, MASSACHUSETTS. Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by t- r ( ` • at �A� ) U��f/G t� E�� has e c"crdance awith the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer _ Designer #bedrooms Approved design flow\ ,J gpd The issuance of th(is permit shall not be construed as a guarantee that the system will fu)nc ion as desi nod. , Date t)� Inspector I / VV_ 7 k.. �s�ii�$,g��sa��sas�s� � 26�P--,. No. HE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS �Digogal 6p5tem CC n5truction Permit Permission is hereby gra ed o ons( rctt epalr ) U grade (l� tden) Abarr System located, `�� and as described in the above Application for Disposal,System Construction Permit.The applicantrecognizes his/her duty- to comply with Title 5 and,the following local provisions or special conditions. Provided: Const ction st b completed within three years of the date of this Date Approved by � , e, 7 cLnv-- c* 6f7 ' i 681A,, iL IT t�. 6+R d1 tZ + rr 3 i i Town of Barnstable 'HE' Regulatory Services Thomas F. Geiler, Director BAM rnBLL % M g Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,I 02601 Office: 503-362-4644 Fax: 503-790-6304 Installer & Designer Certification Form Date: Sewage Permit# "CV O Assessor's Map\Parcel /7o ZS$ J rte� M. ' ^ �( b e � Installer: C. mot/ �a�1CiTjC7 Address: D . -,toy Address: c �� �(•�'/VIUI�DS�i?'Tl-1' On I U ©� (� L[/ ���'V l/1� as issued a permit to install a (date) 2 (installer) septic system at 30-7 _VM 0I R S� o based on a design drawn by (address) 1 rr�✓� e �� dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. 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 f the septic system) but in accordance with State & Local Regulations. Plan revision or c rtified as-built by inner to follow. OF Mgss y o DAR M. nstaller's Signature) �'- No. 1140 k A l '�fG/STENO AJOITNO -7 (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-2641doc TOWN OF BARNSTABLE LOCATION 3®-7 S 1�"rJ1 tiw SEWAGE# V� 0 y J VILLAGE C iv,))Q ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. C�►/`.S ����� SEPTIC TANK CAPACITY Q0 v `{ LEACHING FACILITY:(type) C bwrh' d' (size) NO.OF BEDROOMS OWNER 1 PERMIT DATE: 3 to COMPLIANCE DATE: -71(14 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 Tw.,1or�S Tnritc,T�; 0 5 Z.96 TanpV�-eo1- =52.�1 D F 30Y•TN=S 1.O 9 1000(�q1 Di goY• Oul-_SI a Qy Leah 90,7..a Ttely TanlCFl-�e9t �. -. �evslal�ed 6-2'1-09' TOO Iqe Lcgf6i.c %amber TQnV..pole ill "achN Ole-#I ( ,P,Noleit( a.�l'1>"Dablewash LegcF,Nde.42 Yf'Sri a's D. y r - �{ ground ChawrlperS Qox 2�'4F� ,22 ,�,� H$o IF1 3H'3'� 26' -3"doo6l�.wash 3 NS'.4 2 39r g,l r vENT Is covEr lirti 3 21, 2g' -Fc11��Fgeri� over t Ver,+ " r ! Q270± 'town of Barnstable, P# / oti Department of Regulatory Services ttwsrAVIA t Public Health Division Date_ (/ KAS& e$ 200 Main Street,Hyannis MA 02G01A 167p. ♦ J J Time Fee Pd. 121 Date Scheduled I ,foil Suitability Assessment for Sewage Disigosalrot Performed By: V �/ �C d By Witnesse : + i LOCATION & GENERAL'INFORMATION r Location Address .30-7 ?"q_ �:, Owner's Name //�/ ��`�/�����-i I v v t Address cad 7 J&✓k`/tT Engineer's Name.D r/e^_ Assessor's Map/Parcel: �" Ja✓ NEW CONSIRU 6t'�1',ION r REPAIR Telephone# SO 1-' 36 Z Land Use ��' 7� Slopes(%) Surface Stones T >• J�. >30 b ft Drinking Water Well ft Distances from: Open Water Body ft Possible Wee Area Drainage Way (' ft. Property Line / ft Other ft SKETCH:(Street name,dimcnsiods'of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) P P qJ i\ \ P�O�ilaU L 4 1 _ �s Existing Leach 1 Pit it PREP - -� vent (See Note ` - - - --- - - - CD n3 i ( T 17` �� 6�( Parent material(geologic)e 4CI 0 , en,S,` I Depth to Bedrock ' Depth to Groundwatdr. Standing Water in Hole: �1 i Weeping from Pit Face . d 'IA A Estimated Seasonal l-ligh Groundwater ,� 1 DtTERMINATION FOR SEASONAL HIGI1 WATER TADLE Method Used: ! ___in. Depth to sail mottles: In. Depth obperved standin&p obs.hole: ! ill, Groundwater Adjustment ft. Depth toiwceping from side of olxs.hole: A ,f:ICtOC,,• Adj.Groundwater Level Index Well# _ Reading Date Index Well level - i PERCOLATION TEST . Date Observation I Ti le at 9" � Hole# i Time at G" .-�- Depth of Perc e ... Time(9"•6") --- Start Pre-soak Time.@ - End Pre-soak w� l Rate MinJlnch �j Site Failed; Additional Testing Needed(YIN) Site Suitability Assessment: Site Passed Completed on Back--------- Original:.Public ftIth Division Observation Hole Data To Be ***If percola#pn test is to be conducted within 100' of wetland,.-you must first notify the _ . I , . ma,,;cinn it IPact one (1) wedk prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.clo Gravel �1'' Ic ' SA'lr lbyk s DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) tj t . .�1 -' Cr �• I f/A'1 DEEP OBSERVATION HOLE LOG Hole# NIA Depth from Soil Horizon Soil Texture Soil Color Soil r Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, OravI F � l� Flood Insurance Rate Mai): Above 500 year flood boundary No— Yes X____ Within 500 year boundary No Yes,, , Within 100 year flood boundary No X Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? je If not,what is the depth of naturally occurring pe vious material? Certification (CA I certify that on j (date)I have passed the soil evaluator examination approved by the Department—oMnvi nmental Protection and that the above analysis was performed by me consistent with the required train ,lexpertis and experience described in 3.10 CMR 15.017( Signature j 1 �- Date 1 Q:ISEPTICIPERCFORM.DOC COMMONWEALTH OF MASSACHUSETTS a'$ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ;. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM , PART A }f ' CERTIFICATION r Property Address: 307 SKUNKNET RD CENTERVILLE,MA 0263215 Owner's Name: SEAN ELLIOT Owner's Address: 113 MAIN ST SANDWICH MA 02563 r Date of Inspection: 1/14/02 ' Name of Inspector: (please print) i 7, JOHN GRACI a 3�ik Company Name: SEPTIC INSPECTIONS ,t Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 1 k j Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT t ,y3 is I certify that I have personally inspected the sewage disposal system at this address and that the information reported below true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved systems z , inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)-;,The system: , 1 X Passes . s . _ Conditionally as s ` z' ,� _ Needs Further aluation by the Local Approving Authority e' i Fails Date: 1/14/02 Inspector's Signature: ; The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within ` ^ s 30 days of completing this inspectoo . If the system is a shared system or has a design flow of 10,000 gpd or greater,the owner shall submit the report to the appropriate re ional office of the DEP.The original should be inspector and the systemPg t���`. sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. iop k �¢ ` Notes and Comments 4 � I SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE . SYSTEM'S USEFUL LIFE. t report only describes conditions at the time of in and under the conditions of use at that time.`PhI� ?� ****This rep y inspection does not address how the system will perform in the future under the same or different conditions of use. dd r' Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM w t, PART A CERTIFICATION (continued) 1Akiin Property Address: 307 SKUNKNET RD CENTERVILLE,MA 02632 , t Owner: SEAN ELLIOT r -�i4 y T Date of Inspection: 1/14/02 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 , tt ' CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE `4 1 SYSTEM'S USEFUL LIFE. , a 44, i B. System Conditionally Passes: '(f xi4 _ One or more system components as described in the"Conditional Pass'.'section need to be replaced or repaired.The system, �r upon completion of the replacement or repair,as approved by the Board of Health,will pass. Af following statements. If"not determined"please explain. Answer yes,no or not determined(Y,N,ND)in the for the j n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits i� t 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 rt� that the tank is less than 20 years old`is available. v� 7 - ��ja�k'� 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 Ipipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of ; i Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced I ND explain: n/a k V.- n/a 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): 1K. _broken pipe(s)are replaced I _obstruction is removed ND explain: n/a ,, � ,. yy t i Page 3 of 11 ' r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . �'�* CERTIFICATION(continued) Property Address: 307 SKUNKNET RD CENTERVILLE,MA 02632 �d Owner: SEAN ELLIOT Date of Inspection: 1/14/02 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 ¢„ 1 ; . protect public health,safety or the environment. t 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: Ni PDT 7i _ Cesspool or privy is within 50 feet of a surface waters,' . Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh i yyh �,Hu Ott r ti,h 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the ; ,1 ; system is functioning in a manner that protects the public health,safety and environment: 3 „jL _ 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. ' � Y _ and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS + t _ The system has a septic tank aid SAS and the SAS is within 50 feet of a private water supply well. t 4 + f r;k _ less than 100 feet but 50 feet or more from a private water AO t; The system has a septic tank and SAS and the SAS is supply well". Method used to determine distance n/a " > i "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and 4 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 c w of the analysis must be attached to this form. 3. Other: n/ai, 4. q 9k, A�. a Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS t ,{ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` ar''.; PART A .: ~ CERTIFICATION(continued) Property Address: 307 SKUNKNET RD CENTERVILLE,MA 02632 1; Owner: SEAN ELLIOT Date of Inspection: 1/14/02 D. System Failure Criteria applicable to all systems: ;' You must indicate"yes"or"no"to'each of the following for all-inspections: � Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged. 1 ,. SAS or cesspool fit X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspools X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow F _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times < ' pumped nLa. 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.,_ PP Y rY pp Y �q = _ X Any portion of a cesspool or privy is within a Zone I of a public well. ( _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with ! no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP � . certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pol lution from that facilityand 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 ,wws attached to this form.[ r (Yes/No)The system fails.,l 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. tfir 4 ' E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: ; ;. (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply z} t. i _ X the system is within 200 feet of a tributary to a surface drinking water supply _ X 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 , " failed.The owner or operator of any large system considered a significant threa yes" in Section D above the large system has under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner *' r. should contact the appropriate regional office of the Department. ,° } K f N, 1t 1;. Page 5 of I 1 'f' 'V V. a3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS _:SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 3 , ` Property Address: 307 SKUNKNET RD CENTERVILLE MA 02632 + { Owner: SEAN ELLIOT ' ' " Date of Inspection: 1/14/02 [ .* Check if the following have been done,'You must indicate yes or no as to each of the following: • �r Yes No z X _ Pumping information was provided by the owner,occupant,or Board of Health Fk _ 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? h 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) t s` X _ Was the facility or d'welling,inspected for signs of sewage back up? t° as X _ Was the site inspected for signs of break out'? jt �An: its X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the w s wy> �uY baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ,r X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance , of subsurface sewage disposal systems �Mi h The size and location of the Soil Absorption System(SAS)on the site has been determined based on: � jYes no r°�+ X _ Existing information. For example,a plan at the Board of Health. ; . X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] '{'"' t � '"'ax� K •i! il. tip.�jj� p+. t •i Bin) • f[ 1 Page 6ofII =� a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ';; PART C .. SYSTEM INFORMATION " Property Address: 307 SKUNKNET RD CENTERVILLE,MA 02632 rva Owner: SEAN ELLIOT '' Date of Inspection: 1/14/02 FLOW CONDITIONS 1=r ' RESIDENTIAL 1 Number of bedrooms(design):3 Number of bedrooms(actual): 3 "V : DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 � ^ Number of current residents:2 � " Does residence have a garbage grinder(yes or no):NO � Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] r, a .' r; Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO i { Water meter readings,if available(last 2 years usage(gpd)): n/aA. Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a l y Design flow(based on 310 CMR 15.203): n/agpd ' Basis of design flow(seats/persons/sgft,etc.): n/a n; s � Grease trap present(Y or no):es NO Industrial waste holding tank present(yes or no): NO r r 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 f GENERAL INFORMATION i Pumping Records r' i Source of information: n/a �+ Wass stem pumped as part of the inspection es or no): NO If yes,volume pumped: n/agallons=-How was quantity pumped determined?n/a � t Reason for pumping: n/af�y - 41pr:. TYPE OF SYSTEM s X Septic tank,distribution box,sothalbsorption system ' = _Single cesspool _Overflow cesspool ' '�, �" _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) p . _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from key 4' 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:1987 Were sewage odors detected when arriving at the site(yes or no): NO t a: C'1.e i Page 7 of I I . r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C r SYSTEM INFORMATION(continued) Property Address: 307 SKUNKNET RD CENTERVILLE,MA 02632 , Owner: SEAN ELLIOT ' Date of Inspection: 1/14/02 BUILDING SEWER(locate on site plan) Depth below grade:42" v, Materials of construction:_cast iron X40 PVC_other(explain): n/a Mt Distance from private water supply well or suction line: n/a , # Comments(on condition of joints,venting,evidence of leakage,etc.): l ;7 S TOWN WATER # SEPTIC TANK: X(locate on site plan) 1 Depth below grade:36" ' 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: 1000G L 8' 6" H 5' 7" W 4' 10"" � �> Sludge depth: 2" i' # 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: 16" ' � How were dimensions determined: MEASURED ' Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as relatedit to outlet invert,evidence of leakage,etc.): ' SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. �x, �. RECOMMEND PUMPING 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 , i Dimensions: n/a r r f win 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 t e or baffle condition,structural integrity, liquid levels as related Comments(on pumping recommendations, inlet and outlet te kr ` to outlet invert,evidence of leakage,etc.): �4 +t n/a : i, Iss' ; S p � G %-� '7 r r i Page 8 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ¢. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;; 4: PART C SYSTEM INFORMATION(continued) Property Address: 307 SKUNKNET RD CENTERVILLE,MA 02632 Owner: SEAN ELLIOTY^ Date of Inspection: 1/14/02 r' ` s f r TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) r °y .41s1 Depth below grade: n/a '� Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/axr Capacity: n/a gallons ' Design Flow: n/a gallons/day `} Alarm present(yes or no): N/At 'h 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 leakage intoTO yn or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. `V. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO x Alarms in working order(yes or no):NO , Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a 144 9 1P e v .. f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 4 F" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ,.g " Property Address: 307 SKUNKNET RD CENTERVILLE,MA 02632 Owner: SEAN ELLIOT Date of Inspection: 1/14/02 1, SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) syA If SAS not located explain why: ; n/a015 ,,. f, Type 1000 GAL 6' X 6' leaching pits, number: 1 �d n/a leaching chambers, number: nla k "° ' n/a leaching galleries, number: nla n/a leaching trenches, number, length: n/a ' n/a leaching fields, number: n/a I ; n/a overflow cesspool, number: n/a innovative/alternative system frr n/a Type/name of technology: nla ' 1 �'Y 1 �F ` Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): 3! ` LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THERE HAS NEVER BEEN MORE THAN 2' OF LIQUID IN IT,NOW HAS 2" OF LIQUID IN IT.BOTTOM IS AT 11' WITH 2 OF STONE A � ;: AROUND PIT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a h Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a �' Depth of scum layer: n/a urb� ' Dimensions of cesspool: n/a i 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/a1 : PRIVY: (locate on site plan) �. Materials of construction: n/a r' " Dimensions: n/a ' Depth of solids: n/a � r� Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): , , .r t Page 10 of 1 I ' $ �uray:� f ° t .. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS y; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) , Property Address: 307 SKUNKNET RD CENTERVILLE,MA 02632 , : Owner: SEAN ELLIOT � Date of Inspection: 1/14/02 SKETCH OF SEWAGE DISPOSAL SYSTEM �k ` 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 r J r..�lon •. { r, 9: 1 Y 4 } in ' r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C R SYSTEM INFORMATION(continued) Property Address: 307 SKUNKNET RD CENTERVILLE,MA 02632 ' Owner: SEAN ELLIOT Date of Inspection: 1/14/02 SITE EXAM _Slope T ` _Surface water _Check cellar s , Shallow wells Estimated depth to ground water 14+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 f •y � q You must describe how you established the high ground water elevation: HAND AUGER- 14+ FT. `(N+ c r, #p 1 xxr .: tAy may' b j� M 1TO,.WN OF B TABLE Z3CATION3o� �1.� ea SEWAGE # �o-I.s VULLAGE_ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist _ on site or within 200 feet of leaching facility) � � Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) � Feet Furnished by �J( � �a 5CX {) a TOWN OF BARNSTABLE LO-:ATION SEWAGE # / VU LAGE ASSESSOR' MAP & LOT/ S 'D\JS NAME&PHONE NO. �a SEPTIC TANK CAPACITY A200 _ LEACHING FACILITY: (type) / (size) 000 NO.OF BEDROOMS3 BUILDER O OWNER 5�� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 i�leiP C�q 0 309 3 i . Mq y 0 BORTOLOTTI CONSTRUCTION,INC. tz 3 0 I99 765 WAKEBY ROAD,MARSTONS MILLS,MA 02649 1 508-771-9399 508-428-8926 FAX: 508-428-9399 Q �T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A.. CERTIFICATION Property Address: Date of Inspection: Inspector's Name: Owner' ame and ddress: _CERTIFICATION STATEMENT• I certify that I have personally`inspected the sewage disposal system at this address and that the informa- tion repotted below is true,accurate and complete as of the time of inspection. The inspection was per-' formed based on my training and experience in the proper function and maintenance of on-site sewage disposal yystems. The System: Passes Conditionally Passes Needs Further Eva tion B th Local Aproving Authority Fails Inspectoes'Signature: Date: -7�7 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION MMARY• A)SYS PASSES: I have'not found any information which indicates that the system violates any of the failure criteria as defined ir.310 CNIR 15.303. Any failure criteria not evaluated are indicated below. B)'SYSTEM CONDITIONALLY PASSES; 77777 One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate' ,nor,or not determined(Y,N,OR ND).'Describe basis of determination to 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 sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 00 PART A CERTIFICATION (continued) L� r Broken pipe(s)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 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 the public health, safety and the environment. . . 1)SYSTEM WELL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: a.. 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 IS FUNCTION- ING IN A+MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY,AND THE,I ENVIRONMENT: The system has.a septic tank and soil absorption system and is within 100 Feet to a surface ' water supply or tributary.to a surface water supply. The system has a septic tank and soil absorption system and is with 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 P 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 frotn�, the 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 ouponding of efluent 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 clog- ged 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 -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ` 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 a large system in addition to the criteria above: The design flow of a 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 well. 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if:the following have been done: - .Pumping information was requested of the owner,occupant,and Board of Health. ✓ None of the system components have been pumped for atleast 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 as part of this inspection. As=built plans have been obtained and examined. Note if they are not available with N/A. r The facility or dwelling was inspected for signs of sewage back-up. _, The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System, have been located on site. k-- Th&septic tank manholes were uncovered,opened,and the interior of the septic.;tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) V The facili and ants, if different from owner)were provided with information on. ty owner( occupants, the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RF.SIDENTLAi.: Design Flow: 3X allons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use:i(A Water Meter Readings, if ailable: Last Date of Occupancy: ,h J a / 1� CO MER LAIJIND 14T IAL*Leo Type of Establishment: Design Flow: Rallons/day . Grease Trap Present: (yes or no) t Industrial Waste Holding Tank Present*' Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: . OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informationlkm ^ System Pumped as part of inspection: /J- () if yes,volume pumped: 47 gallons f Reason for pumping: TYPE F-SYSTEM: eptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy try.: Shared System(If yes,attach previous inspection records, if any) Other(explain): "PROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detect when arriving.at th ite: U ,15 -4- ; i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction:_Izconcrete metal FRP_Other (explain) Dimisions: S'Y ' X S" Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: // Distance from bottom of scum to bottom of outlet tee or baffle: �/mh Comments:;(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to utlet invert,structural integrity,evidence of leakage,etc. p (� 4 GREASE TRAP: Alb Depth,Below Grade: Material of Construction: concrete metal FRP Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK:/t -) 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: t/ Depth of liquid level above outlet invert: Comments: (note if 1 1 and distribution is equal,evidence of solids carryover,evidence of 1 ge int or out o box etc.) ® / a PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOEL 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: a Leaching pits,number:_Leaching chambers, number: Leaching galleries,number: Leaching trenches,.number, length: Leaching fields,number,dimensions: -,,.Overflow.cesspool, number: t Comm nts: (note condition of soil,si ns of by lic fa' re level o ponding, condition of vegetatio etc. CESSPOOLS: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conlimied) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. / O„ a9 ' o &6kl y,, -- a DEPTH TO GROUNDWATER: Depth to groundwater: /S Feet MethQd of Determination or A prom ation: D -7- t , 8 '�7 . 0 3 n S S 1 30Nd11dW03 31Ma a3nSSI llWb3d 31Va V3 NM0 MO 1! 3 011 n 6 SS3Vaa11 1 3 N V N S.M311 r1SNI E 3 9 S 11- `A 4 '0N. lINVId 39VM3S _ =` N011V9 1' p� _ 13O Vd l � ! b 'ON dHW S.JQSS*,3SSV J r �� lf�nD y'/aG '��i�. . .��� �� � , ,, � . - l . - ; � . .. r \� �� r"11 ��. � I 1 �fi FPS . THE COMMONWEALTH OF MASSACHUSETTS OA RD O(�F HEALTH � .....VU.1/lJ. ... ...........OF...... ir..4' !1.......................... A4;ji irattun for Disposal 3Vnrkp Tonstrur#inn Veratit Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System a ....:.......... ~�.. :.. ........._...�-- . 1 . . ----.••..--......••.................. ... . Loc .............� ......./at' n• dd-re$s�- \(�.-....._._........... ............................/_._ d.-• o. .......................-....... ��Ik� f�l.dl.r` � er ............... ...... ........._....:I .... Z.! ..�.G?G n� l .............. �ess . Address. e Type of Building Size Lot..�.�.1 f.� .... ....Sq. feet, .-� Dwelling—No. of Bedrooms.........................................••.Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ N�,o�froff persons............................ Showers ( ) — Cafeteria ( ) a Other fix res ............................•-•• � tkk•......... ..... W Design Flow.........�,_.�. . ......... ....... .gallons per pescez�par (�y. Total d it l�iow...........�,,,? .fa. ._--....... to b. W Septic Tank—Liquid capacity�lons Length._ . ../��, Width:_... Diameter:.. D eft 5 .. .. . .. ep .....� .... x Disposal Trench—No. .................... Width .'f..........._._ Total Length.................... Total leaching area... .......sq. ft. 3 Seepage Pit No..._...�.. ..--..... Diameter...... ...... Depth below inlet..... ....... Total leaching area.. A., q, ft. Z Other Distribution box ' Percolation Test Resul Performed b �. l 04 Test Pit No. I...Lominutes per inch Depth of Test PitA.G-J6....._. Depth to ground wa er........... 5 .. Gk Test Pit No. 2................minutes per ch Depth of Test Pit.................... Depth to ground water.......... ...:...... 0 f.... .- t ...... . ........ Description of Soil.... .. �i.... ... ._...-- C ...............................••••••.........................•..... ..... .............. f- . Alt `r... (D . ...... Uw .......................•.•....••........-••-•-..•-••---•----•----.....................................: -�-••-••------.-•---- ......-•-...........::::::::::: Nature of Repairs or Alterations—Answer when applicable............. ................................................................................. .......................... ...••••--•.............................-. Agreement: .,The undersign agrees to install the aforedescribed Individt 1 Sewage Disposal System in accordance with -the provisions of TITUZ 5 of the State Sanitary e " he un rsi further agrees not to place the system in opeiation unAaertilfj, Com liance has b n ss a th o health. J Signed. .............••-•.................... r.. .... atq Application Approved By... ._�2�:............ ��..... ..............•-•-•-........... ......... .� 1 /.. .. Date Application Disapproved for the following reasons:............................................................................................................. .......-•..............................•..............................................................................---............•••---.....................................................-------- -� Date Permit No........ T�.. -. .......... Issued.......- ....:...-•---......... Date r �; � % � i.� _�, ► Ate' l ' 0 Y1 e f ........- .._ F1es........................... M THE COMMONWEALTH OF MASSACHUSETTS �+ BOARD OF HEALTH ...........OF......0 .( � '{ ` _1. ...._... A liratiun for Diu ur�� Disposal \k� C�unutrtzrttun Vrrmtt Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat,: V �, -- .............................................. r Location.A1 dress (� •� .............. or Lot No, r ............. 1/ ('). . ......•................. ..-•--•-....------------•-)� `l� 1•� �°.�..1 ..................................... W Owner,7 I ..'.... V ,Address Installer Address tt Type of Building Size Lot..` .V.M -..Sq. feet .•t Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (/ ; `1 Other—Type of Builditt p•, yp g ............................ No: of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures .. ...... .1--elf -VAtA4fAC- •- W Design Flow.......... t......_...gallons per per-son-p r dray. Total d�il�'` low---........ �,a_!�., ...---.-•.--gallons. WSeptic Tank—Liquid capacity.. gallons Length.. ... Width_��,.. ... Diameter................ DeptOr .f C3.._. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...P................sq. ft. 3 Seepage Pit No........1.. _..... Diameter.....� ....... Depth below inlet....60� ....... Total leaching area... 1 sq. ft. Z Other Distribution box Dosin nk (� ) i' '-" Percolation Test Results Performed b S. .A........ ��� %} k a y._. .�,.. ip! Date.. 1.. Test Pit No. 1... —.......minutes per inch Depth of Test Pit.. ..:.:'. "..:.... Depth to ground water......:.....f :. w Test Pit No. 2................minutes per 'nch 'Depth°of Test Pit.................... Depth to ground water...........n*.......... O Description of Soil--- � �-' ._� � 1 I: ........ ..... .14-�1t �. �1)�,_ � t�t t',�� ................. V .. w ........----••-•-••--•••••-•- • . x ------------- ------------------------------------ ------ U Nature of Repairs or Alterations—Answer when applicable.....::.:...................................................................................... ..........................� y,........._.... :....... ............ Agreement The tmderst ag o install the aforedescribed Individual Sewage Disposal� t System in accordance with g the provisions of.TI U- Hof the State Sanitary Code /—/ Fhe undlsiigded)further agrees not to place the system in operation until a Certificate of Compliance has been isstfedfby,th abl�oaar—br,,health. Aa, Signed. � 11...// .............••...................... ,rf/-„- .................... Date. Application Approved B ..,....Date.............. Application Disapproved for the following reasons:.............:......................................•------.........--------.........•-•--...................... I Date PermitNo..-•......................-..t` . .may........... ,\ Issued.....-•----•-----•• --........ • ................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF ...................................................... Trrtifiratr of Buntp littnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.................. '- ' -- r..^L. : +°! ✓. ............................. .... at............. ` Installer-� / ................................. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._. '-�.-.� ..... dated....._1..:���?.r ?.��................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILLfFUNCTION SATISFACTORY. `r DATE.............. _ 5(o ............................. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �"1 '.�.. ? ..........................................OF... . I"d f:� ? ............... No FEE. ..&.....::�. . 11iopouttl Worko Tonutrnrtion Prrmit � ,/ Permission is hereby granted....., .f................. '�r.�....... Z�:..�...../is�'":.............................................. to Construct ((,)orJ/Repair ( ) an Individual Sewage Disposal Syst at No............. ....,- rf'�� rl 1� .1`'i .............-----••-- '•..-`:' x:..................t a....... Street ." as shown on the application for Disposal Works Construction Permit No.S -1r-/3Dated........!����.`��............ . . .. DATE........... 'Zr-2 _ ..�...................................... y Board of Health ••- ---. •. SURVEY REFERENCE: LEGEND PLAN OF LAND BY: WARWICK AND ASSOC. DATED: MAY 17, 1985 i IC! PROPOSED CONTOUR ' ' 9® PROPOSED SPOT GRADE - -- EXISTING CONTOUR ' c; j' 1 p.' 1 r: + 96.52 EXISTING SPOT GRADE I, , } ;- W— EXISTING WATER SERVICE /- - - - -- - TEST PIT �, , Qfa,6 1 gym" ---- 13 7.05 ft im 1 -— — -- 56 I zt rra�� n :''- - ---' of ��, i t - 4�0 / \ � ,,yam., •'1' r: r' r aJ h�f 4�+;, S �o � \\ LOCUS MAP N.T.S. ! PAVED DRIVEWAY � ! GENERAL NOTES: / 20 fF ` �� ! \\\ 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS TH-2 /� O Z T 1 OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE 13 n 1 /) j o LOCAL RULE AND REGULATIONS, EXCEPT AS REQUESTED BELOW: j TH-1 / i 1 , 16 1) UP TO A 1.35 FT. VARIANCE FROM 310 CMR 15.211 TO ALLOW � 57 // / o LEACHING TO BE UP TO 4.35 FT BELOW GRADE VS REQ'D 3 FT. (VENT PROVIDED) C—0 N Z // ! 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR O O ,/ / i TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE j 5 r� 2 , ,/ j DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING ��LULL111 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION 5. ALLELEVATIONSBASED ON ASSUMED DATUM W 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF �I N O ABOVE - / ! HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. LLJ 13 ft GROUND J/�/ I Q 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. I O SWIMMING / Q Z 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED POOL l TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 0 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE if I THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING vent /� ! W CONSTRUCTION. Existing Leach Pit /� L O T O 10. EXISTING LEACHING PIT TO BE PUMPED, CRUSHED AND REMOVED. (See Note 10) // j U REPLACE WITH CLEAN MEDIUM SAND. AREA = 15197 S f 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION L-- - ------- --------------------------------------—-- --- / 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY 138.03 ft 56 ----------- ----� AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY v. 13. NO PRIVATE WELLS WITHIN 150'-OF PROPOSED LEACHING. 14. NO WETLANDS WITHIN 150' OF PROPOSED LEACHING. B E I\I C H MARK 15. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPECIFIED) ' �N\\ OF Xt, PAINT SPOT ON BULKHEAD CORNER .� D RE R G ELEVATION = 57. 35 PROPOSED SEPTIC SYSTEM UPGRADE PLAN I o '0. 1 11T0 BARNSTABLE CIS DATUM 307 SKUNKNET ROAD, CENTERVILLE, MA 'PEClS-1 0 Prepared for: Sanders �N(TARIa� MAP; 170 Engineering by: Surveying by: SCALE DRAWN JOB. NO. DARREN M.MEYER,R.S. DMM [n�-��/ QQ LOT.'258 PO BOX98f a'co-Tech Eaviroaaaeata! 1"-2Q' 3 'o- .Q" l DEED BOOK: (508) 364-0894 SHEET N0. EASTSANOWlCH,MA02537 DATE CHECKED DEED PAGE.'204 508-362-2922 03/09/09 DMM 1 of 2 ELEV. TOP ALL COVERS TO WITHIN 6 " OF GRADE vent required FOUNDATION NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS (Existing) FINISH GRADE=56.6 58.20 F.G.EL: 56.8 F.G.EL: 56.7 F.G. EL: 56.6 s n MAINTAIN 2% MIN SLOPE OVER LEACHING AREA { ° 3/4" - 1-1/2" DOUBLE 2" OF 3/8" DOUBLE WASHED WASHED STONE .. . ,a' STONE OR FILTER FABRIC 6' 4" SCH 40 PVC 10"1 _ (MIN. ®®®®. O EB®®® 14 a '71NV.51 .94 1% ) ®®®®®®®®®®® a: TEE'S ARE TO C INV.52.11 2 EFF. DEPTH ®®®®®®®®®®® 4" SCH 40 PVC INV.52.71 4' 2 X 8.5' 4' GAS PROPOSED DB-3 EXISTING OUTLET BAFFLE EFFECTIVE LENGTH = 25' -:-- ••.".• -. ".-•-- --. H-10 DISTRIBUTION BOX INV. ELEV.= 51 .74 INV. 52.96 EXISTING 1000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON BREAKOUT OUTLET TEE AS MANUFACTURED BY ELEV.= 52.25 TUF-TITE, ZABEL, OR EQUAL TOP CONC. ELEV.= 52.25 INV. ELEV.= 51 .74 MWES ® O ®®®®®®®® ®®®®®® "®®®®®® NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING BOTTOM EL.= 49.74 ®®®®®® PIPE INVERTS PRIOR TO CONSTRUCTION 3.75' 5 FT. 3.75' 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE ON A MECHANICALL COMPACTED SIX SEPARATION 5.24 FT. EFFECTIVE WIDTH = 12.5' INCH CRUSHED STONE BASE, AS SPECIFIED IN SEPTIC SYSTEM PROFILE 310 CMR 15.221(2) SOIL ABSORPTION SYSTEM (SECTION) 3) REPLACE EXISTING TING11,000 GALLON SEPTIC BOTTOM OF TESTHOLE EL: 44.5 r TANK WITH 1500 GALLON SEPTIC TANK (500 GALLON LEACH CHAMBER (H-20) LOADING) IF FAILED, DAMAGED, OR UNDERSIZED. 4) INSTALL INLET & OUTLET TEES AS REQUIRED /� DESIGN CRITERIA SOIL LOGS P#: 12504 NUMBER OF BEDROOMS: 3 BEDROOOM DATE: MARCH 9, 2009 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) SOIL EVALUATOR: DARREN MEYER, R.S., CSE DESIGN PERCOLATION RATE: <2 MIN/IN WITNESS: DONNA MIORANDI, BARNSTABLE B.O.H. DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. GARBAGE GRINDER: NO (not designed for garbage grinder) SEPTIC TANK: 330 gpd x 2.0 = 1,000 gpd USE EXIST. 1,000 GALLON SEPTIC TANK Elev. TH- 1 Depth Elev. TH-2 Depth 56.5 0" 56.5 0" (330) = 445.94 S.F. A LOAMY SAND A LOAMY SAND .LEACHING AREA REQUIRED: 10YR 4/1 10YR 4/1 .74 55.67 B 10" 55.75 B 9" USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS (H20) W/ 4' OF 1'/ LOAMY SAND LOAMY SAND STONE ON SIDES & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D gss9�y 10YR s/8 10YR s/8 BOTTOM AREA: 25 x 12.5= 312.5 SF D R N M. ;�% 53.67 34" 53.58 C1 35" R SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF _ No. 1140 "' C1 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D f MEDIUM DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd MEDIUM SAND 'AEG/SZE � PERC 051.60 SAND 2.5Y7/4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN t SANI TA0'\ 2.5Y 7/4 D2J 0i -0 , 307 SKUNKNET ROAD, CENTERVILLE, MA t Prepared for: Sanders Engineering by: Surveying by: SCALE DRAWN 44.5 144" 44.5 144" DARRENM.MEYER,R.S. Eco-Tech Environmental N.T.S. DMM Box PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) 64S SANDWICH,,MA pp537 � ) 364-0894 CHECKED 508 DATE SHEET NO. NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED 506.3622922 03/09/09 DMM 2 of 2 SECTIO`1V E- SEWAGE �' ;z; - 4CG-I 1'j SEPTIC TANK — —"D"BOX— —LEACH. TOP OF FDfN� v, 7��Y-(MSL)i► ..2..OF t�eTO y='. WASHED STONE IN- I3 n OUT• IN / !aa OUT• IN• SEPTICAwl TANK �J 1ELEV. ELEV. ► \ i J�� ! 1 ELEV. c - ELEV. ELEV. OF 3A"-lVzl' x 4pWASHED STONE TEST HOLE LOG ar-T-nrr o;= �+-1 TEST BY �.�i IZE3AfJ K G4N1 L01� ' \✓� �{ tf IO D S WITNESS /g A} � * / , TEST DATE _T DESIGN BEDROOM HOUSE T.N: • 1- T.H. +� 2 , -rY[ ELEV.- , ELEV. NO 2A'� LOaM �f �S 53 '�'Z DISPOSER DISPOSER J J -2-7 PERC RATE MIN/IN.' J \ FLOW RATE 330 (GAL./PAY)3d d� GI. Go h'SE. SEPTIC.TANK -330 {/��_ �'q� -�� • � � fr` r �YE1, REQ'D�SEPTIC TANK SIZE IA rTµ ps I I q 7 i5� OF IG E AMID LEACH FACILITY SIDE WAL E g/SI��g ) . 3��.O.G/D. 2_6 T � 2C9 TOTAL Zc>/ / S� 1-177i`3G.�Y� USE: alE LEACHING cat I f WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) T.DATUM(MSU+TAKEN FROM �� ��/'�TQUADRANGLE MAP � I I O I 2:MUNICIPAL WATER ._ _ AVAILABLE 3.PIPE PITCH:IA"PER FOOT J i ,/O `H OF 4.DESIGN LOADING FOR ALL PRECAST UNITS:AASHO, •44 S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. p �y APN� 6.PIPE JOINTS SHALL BE MADE WATERTIGHT S Ov,i•,` - .� • 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. SITE PLAN STATE ENVIRONMENTAL.CODE TITLE S �..D C t, .. LOCUS' 2 o.'�` !..� s ARNE p� ti C��f .�'e!RG`.(= a"'try� REG.PR NGINEER ' ✓ OJA �=.1 REF: - W®64+P! cil.Pe efgi�ee�i�� ",3 r r o PREPARED FOR CIVIL ENGINEERS (EXISTING) BOARD OF HEALTH LANDSURVEYORS -----= --- CONTOURS --- 'ai,A St. REG.L A NQ. EYOR (PROPOSED)—O—O—O—_ 4- APPROVED DATE �'4�`�N5/'��` !A SCE - - ��;;El - �'(a DATE 2 b