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HomeMy WebLinkAbout0530 SOUTH MAIN STREET - Health 53(Y Sou ain-Street Centel viiie P A - 187 043 1 Omffo, d NO. 1521/3 0RA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your V cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Company Name vQ� 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 by the Local Approving Authority 05/20/2014 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. LtrtiFor.m: � Fq I t5ins•3113 Title 5 OfficiaSubsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. Cityrrown 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: 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction Is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a.surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 t5ins•3113 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MM 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. City/Town 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. El ® 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 l5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. City/Town 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 nts pumped out in the previous two weeks? ❑ ® Were any of the system components p p ® ❑ Has the system received normal flows in the previous two week period? El ® 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): 464 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t5ins-3/13 i Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information Description: 1 Number of current residents: 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. El Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: o2o) 61,o,)���°J S Used ,2 0/Z. Zf.ac* Sump pump? ❑ Yes ® No occupied Last date of occupancy: 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 t5ins-3113 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. CityrFown D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 t5ins•3113 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 11/08/2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 12" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Standard 1500 Gallon Septic Tank Dimensions: < 1 ' Sludge depth: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t5ins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 39" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 11" field instruments How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the tank should be um ed based on the future use of the home. 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t5ins•3/13 Commonwealth of Massachusetts x W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Ma, 02632 05/15/2014 required for every Centerville State Zip Code Date of Inspection page. City/Town 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 t5ins•3/13 Commonwealth of Massachusetts _ Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM °' 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d box has a riser and the were no signs of leakage or solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 t5ins•3/13 f Commonwealth of Massachusetts _ W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments g p 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Type: ❑ leaching pits number: 3 ® 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.): 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 t5ins-3/13 f Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. City/Town 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.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 t5ins•3113 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. Cityrrown 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 t5ins•3/13 r Assessing As-Built Cards rage i or Sol OF BARNSTABLE LOCATION �d Sol r mt/1 Sr SEWAGE M a001' VII, ,,E �� e r.n L ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACrrY l S_&V i LEACHING FACILrrY:(type)3' S"� GLt t iS (sift) .sx a X a.a NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: CCtltCE'DA 7 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 Feet within 300 feet of leas s facility) Furnished by' S' �Ay Q A s a 13 !9 a C-G ash 3 3 / ' 38 ffT-O±j y a3.6 yy f - Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 12 plus feet Estimated depth to high ground water. 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: I augured.a hole at a lower elevation and shot it with a transit. 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 530 South Main Property Address Kathleen Deerman Owner Owner's Name information is Centerville Ma. 02632 05/15/2014 required for every State Zip Code Date of Inspection page. City/Town 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 f Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 t5ins-3/13 TOWN OF BARNSTABLE LOCATION 5 3� SOV M'91n sr" SEWAGE # o;ODI 7O'b VILLAGE ASSESSOR'S MAP & LOT l OY3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l rW LEACHING FACILITY: (type) 3' Y'OD Uo1CIr &"s (size) .Sx a x13•oL NO.OF BEDROOMS BUILDER OR OWNER 7,o M RUcA4✓%ol0el PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet. Furnished by=it,- -''{.t m For . t I A a 113 �9 i s a �s.6 aye 3 /9' 38 0y LOCATION TOWN OF BARNSTABLE � _��� ,� �a r SEWAGE # 2O-PI— 7d VILLAGE - y,��/ f INSTALLER'S NAME&PHONE NO. '! `a ASSESSOR'S MAP & LOT I y ? SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3' goy$ GSc�,l�es-S NO.OF BEDROOMS -j (site) 12 BUILDER OR OWNER PERMITDATE:fa•?"�'—�D�J COMPLIANCE DATE: 4 2 Separation Distance Between the: r Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching FacilityFeet on site or within 200 feet of leaching facility) any wells exist Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet i >3 / 9 0 i A 3 � 3 22 3 k5Y- 22 3Y 5- � '� Yi y� sZ1z3G COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMEN �1 jqN MAY 1 5 2003 TOWN OF BARi,4STABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 530 South Main Street 4 Centerville, MA 02632 Owner's Name: Tim Buchannon Owner's Address: Same Date of Inspection: April 24, 2003 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Map: 187 Mailing Address: P.O. Box 49 Parcel.043 OweryUk,ILA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes N Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: April 26, 2003 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 530 South Main Street Centerville, MA Owner: Tim Buchannon Date of Inspection: April 24, 2003 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 ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 530 South Main Street Centerville, MA Owner: Tim Buchannon Date of Inspection: April 24, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15-W(l)(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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 530 South Main Street Centerville, AM Owner: Tim Buchannon Date of Inspection: April 24, 2003 D. System Failure Criteria applicable to all systems: You must indicate either`W or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 1;Pd• 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 530 South Main Street Centerville, MA Owner: Tim Buchannon Date of Inspection: April 24, 2003 Check if the following have been done: You must indicate`yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 530 South Main Street Centerville,MA Owner: Tim Buchannon Date of Inspection: April 24, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL 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: Never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: ¢allons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Jan. 17102-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 530 South Main Street Centerville, MA Owner: Tim Buchannon Date of Inspection: April 24, 2003 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: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 3'6" Material of construction: ✓ 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: 1500 gal. Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs ofleakage Scwwsludge were minimal The cover was 15"below grade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity;liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 530 South Main Street Centerville, MA Owner: Tim Buchannon Date of Inspection: April 24, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level and clean. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): s 8 Page 9 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 530 South Main Street Centerville, MA Owner: Tim Buchannon Date of Inspection: April 24, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3-500 gal. chambers-33.5'x 2'x 13.2'(per as built card) 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.): The chambers were&Y and w new condition No scorn line was present. The bottom to grade was 6 5'. The cover was 16"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: 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: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 i • Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 530 South Main Street Centerville, MA Owner: Tim Buchannon Date of Inspection: April 24, 2003 Map: 187 Parcel:043 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. Ay a a ,q r3 l 13 /9 3 a /3.G a.Cb 3 /9 38 oy y ;)3.6 yy 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 530 South Main Street Centerville, MA Owner: Tim Buchannon Date of Inspection: aril 24, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: 10115101 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 most describe how you established the high ground water elevation: According to the design plans, no water was observed at 132"when the system was installed This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCATION �b S0V SEWAGE # aoDl- 70 VILLAGE ���e rv►�(�. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l S(/U { LEACHING FACIL=: (type) 3' rOD t-H4rr►�Lis (size) 33.Sx a`x/3•a' NO. OF BEDROOMS 3 BUILDER OR OWNER auc,14140011 PERMITDATE: DA Q 7/4 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 leac�ng facility) Feet Furnished by /t Qec, wi Or _ r A a / /3 9 a 13.6 asb 3 3 IF 39 o y �3.6 yy TOWN OF BARNSTABLE �L LOCATION S�3® r,�� A/4.'� �ts"�r'1� SEWAGE # d�1 ��0 VILLAGE G- ✓, �/ f ASSESSOR'S MAP & LOT 7-0 INSTALLER'S NAME&PHONE NO. ,�. ���� MY fe rm•T SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3 ti°'s G4 c,"44'S (size) 3 3, X.X NO.OF BEDROOMS .3 BUILDER OR OWNER Ti w PERMITDATE:1�'��' �� COMPLIANCE DATE: 11 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 a 3 13 � 3 60 U:22 �/ No. Fee �O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BAPINSTABLE., MASSACHUSETTS ZIppfication for Migoml *pztem Cow5truction Permit Application for a Permit to Construct( )Repair(v4pgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. �n Owner's Name,Address and Tel.No. Assessor's Map/Parcel C_.Io +y,"YIUX r Installer's Name,Address,and Tel.No. Designer's I§,f �fjs yd T�,j�jp,E & ASSOC. C_ A 1L` 42 Canterbury Lane v East. Falmouth, MA 0536 Type of Building: - -1" _1 Dwelling No.of Bedrooms A Lot Size Gam.4y 1 sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ':S3 D gallons per day. Calculated daily flow 1k4 gallons. Plan Date our- 7d _ Q I Number of sheets 1 Revision Date Qom. -L D 1 Title e r` A► "1� Size of Septic Tank% Type of S.A.S. Description of Soil!mjm �� _ ��i.�.�1 S e�LL—pta Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of itle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue b t ' oard of Hea - Signed a Date a 7" Application Approved by L. Date Application Disapproved for the following reasons Permit No. Date Issued l (` ' v Fee v .� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: COMMONWEALTH, _ PUBLIC HEALTH DIVISION -TOWN OF BANSTABLE, MASSACHUSETTS j Yes Rpprication for Mioozat *pztem Construction Permit Application for a Permit to Construct( )Repair( Apgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 30 ��� Owner's Name,Address and Tel.No. Assessor's Map/Parcel C" NYC�Y14 1 "A 1 — Installer's Name,Address,and Tel.No. Designer's N ff"2R1 Telflbq'LE & ASSOC, 42 Canterbury Lane East Falmouth, MA 02536 - Type of Building: _1 Dwellings1 No.of Bedrooms Lot�Size G3.4(n I sq.ft. Garbage Grinder( ) Other ,t Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ti Design Flow 33 gallons per day. Calculated daily flow ArtA gallons. Plan Date Z5A . ` Number of sheets 1 Revision Date D gzj'. `2.! D 1 »� < Title St=y�,&c< <,.c�.�-r�-� Tsa`-PASrz_ �-L��S o tt. 5'lD 1��\,a►> i s;�, �— Size of Septic Tank 1 S'�0 0 �r��Q.,,�Type of S.A.S. �,e t..nr�r�'�'( ' Description of Soil �� �� :5\--T''��r!�!\7'i._-A.wA S o I L ors Nature of Repairs or Alterations(Answer when applicable) . r t Date last inspected: Agreement: , The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ale 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this''oazad','af Heaallth: Signed -Date /;2- _ Application Approved Date � � t a Application Disapproved fheJfollowing reasons Permit No. Date Issued J CC IL I. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(Y/)Upgraded( ) Abandoned( )by at V1 I Le has been constructed Vrordance with the provisions of Title 5 and the for Disposal System Construction Permit No. P cUl- U dated Installer 1 t dd L n2 Designer �?T i/L G The issuan6e of pe . t shall not be construed as a guarantee that the syste1 will fu�nction a designed. Date 1 /7 ��7— Inspector cY A"/ A. — ---------- No. ��f�l' /LV Fee--- -. — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligoal *p5tem Construction Permit Permission is hereby granted to Con truct( )Repair(X)Upgrade( )Abandon( ) System located at r q and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ,xPrgvI ed:Co traction must be completed within three years of the date oft ' ermit Date: LGu Approved byi� C:� ---E7 __�E7 -A/—f A7_T_E7 W1 I\Fd% .6- TOP FOUND. EL tt.S "Sr - -tZ.3 w+s s! i WATER ncyr covEa -ad - Total Trench Length 33�5 — INV. EL 1(,,4' rl XXIFlow LINE ('----r ------ 3/4" - 1-1/2" Mashed Crushed Stone " " a 'f 4" PVC �o• wnN. _t, EL• t S.o' 2 of 118 - 1/2 Peastone N SCHEDULE 40 VENT IA INV. EL. FINISH GRADE 1 4 AI1. 8" i4• :. � _ 10 MIN, V uano t� InY. 1;'1. , o . 7H INV. EL. P ---L-Z e ;, c� eo o ca e� �._ • o 0 o e--, •e�°a. ° a e INV. EL ' EL 12.5 0 0 ' Dawn INV. EL ' No. of Trenches _1_._ 5 2' No. of 500 Callon Precast Cbembers 3 b' Trench 1lidtb 13'Z 3/4" •- 1-1/2" Hashed. Crushed Stone 3/4" - 1-1/2'" Washed Crus ed Stone PRECAST REINFORCED CONCRETE -Ass- N,�u _,1A'Al en•�w .- 1500 GALLON PRECAST REINFORCED CONCRETE SEPTIC TANK Az -Ts PROPOSED 'S.A.S, TRENCH SECTION DISTRIBUTION BOX MINIMUM CONSTRUCTION MATERIALS PER 310CMR 15.226(2) INSTALL ON A LEVEL BASE TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND MINIMUM WALL THICKNESS 2" SHALL EXTEND A MINIMUM OF 6" ABOVE THE FLOW LINE General Construction Notes OF THE SEPTIC TANK AND BE ON THE CENTERLINE OF THE MINIMUM INSIDE DIMENSION - 12" SEPTIC TANK LOCATED DIRECTLY UNDER THE CLEAN-OUT MANHOLE. 1. All the workmanship OUTLET INVERTS SMALL BE EQUAL TO EACH p and materials shall conform to D.E.P.Title 5 and the Town of OTHER AND AT 2" MINIMUM BELOW INLET INVERT. Barnstable rules and regulations for the subsurface disposal of sewage. THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2" NOR MORE THAN 3" ABOVE THE INVERT ELEVATION OF THE THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX - OUTLET PIPE. SHALL ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING - 2. At least one access port over tank tees shall be accessible within 6 inches of finish grade, THE DISTRIBUTION BOX TO THE HEIGHT OF THE DISTRIBUTION ; SEPTIC TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRADE LINE INVERT AFTER ALL LINES .HAVE BEEN SEALED IN PLACE. with any remaining access ports brought to within 12 inches of finish grade. , ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH DURABLE -,�---'-"""'"----'�,,,� ; ZO11TI11TG 'DISTRICT.' RD-1 � CEt�TERVILLE COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE AND NON-OEFORtdABLE MATERIAL PERMANENTLY FASTEND TO THE -' 3. All Components of the Sam Cm Shall be Ca '9� " "� HAS BEEN PLACED TO ENSUREi LINE OR RECONSTRUCTING 'THE-LINES LINES t INTIL ALL INVETS ARE OF �Y capable of withstanding H-10 loading �, Fe, STABILITY AND TO PREVENT , g OVERLAY DISTRICT. '�-----r- unless they are under or within 10 feet of drives or parking." H 20 loading shall be used AP _ Rp �- N `" - P"+ i P SETTLING. EQUAL ELEVATION. ----- , } s i under or within 10 feet of drives or km unless noted, , ; • SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9". "71.09 ,. `�2eS i g AP BUILDING SETBACKS.• �! pb z"�} � �'�CENTERVIIlE 9��q� - THREE 20". MANHOLES WITH READILY REMOVABLE IMPERMEABLE 536'js'27 �j�' 1 4. The excavator/contractor shall verify the location of all site utilities prior to any FRONT — 30 � E5 � 11 @ 9aea�- ,,� COVERS OF DURABLE MATERIAL SHALL BE PROVIDED WITH ACCESS excavation. SIDE 10 PORTS BEING PLACED AT THE CENTER AND OVER THE INLET AND , cp REAR - 10 OUTLET TEES. N 13� 5. Sewer pipes shall be 4-inch Schedule 40 PVC laid at 0.02 slope. -' FF.NA DATA.• THE OUTLET TEE SHALL BE EQUIPPED WITH GAS BAFFLE. JP . i sr •�,r ww� ZONE A10, B do C ` bvrP C 6. Any masonry units used to bring covers to grade shall be mortared in place, - FLWPA FAAM DATE: DESIGN DATA: ,. % F „ Crai Ville g,• STRUCTURE .�y, �wtu'�.. 3 0 7. Finish grade shall have a minimum slope of 0.02 feet per foot. - - -. rSZrLs,� ASSES'S"ORS DATA• TYPE NO. BEDROOMS GARBAGE DISPOSAL jj --1 `, �� 1 ` -'-- --'--' NAP 187 PARCEL 43 DESIGN FLOW __. a 3 -ttu -a�a cep► 2� \ :, +, brw A ,-- d , _� 13g.6 20 .L Wetland Delineation ` �� `�k .� �8 $' By "A N Wilson" \ ��`�� \ byrr "B" .� SEPTIC TANK ust= 5 yt� Ilk 10 y� r�Q - ' - 1 Cr�uet.1 1 -xST S23'46 00"E �b' d 12 LEACHING FACILITY w's Z+t--s,-L i- =.r't-y 3.f >•�c I \ \ bvir 2 r / ,`''r�`9�15 " 1749 ••"�:-'- r - 15 tom.-z>< •���r -- gA� f ,P ' � , ' �'�-°� "•• - ' �16 -17 b 31 7,' l // / '�' ♦' ♦' ♦ �18 ,� e ♦� 1g b6 ,y0"� r / ti..�Z1�' ♦' ♦ .. ♦ 100'de lC'Ie 6•A6 bvir 4/ 8 ti�/� /' �;` ,y �' 1610 � '' ••102' , ¢�S �.,�../;........t-.....�♦ �i - � ,, ..- � " �� :9 � � 1B � i , 17 ' ' 20 Note: E.�ds water lines shall be sleeved R 20.00 '�` I / ; / ; / / / / `' in 2" vc � ten feet of system. 11 51 0 l Stockade 11'ence / 13 Proposed S.AS. Trench Proposed 5AL 1500 Gallon is r 63,461d-sq.ft / / 60` • —�-��.'' I t 1 (/ �� Tank ,.• 20 11�•p4 fl I I I/ I no basement 1 t / ,P p i ...•-. NOs / / I/ I/ �/ / t I �\ •"..-•••� d/b �/ 17 147y0'30 7y50 ti 1 1 1 1 \ \ �� I 16 I I ` 16 ♦ 16 15 SOIL OBSERVATION DATA: bvw-6 1 \\ `\ \� \ \ \ _ I 1 O ff_ , '♦� ' / 15.2 � 4 r¢e 0e 7 so AL I \ \I 15 TEST DATE - L�'o ) I \ 100' 1 t 17 \ i �2 ••'� i g' / I • _ �o I \ • \ 1 I M Se wage System Repair Plan 1 I y SOIL EVALUATOR - r I I \TP t ` _ • / A / / // I 1437 10 s� Prepared For. JL 13.r�.�l. AGENT �L' �.r>< I 'SO64eb8�, I I ► I 1 `� 1 ` basement ,' . �� ,' 14530 Mc'� 3 I I I I I I .� / / '.n �..7 tre e t . EXCAVATOR G�A1-Tl� f / �` , -- I I I I ` basement ' / 16 15 In Pet?t,;RATE s -z- .',�-�1 8 9 10 11 12 13 14 130e \ d .• a i 17 Cen te.,r'Vllle, Massa ch use t is 5 �� 18 18 Scale: 1" = 20' Date: October 24, 2001 and filled with clean course, a pumped \ �� ��•,�y.°�_ e e F L. -�o,o Note: Existing cesspool shall O rand 14 � 1 Prepared By.• �� A _ �/g u A s` w-1Q`s'`z ti _ �b� Stephen J. Doyle And Associates 'fir,. •� y q I 1 �/'-o\ 42 Canterbury Lane, X Falmou KA 02536 0 tc 15 I 1�, •r? Telephone.- 5081540-2 34. ''� { LS Yti�Ilr 'f� >.S 1°`1Q- 41L IB �j or 01 ,r4�+ w GRAPHIC ` SCALE - oo37 tro A'9� 20 o t0 to 10 so 1`�.g•O I ll C_L.9A t`3z _ IgNO SI °`rsstalks w +•mot�>'l. csw► .. - , �cc•�-*� N.c.t v e coN�atcEel�� - - y _ Il� FEET i 10 t1•s 1 A1- VJ We t.w�ats '�- a 1 .1nch 20 i't._ N0. ; DATE- DES P CR! TION .. 8Y .