HomeMy WebLinkAbout0816 SOUTH MAIN STREET - Health 816 South Main Street
Centerville
A= 185 - 059
S M E A D
No.2-'i 53LOR
UPC 12534
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• \ COMMONWEALTH OF MASSACHUSETTS
r 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
CER{T�IFICATION
Property Address: (� ,.`)`v\ `:till
t_7, T ?1
Owner's Name:
Owner's Address:
Date of Inspection:
Name of Inspector.(please print)_150
Company Name: William E. Robinson Septic Service
Mailing Address: ' P O Box 1 089
Centerville, NIA
Telephone Number. . (508) 775-87T6-
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 Sec'on 15340 of Title S(310 CUR IS.940). The system
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shalt submit a copy of this inspection report to the Approving Authority(Board of Healthvr
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of I0,000
gpd or greater,the inspector and the system owner shalt submit the report to the appropriate regional office-of the
DEP.The original should be sent to the system owner and copies"sentto thebuyer,if applicable,and the approving
authority.
Notes and Cornments
**•*This report only describes conditions at the time of inspection and tinder 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 6/152000 page I
b � o
Page 2 of I 1
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I
PART A
CERTIFICATION(coucinued)
t
Property Address: �5 1 ``�'�r\ �«LY.
C
Owner. �t,.yCa,� �6-x-
Date of lnspectlon:
Inspectiou Summary: Check A,B,C,D or E/ALWAYS complete all olSeetioct 13
A., Sysstt 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: f ,q
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 1f"not determined"please
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 S
existing tank is replaced with a co 2 s Yam will pass inspection ifthe
•A metal septic tank will as mP Ymg septic tank as approved by the Board of Health.
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
obMction is removed
distribution box is leveled or replaced
ND explain:
the system required pumping more than 4 tints a year due to broken ar obsttect d Pis) .The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rtmotnW
ND explain:
, e
• Page 3 of I
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) '
Property Address: 151(41 S Cl.-i.r4\
Owner:
Date of Inspection:
C Further Evaluation is Required by the Board of Health: S
Conditions exist which require fiuther 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 15303(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
Z. 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 front a
private water supply well" Method used to determine distancc
"This system passes if the welt 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:
Owner:
Date of Inspection: vg
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%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. P
_ V 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.
i/ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private eater
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEC certified laboratory,for coliforin 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/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:,
!v
To be considered a large system i e system must serve a facility with a design flow of 10,000 gp d to 15,000
gpd-
You must indicate either"yes"or"no"to each of the following:
(Ttte 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—1WPA)'or a mapped
Zone I I of a public water supply well
If you have answered"yes"to any question in Section E the system is rnmsidrred a significant threw,or answered
"yes"in Section D above the large system has fined.The awner 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 CM
15.304.The system owner should contact the appropriate regional office of the Department-
4
Page.5 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: � � i`1Q.t•ti'� ti T
Owner.
Date of Inspection:
Check if the following have been done.You must indicate-yes"or"no"as to each of the following:
Yes o
_ _ 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 7
,l 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 7.
✓ Were as built plans of the system obtained and examined?(If they were not-available note as NIA)
_ Was the facility or dwelling inspected for signs of sewage back up 17
✓ 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 ,�rto
✓� 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)J
5
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
c _
Property Address:�l�' >t,``C"t ` LCL �� =
Owner.
Date of Inspection: Oq
FLOVVONDITIONS
RESIDENTIAL.
Number of bedrooms(design):: Number of bedrooms(actual):
based on 310 CMR 15.203 for example: 110 d x#of bedrooms): &5'0 6.
DESIGN flow bas gp )
( P
Number of current residents:
Does residence have a garbage grinder(yes br no): _'O
Is laundry on a separate sewage system es or no):. z (if yes separate inspection required]
Laundry system inspected(yes or no): (yes
Seasonal use:(yes or no): nLO -
Water meter readings,if available(last 2 years usage(gpd)): �' - -�=
Sump pump(yes or no):N0 CIO "> y_ ,,00 0
Last date of occupancy.
COMM ERCIALQNDUSTRIAL
Type of establishment: /V
Design flow(based on 310 CMk 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(yei or no):
If yes,volume pumped:gallons--How was quantity pumped determined?
Reason for pumping: 4--�
TYPkOF SYSTEM
_Septic ,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:
19 9.1, - jccc, ,1J
Were sewage odors detected when arriving at the site(yes or no)-?V*�)
6
1'a6c 7 of 1 I
OFFICIAL INSPECTION FORM—NO71'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYS tEt1I INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:_ IF /�per
DUILUING SEWER(locate on site plan)
Dcpdi below grade:
Materials of construction:____cast iron --*"40 PVC_oilier(explaur):
Distance from private water supply well or suction 6c:
Comments(on condition of juutts,venting`,evidence of leakage,c(c.):
•.�i7•rt �#'S cJ�s .y J i CQ tit 9�L.
SE;1 TIC TANK: (locate on site plan)
Depth below grade:_ c
Material of construction. concrete_metal fiberglass_polyetltytene
_odicr(cxplain) _
If tank is metallist
certificate)certificate) age:_ Is age conRrn,d-by a Certificate of Compliance(ycs or no):_(attach a copy of
Dimensions: /000 /10^S
Sludge depth:
Distance from top of sludge to botion,of outlet ice or baffle: '—
Scum thickness:
Distance front lop of scum to top of outlet tee or baffle:
Distance from,bottom of stun,to bottom of outlet ice or baffle:
I low were dimensions determined: A4`
Comments(on pumping recommendations,cadet and outlet tee or baffle condition,structural integrity,liquid levels'
as rclatcd to outlet invert,evidence of leakage,etc.):
4t `
level 4,1-
v_.
GREASE WRAP: (fo caattc on site plan)
Dcpth below grade:_
Material of construction:_concrete_metal_fiberglass___Jrolyethylene__other
(explain):
Dimensions:
Scum thickness:
Distance from top of scull,to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Conuticnts(on pumping rccortulicttdations,Wct and outlet(cc or baffle eondlttUa,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,ctc.):
7
8ofII
OFFICIAL INSPECCIO14 FORM—NOT FOR VOLUNTARY OLUI�ITAIs,� ASS>;SSi4ZENTS
SUBSUKFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEAI INFORMATION(continued)
acrt}•Address: r l
�
t of Inspection: �di
''+IIT or HOLDING TANK:/t//Rnk must be pumped at time of inspection)(locate on site plan) ,•,
A below grade:
erial of construction:_concrete_metal fiberglass_polyethylene odter(explaut): ,
tensions:
lacity: gallons
ign Flow. gallons/day
nil present(yes or no):
Fin level: Alarm in working order(yes or no):-
c of last pumping:
runcnts(condition of alarm and float switches,ctc.):
STIUBUTION BOX: (V klplt-cscnt must be opcncd)(locaw on site plan)
pth of liquid level above outlet invert:
numents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidcuce of
kage into or out of box,ctc.):
iNIP 1
C tAN113>rR.Alocate on site plan)
imps in working order(yes or no):
amis in working order(yes or no):_
munents(note condition of pump chatnber,condition of pumps and alipurtenances,etc.):
Pagg 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
C -
Property Address• ,I u c-'C A-1'
C"L
Owner: Sy`-,&- \
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):/(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number._
./leaching chambers,number.
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number.
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
e.y+- �-� cp� ax
d rcSf— T 4 't^/�'.2 JLrz t `9 t.fi A:w N.)�`✓4..sa� # .Sr7r�J
CESSPOOLS: IV( es pool 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: �ocate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)-
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: �� iv
Date of Inspection:
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.
i .
t
o29
10
Page If of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
G �
Property Address:
Owner. C-
'JU C,-v-\ i �c£�
Date of Inspection: g�tm1,20 09
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:
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
aase���
n�
11
�\ COMMONWEALTH OF MAssACHUsETTs
ExEcwm OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 816 South Main Street l
Centerville � 3t
Owner's Name: Susan Reynolds tA
Owner's Address: 816 South Main Street •� - \
Centeryille
Date of Inspection. ,V-�T.22Lt? /^ �
Jones
Name of Inspector:(please print) Sean_ _
Fri
CompanyName: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville. MA
7,
Telephone Number. t SE181 77S-11776 C;
CERTIFICATION STATEMENT
CV
I certify that I have peisonaliy inspected the sewage disposal system at this address and that the informa ion reported r—
below is true,accurate and complete as of the time of the inspection.The inspection was performed ba d on myco r
training and experience in the proper function and maintenance of on site sewage disposal systems.I a14 a DEP
approved system inspector pursuant to Section 1S340 of Tate 5(310 CMR I5.000). The system:
`_�passes
Conditionally Passes
Needs F valuation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shalt submit a copy of this inspection report to the Approving Authority(Board of Neatth*or
DEP)within 30 days of completing this inspeetn.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 611V2000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 816 South Main Street
Centerville
Owner: Susan Reynolds
Date of Inspection.-
Inspection Summary: Check A,B,C,I)or E I ALWAYS complete aB of Section D
A. Sys m 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 15304-exist.Any failure criteria not Evaluated are indicated below.
Comments:
B. System Conditionally Passes: /\f� -
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`%ot determined"please
Explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is s ucturally
unsound.exhibits substantial inf Itmtion or exfdtration or tank failure is hnminML System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Hoard of Health.
•A metal septic tank will pass inspection if it is structurally sound,not leaning 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 tw broken or
obstructed pipes)or due to a broken.settled or unevcn 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 obsrtcted pipc(s)-'the system will
pass inspection if{with approval of the Board of Health
broken pipes)arc repLwtd
—obstruilin gst to ud
ND explain:
Page 3 eA i
OFFICIAL INSPECTION FORM-NOT'FOR VOLUNTARY ASSESSMENTS �
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERTIFICATION(continued)
Property Address: 816 South Main Street
Centerville
owner. Susan Reynolds
Date of Inspection: 3
C. Further Evaluation is Required by the.Board of 13eaaltla A 1'4/4
further_ Conditions exist which require evattation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment
I. System will pass unless Board of Health determines in accordance with 310 CKR I5.303(i)(b)that the
system is not Eumnoning is a tt aomw which will protect public be21114 safety and theenvlronment:
Cesspool or privy is within 50 feet ofasurfam crater
_ Cesspool or privy is within 50 feet ofa 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 pablicehealith,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 wkhin a Zone I ofa public water supply.
_ The system has a septic tank and SAS and the SAES is within 50 feet ofa private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 1.00 feet but 50 feet or more frond a
private water supply welt•• Method used to detetnitine distance
"This system passes if the well water aw4-sis,pafonmd at a DEP certified laboratory,for colifonn
bacteria and volatile organic compounds indite that the well is free kom pollution from that facility and
the presence of ammonia nitrogen and nitrate-nivagetr is ell to or less than 5 ppms 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 I I
, G
OFFICIAL I14SPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 816 South Main Street
Centerville
Owner. Susan Heyno s
Vate of Inspection: o T
D. System Failure Criteria applicable to all systems;
You must indicate"yes"or"ne to each of the fallowing for all 0ispectians. =
Yes No/
_ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
V Discharge,or ponding of elfluent to the su&=of the ground or space waters due to an overloaded or
clogged SAS or cesspool �
g4 spoo
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
g
cesspool
Liquid depth in cesspool is less than fr"below invert or available vehtme is less than`h day flow
_.&/Rcquued pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
oftimes pumped
✓Any portion of the SAS,cesspool or privy is below high ground water elevation.
/Any portion of cesspool or privy is within 100liet of a surface water supply or tributary to a surface
water supply.
_ _ Any portion of a cesspool or privy is n a Zone t o€a publie 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 v4atcr
supply well with no acceptable wam quality atalyshu['ibis system pis if the well water analysis,
performed at a DEP certifted laboratory,for eoMrm bacteria and volaM organic compounds
indicates that the yell is free-from pollutiots from that facTtty and the presence of ammonia
nitrogen and nitrate aitrogen is cgwA to or less tt"S ppm,provided that no other failure criteria
are triggered.A copy of the analysis setter be attached to this foroLl
(Yes/No)The system fail&t have determined that one or more ofthe above failure criteria exist as
described in 310 CMR 15303.therefore the system fat'is.Tht:system owner should contact the Board o f
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'W'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 drB dit water supply
the system is within 200 feet of a tribaury to a su face dFbtk tg wat"supply
— the system is located in a nitrogen sensitive amonerim Wellhead Protection Area-1WPA)or a mapped
Zone 11 of a public water supply veil
If you have answered"yes"to any questiim in Section E the systm is considered a significant threat,to answered
at in Section D above the large system bas fntkd The earner 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 a%vner should contact the appropriate regional office of the Department_
4
Page 3 of 1 i
OFFICIAL INSPECTION FORPA--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
t ART B
CHECKLIST
rroperty Address: 816 South Main Street
Centerville
Owner: Susan Reynolds
Date of Inspection: 3 Ar
Check if the following have been done.You must imlicate nmE or`3mW as to each of the following;
Yes No/
V Pumping information was provided by the ow .occuRid.or Board Of Health
✓Were any of the system components pumped out in efts previous two'weeks?
Has the system received normal flows in the previous two vreekperiod?
t,f Nave large volumes of water been€tttsod=A to the system recently or as put of this inspection?
Were as built plans of the system obtained and examined?(if they were not available note as NIA)
, /_ Was the facility or dwelling inspected for sign of nwage back tip?
V- _ Was the site inspected for signs of break out
Were all system components.euclttding,the SAS,located on site?
Were the septic tank:manholes uncovered.openak and dw fiver of the tank inspected for the condition
of the baffles or tees,material of consouctio%dimensi ,depth,of L-pid,depth of shulge 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:
Y7es 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)13 10 CMR 15.302(3)(b)j
5
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address. 816 South Main Street
Centerville
Owner. Susan Rijynolds
Date of inspection:
'FLOW CONDITIONS
RESIDENi'144L
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15203(for exampIc 110 gpd x g of bedrooms): 6��
Number of current residents: l
Does residence have a garbage grinder(yes W no):
Is laundry on a separate sewage system(yes or n9):/_VC> jifyes separate inspection required]
Laundry system inspected(yes•or no).-JIA
Seasonal use:(yes or no):nA
Water meter readings,if available(last 2 years usage(ggd)}: 2006 — 127 ,000
Sump pump(yes or no): /+O 2005 — 38,000
Last date of occupancy.—Zv1-11../e
COMMERCIAL/ KDUSTRIAL /
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons1sgft'etc.):
Grease trap present(yes or no.—
Industrial waste holding tank present(yes or nod—
Non-sanitary waste discharged to the Title 5 system(yes or nod_
Water meter readings.if available;
Last date of occupancytuse:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as pa*"4he inspection(yes or no)eY�
If yes,volume pumped: gatlorts—Ww was quantity pumped determined? �—
Reason for pumping: --
TYP,E OF SYSTEM
Septic tank,di�ibmti�#€mc,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(i€yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a ropy of the cumv:ut 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:
[`�S i
Were sewage odors detected when arriving at the site(yes or no):.�
6
I'agtal of i.
OFFICIAL INSPL'crION FORM—1 orr FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'ART C
SYSTEM INFOIUsfATION(continual)
Property Addrtss: 81 6 South Main Street
Centerville—
Q%vocr: Susan Reynolds
Date of Inspection: _
ilUILULNG SLNVEll,(locale oil silt plat►)
�
Ucptii below gradr. �- fi
� -
lvlatcrials of construction:_Las(itut► _✓4u PVC_ou►ct(cx}slau►).
Distance froth private haler supply well of suction lisle:_
CullunctNs(Oil condition of juulis.Ve"IM&evidence of lfakagc,etc.):
(
,bLPTIC TANK: (localc on silt plats)
Dcptl►below grade: IS
Malcrial of tonstructiot►: ✓nac►c_n►clal ftbttglaSS_pulycd►ylcric
_vll►ct(cxplain)
if tank is n►etal list age:— is age cuufun►td•by a Ccrtificatc of Cutupliatice(yes or no):_(attach a cup}•u(
ctrtiftcatt)
Dimensions: 6D.2z' l s
Sludge deplll:
Distance froth sup of sludge to builvul of oullct tee Of ballle:.. 3
Scutu lltickitcss: 'C?``
Distance from top of SCUIll tv top of uutict lee or bank:
Distance Dorn buttum of seuns to butivin of uutict tee or battle:
I low were ditticasiotts dticntlincd: �P�,� C�,;�
Cumnttnis(fin pumping rccutnntc4atio►►s,inlet aaid outici tee at batik eutatliticu,structural iutebtily, liquid levck
as related to oullct ir►vcrt,tvidence of Itakage,tic.):
f
GREASETILkP. ocatc on site plan)
Depth below grade:—
Matctial of construction:_tuucictc metal_fiberglass_ltul�-cdlYlulc__vlltcr
(caplauij; — •
Dinicusions:
Scum Iltickncss:
Dislancc Gott top of scum to tulr ut outicl ice of battle. _
Distance from button,of scull[to bultuut of outlet ice or bafllc:
Date of last pumping:
Culluncnls(oil l►utliping tccuinrac►idaliotrs,mict and uutict ice of baflic cuiWitrto:►,siructutal inicgtity,liquid Icy cl;
as related to oullct iliccrt,ccidrncc of lcakag,nc_ .-
7
Pagc 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSLSSNILN"1"S
SUBSUIU'ACE SENVAGE DISPOSAL SYSTEN) INSPECTION FORAM
I'ART C
SYSTEM INFORMATION(continued)
Property Addrus. 816 South Main Street
Centerville
Owner: Susan Revnolds
Dolt of losptctloo: T as ?
TIGILT or HOLDING TANK:-4-,)A,tank utust be pumlictl at tittle of insltection)(lucate on site plan)
Dcptlt below glade:
Matetial of construction:_ cuttctett:_ntietal ftbcaglass_J}rulyetltylcne otlitr(cxplairr):
Dimensions'
Capacity: �ailutrs
Design flow; yaiiunsiday
Alarm present(yes or no):
Alum level: Alarm,ill working urdcr(ycs of tto).
Datt of last pumping:
Cottencnis(condition of alarm,and Boat swittlres.ctc.):
DISTRIBUTION BOX./
(if pttscnt,,test be olurrcd Locale on site plan)
Depth of liquid level above outlet invert:
Cotruncnts(note if box is level and Jisuibutiun to oudcas cq"L any evidence of solids catryover.any eviticncc of
Itakage into or out of box.
VUl1IP CHAMBER:Nklucate ore site}elan)
Pumps in Working order()�cs or ttu):_
Alarms in,corking order(yes or no):—
Cvtatncnts(nutc condition of}lump chambct,ctatdlitivil of lrumps and appultcnautcs.ctc.).
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: 816 South Main Street
Centervilie
Owner. Susan Reynolds
Date of Inspection: T71-a f7:GQ?
SOIL ABSORPTION SYSTEM(SAS). eZ(locate on site plan4 excavation not required)
If SAS not located explain why.
Type -
leaching pits,number._
leaching chambers,number.
leaching galleries,number: 3 TI.- J.
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number.
inn ovativelaltemative system Type/name of technology:
Comments(note condition of soil.signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): I - ,
r
v e4--4%.;—
CESSPOOLS: ./A(cesspool must be pumped as part of inspectionXlocmte on site plan)
Number and conitgtuatton:
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):
Continents(note condition of soil,signs ofhydraulic failure,level ofponding,condition of vegetation,etc.):
PRIVY- t�'( '(locate on site plan}
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure;level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 816 South Main Street
Centerville
Owner, Susan Revnolds
Date of Inspection:
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 welts within 100 feet.Locate where public water sappy enters the building.
s �
- r . 3Y
A'd +
13 - = a�
A:
10
Page l to ref 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 816 South Main Street
en ervi e
Owner. Susan Reynolds
Date of Inspection:_��3/—
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water3fe -feet
Please indicate(check)all methods used to deter the high gad water elevation:
Obtained fivm system design plans on record-If tltecked.date of design plant reviewed:
Observed site(abutting property/observation hole vAthin ISO feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach doeutnamtion)
Accessed USGS database-explain:
You must describe bow you established the b%h ground water elevation:
• r
Caw,
it
OWN OF BARNSTABLE
LOCATION r SEWAGE # V
VILLAGE ��h�r�� r �•� ASSESSOR'S MAP & LOTS
7-7Y-
INSTALLER'S NAME & PHONE NO. �s
SEPTIC TANK CAPACITY 1()O d
LEACHING FACILITY:(type) 3 F (sue) f S
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER a, i., ir,V - S
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
Iq c,;, —
VARIANCE GRANTED: Yes No 1.
3 F��
t=iro��
Ccr-r, 000
<Fro P\
E�+
I
No.....l..- O L , Fps.... .o...:.......
�epa tmentTHE COMMONWEALTH OF MASSACHUSETTS
LZ BOAR® OF HEALTH
—TOWN OF BARNSTABLE
' Date
Appliratilan for Bisp.aaal Works Tomitrnrtion rumit
Application i�.,h_ereby made f a Permit Co st ) or Repair ( n Indivi al Sewage D'
System at: y �Q_.YI C� /'���/ )
...............�..� .......--..........._.... ...._. .......... �. ......................... ' d........ �----..
Lo tion-Address O,Wa Q � or tNo
Owner
�-I- -2-
.�. ............P -- ---------------------- •--•••..... =Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms----�_,�.....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures . ..... -W Design Flow.........5-- ........................gallons per person per day. Total daily flow____3—R• _ gallons.
1:4 Septic Tank-L Liquid capacity( .gallons Length-__-......... Width---!�C_._..... Diameter................ Depth................
Disposal Trench—No. _Yp .. Width.. .......... Total Length....Q 3...... Total leaching area....................sq. ft.
Seepage Pit No____________ ________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water.......................
0� Test Pit No. 2................minutes per inch Depth of.Test Pit--------.._:........ Depth to ground water........................
a .-•••••--•••-•------••-••••••••-••---•••-••••-•-•••-•••---••----•-•--•••---••--•-•-•-•-•..............•--••......-•-•--............... __...........
0 Description of Soil...............................................................................------------------------•----------•------------------------------......................
x
U --------------------------------------------------------------------------------------------------------------•--•---------------...------------------...----------------------------...-••-••......•••.
w
x ••••••-•---••----•-•--------••----••••••---••-•••••-•-••••----•-----••••-•-••---•-•••-•.....-•••••-----••-•-•-•-•••••••-•-•---••-•-•-•••---••-•••--••-•-••---•--••--•-•-•••••••--•-•••-
V Nature of Repairs or Alterations—Answer when applicable..--_�4ZN5T-4..&....j,_U.-M... .r.
............ .._ �0 -5.....��1 f�S D .....1 _� _. .t� ---------------------------•----------......_....----------................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been is uei t d health.
Signed . ----- � .-03 r
A Date"46 _ _
Application Approved By .................. �... - j............ - ----..... .`-a-:tAs.`- /---
Date
Application Disapproved for the following rea ons:--------------------------------------------------------------------------------- ..------------------------------------
... ..................... ---------------------...-----...-------------------------------.......----------------------------- -
Permit No. ....... ... ..'`�/...- ................. Issued ........------------------ ....................---....Da[e.....
' Darete
ram+
q `
"-No................. - � Fims.............................. �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinn for Uiiipuiittl Works Tonstrnrtiun Vamit
Application is�hereby made forr a Permit to Construct ( ) or Repair ( v) an Individual Sewage Disposal
System at: ��.2 t1 L� Q d I
Location-Addr ss or Lot/� o
W
Owner Addr
ess
Installer Address
U. Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms....��`____________________________________Expansion Attic ( ) Garbage Grinder ( )
aV Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other.fixtures
W Design Flow._______` ______________________gallons per person per day. Total daily flow----7��__ _Q_----------
.............__gallons.
9 Septic Tank•-V Liquid capacit)�_()(I)_gallons Length__.._........ Width____:________ Diameter________________ Depth................
W If
Disposal Trench—No. .� p A., Width-.49............ Total Length.._.?•_....... Total leaching area.................... ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4 Percolation Test Results Performed by•-••------•------•-------•----•••-•••--------••---•-•-------•••---•------ Date........................................
Test Pit No. i________________minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---------------------------------------------------------
•..........................
-••-•-----------
--------------------------------------
•......
•.......
0 Description of Soil.....................................................................................................................................................
V -----------------------------------------------
•---------------------------
•-------------------------------
-------------------------------------
•---------_____----------•-----
W
U Nature of Repairs or Alterations—Answer when a hcable.___:�-_�: ._ T?- - -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board&health. /f
- Signed - ... .. a` R
Date
Application Approved By .. eC � c- .... ............................. ...:......... ...... �-�- ..... �-
Date
' Application Disapproved for the following reasons- ----- -------------------------------------------------------------------------------------- ---------- -------------------
Date
PermitNo: - ... .... ................. Issued .........----------------- .....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ` \
TOWN OF BARNSTABLE '
CertifirUte of &-mytianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �):---'-
y------------------------------_---------------..-. �. �:..-�..sA------= - --........----..........------ . -------- -----------------.. .... ....
Insmller
at .�.' ..-.... -�----..-..- /1 ci-1!K. ----,---�------------ ------------------------------
has been installed in accordance with tbe.provisions of TITLEf5 of'The State Environmental Code as described in
the application for Disposal Works Construction Permit No- -------- /- J�7.2..-- dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. r.b 1 ,
{ f
DATE....................------------- 4` = � Inspector .................... I' `.f....L..L....:.�!.�'...:_!t S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� 5�7� TOWN OF BARNSTABLE
No..................... FEE.._ `?.. ..•. 'r
Disposal Workv TwUnstr inn rrntft
Permission is hereby granted...........4�A••1_A f?_E_..f-- tl��t11 C��IT
to Construct ( ) or Repair ( '--)—an Individual Sewage Disposal System
atNo. -u1; < t'' t /1!I c , ' �- =-------- -----..--•--------------------------------------••-•--•--•----
Street
as shown on the application for Disposal Works Construction Permit No..��=� Dated__________________________________________
-----� �1 ......................................................
" -Board of Health
DATE------------------- =-.._
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE
LOCATION SS I (0 5,,.., I, C,.,-• f-q �'C�t . SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT /�►�/�
-7J_
INSTALLER'S NAME & PHONE NO. ��,�� ,�,�� St�a O-; D 6 ct
I
SEPTIC TANK CAPACITY 1006
LEACHING FACILITY:(type) 3 F/b(--j 1;4Z s-,s (size) c;Z S
NO. OF BEDROOMS ,3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER ��;,, A 9
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No l
i
c�ra�1
Fe b h
i
j
i
- I
SPECIAL USE PROVISIONS, BUILDING SETBACKS AND ZONING REQUIREMENTS p—'�' Q
STATE OF : MASSACHUSETTS ARE THE RESPONSIBILITY OF THE LOCAL CONTRACTOR , `�,O STORY MODEL z00
CONDITIONS, LIMITATIONS: MASSACHUSETTS: 5'-0" MINIMUM SETBACK FOR TWO�' STORY l�'1 0 Q O�
ZERO HOUR WALL. ONE 82654 z < LL
HEATING SYSTEMS: PREFABRICATED FIREPLACES AND FLUES, U.L.
CODES: LISTED AND MASSACHUSETTS APPROVED,
MA SINGLE & TWO FAMILY DWELLING CODE 780 CMR)-9TH EDITION INSTALLED ACCORDING TO MANUFACTURERS ® ` > ~^ a
( J INSTRUCTIONS (OPTIONAL). FURNACES OR ��CFWSS'lO�^� w I-
248 CMR, THE MASSACHUSETTS STATE PLUMBING AND GAS CODE HEAT PUMPS TO BE INSTALLED ON—SITE o
ACCORDING TO MASSACHUSETTS, AND/OR CORPORATE OFFICE BULDVING
I
LOCAL CODES.2015 INTERNATIONAL MECHANICAL CODE W/AMENDMENTS VENTING SYSTEMS: RANGE HOOD AND BATH FAN TO BE 72 EAST MARKET STREET U J C, 0
2015 INTERNATIONAL ENERGY CONSERVATION CODE W/ AMENDMENTS EXHAUSTED TO EXTERIOR. Cp Q o
EXTERIOR ENVELOPE: SEE ATTACHED REScheck P.O.BOX 219 �+_-�-���+ ��/+� H— 3
2017 NATIONAL ELECTRICAL CODE W/ MA AMENDMENTS THERMAL PERFORMANCE: SEE REScheck FOR INSULATION , F I"� ` �� Q � � �
AMOUNTS. R-20 I.C.F IS REQUIRED TO BE MIDDLEBURG, PA. 17842 -� -� —.'YNI'?) -� z N v
SOLAR READY ZONE PER AU103 INSTALLED ON—SITE BY THE BUILDER TO o �
COMPLY WITH THE REScheck R-30 IS TO PHONE: (570) 837-1424 0 Q �
BE INSTALLED IN THE FLOOR PERIM. Q m z (D
SITE CONNECTIONS TO BE VERIFIED BY CONSTRUCTION SUPERVISOR FAX; (570) 837-6133 I J
U1 0 00
Of
DRAWING INDEX (TOTAL SHEETS IN SET=74) ' SITE ADDRESS ' P.E. SEAL o
J
PAGE DESCRIPTION 816 SOUTH MAIN ST ` �P OF Mgss m J
�(N Z
CENTERVILLE, MA 02632-
1 COVER SHEET ` �� DAVID T. G� w
2.1-2.4 ELEVATIONS o FEENEY � � w .
�
3.1 FIRST STORY FLOOR PLAN MANUFACTURER INFORMATION ' CD No.54747 "' O v a Zco
o = N (o
3.2 SECOND STORY FLOOR PLAN . A909'Q/STEP�����'Q m 3
3.3 FIRST STORY BRACED WALL PLAN PROFESSIONAL BUILDING SYSTEMS ass/ONALEN�'`
3.4 SECOND STORY BRACED WALL PLAN 72 E. MARKET ST. MIDDLEBURG, PA 17842 n `
MA MANUFACTURER MC #: MC221
4.1 FIRST STORY ELECTRICAL EXPIRATION DATE: APRIL 30, 2019
4.2 SECOND STORY ELECTRICAL !''r W N N
5 FOUNDATION BUILDING INFORMATION
6 CROSS SECTION(s) 4-22-19D.Feeney 00� W a 2
he 17^
Q( O^co
7 RAFTER(s)
CONSTRUCTION TYPE: VB z ': Nm--�
8 CONNECTION U� <�W
9.1-9.2 TYPICAL PLUMBING USE GROUP: ONE X N�
10 DOOR AND WINDOW SCHEDULES ` ' THIRD PARY INFORMATION ' N W
RESCHECK DESIGN LIVE LOADS ' U
PFS CORPORATION M z a ci
RAFTER / BEAM CALCS MA THIRD PARTY APPROVAL AGENCY: TPIA-02 Ucn
o
WIND CALCS WALLS (MPH): 140 VULT ° EXPIRATION DATE: APRIL 30, 2020 LU
N z
ROOF (SNOW): 30 PSF set t
FLOORS: m N
PFS STAMP
SLEEPING AREAS: 30 PSF 00 N
KITCHEN, LIVING, ECT.: 40 PSF 1. IT IS MANDATORY FOR THE STATE STAMP N
CORRIDOR: 30 PSF BUILDER TO COMPLETE THIS HOME IN a m
STAIRS: 40 PSF COMPLIANCE WITH THE
BALCONIES: 40 PSF INTERNATIONAL BUILDING CODE
OTHER: NA REQUIREMENTS ADDITIONAL SITE
LABEL LOCATIONS: WORK MAY BE: PFS CORPORATION
DATA PLATE PER DWELLING AS INDICATED ON PLANS. a. FLOOR INSULATION - CRAWL Approval Limited to Factory Built Portion Only
THIRD PARTY EACH MODULE AS INDICATED ON PLANS. ROOF DESIGNED FOR SOLAR READY ZONES PER AU103. TRUSSES SPACE a
STATE LABELS EACH UNIT AS INDICATED ON PLANS. DESIGNED WITH 10 PSF DEAD LOAD FOR ADDITIONAL OVERFRAMING. ' b. FOUNDATION WALL State: Massachusetts o a o
INSULATION - BASEMENT
Signature: �� o z
THE DRAWINGS IN THIS SUBSET SHOULD NOT BE SCALED FOR c. PERIMETER INSULATION - Cnn U 0-
FIRE ALARM SYSTEM: SMOKE/CO DETECTORS (P.E.) SLABS Title: Staff Plan Reviewer a
TO BE INSTALLED EVERY 1000 SQ. F.T. PER LEVEL DIMENSIONAL REFERENCE. ALL DIMENSION LINES AND NOTES d. INSULATION - PIPING Date: 4/22/19
AND SHALL BE AC/DC TYPE PER SECTION R314.3. SUPERCEDE ANY SUCH REFERENCE. DISCRETE MODELS (PLANS EXPOSED TO UNCONDITIONAL
HAVING THE SAME SPECIFIC ROOM ARRANGEMENT OR
HEAT DETECTORS TO BE INSTALLED IN GARAGE PER SPACES THE ABOVE MUST BE
SECTION R314.8 2015 IRC / 780 CMR ARCHITECTURAL STYLE) SHALL BE PREPARED FROM THESE ACCOMPLISHED WITHIN STATE m
DRAWINGS WITHOUT MODIFICATION, ADDITION OR DELETION IN CODE REQUIREMENTS
ANY MANNER. Z C) m
2. BUILDER RESPONSIBLE TO FILE
PBS WILL BE CONSIDERED AS A SUB-CONTRACTOR IN ALL Q m � 0
THE REQUIRED CERTIFICATION FORMS
BUILDING PROJECTS, SUPPLYING A BUILDING COMPONENT TO A �
GENERAL CONTRACTOR OR BUILDER. ALL NOTES WITH ALL MECHANICAL HEATING SYSTEMS TO BE DONE ON-SITE BY WITH THE LOCAL ELECTRIC UTILITY o
REFERENCE TO "IN-FIELD", "ON-SITE" OR "BY BUILDER" ARE OTHERS , PRIOR TO OBTAINING PERMANENT
PERTAINING TO THE RESPONSIBILITIES OF THE GENERAL ELECTRIC SERVICE 48 HOUR NOTIFICATION IS REQUIRED PRIOR TO THE SET. THE CSL ON RECORD WILL RELAY
CONTRACTOR. FLOOR PLAN MAY BE FLIPPED AND OR MIRRORED , 3. PBS TO USE INTERNATIONAL THIS TO THE LOCAL BUILDING AUTHORITY. IF ANY CONNECTIONS HAVE BEEN CONCEALED PRIOR
ENERGY COMPLIANCE CODE. SEE
TO INSPECTION, THE BUILDING OFFICIAL MAY REQUEST HAVING THE REMOVAL OF ELEMENTS THAT
SUBMISSION SET FOR EXAMPLE. CONCEAL THE CONNECTIONS TO PROVIDE ACCESS. THIS WOULD NOT CONSTITUTE "DESTRUCTIVE CN
CN o a
THESE DRAWINGS ARE PROPERTY OF PROFESSIONAL BUILDING SYSTEMS, INC. AND EACH INDIVIDUAL MODEL DISASSEMBLY". ALL CONNECTIONS ON SITE MUST BE INSPECTED BY THE LOCAL AUTHORITY. Q N
TO REQUIRE A RESCHECK TO MEET o
SHALL NOT BE REPRODUCED AND OR COPIED WITHOUT AUTHORIZATION. THE I.R.C. REQUIREMENTS CHRISO 4/22/2019 9: 13: 54 AM 0
Lij
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17'-0" 27'-3" 36'-0"
*KITCHEN CABINETS PER BUILDER'S REQUEST* 3" RADON VENT HDR:3-2x H x m a o
2" FUTURE VENT SPF#2 3/0-EXT 3052 SPF#2 3052 3052
PFS Corporation m Q 9 3. 0
Northeast Region r----- o z z r
9 `o W2436 W3636 W3018 i W2436 W2436 20'-10" O
APPROVED �Pti `° Ln
BD24 4D B24 7�t/s'`� 824 B24 N N > m z Z Ln(.0<
H Raup - 3 OP��� =_== F-1" cis
4/22/19 0 13�-7" F-3 4" 3^ DRAIN & G�\J� W ,�
2-3/4" SUPP. P p� 0 >
Approval limited to 3 FROM 2nd STORY M J W d
Factory Built Portion KITCHEN , _ = Z
CV OMIT C-TOP, SINK, �r DINING ROOM !V m � o
O AND FAUCET Room Sq Ft: 276.32 w O N M �----1
1 i RAISE CAB. 3/4' Light
Re 22.11 W 0
z V i l` �) N FOR ON-SITE FLOORING Light Provided: 76.41
Vent Req: 11.05 w d Ln
m (� N1 B42 B24 BD21-4D Vent Provided: 97.9 w = U N z c0
I ( i 4' 3" �0 } o N
w Z =__ , _ 3 0 °°
aF -
a o �, Lu
o ���pJ�N OF�Ass9c9
_j ----- -n BUILDER WILL BE RESPONSIBLE O G
V'm TO PROVIDE APPLIANCE SPECS 00 DAVID T. m
a i TO ENSURE PROPER CLEARANCE o FEENEY W N N
g to M FOR DOORS TO OPPERATE _ __ __ �
--------- No.54747 F5m�
a a 3 RAISE PEDESTAL SINK ^ N^^
a �NO COMP.
F-0 LOUV 2-2x4 FS 3/4" FOR ON-SITE FLOORING o
oQ a L"--- STUD GRADE STRIP 90,�FF�/STEF ���' a o
310 2/6 I 2-2x6 FS ssrorvat�� M W o
OMIT 3'-11" SECT STUD GRADE "^
CLG & WALL GYP c w
c� 6'_5" TB 4'_ O $TD 1RIM 2-2x4 FS `'$o i2
11'-9 11 16" /
6'-5" N STUD GRADE W <
o OMIT GEG GYP THIS AREA o 3'-0" r "
MEC I ROOM N CCO� ------------------ o
210 210 BATH #3 STORAGE o M 4-22-19D.Feeney o z
216
Q W Z w
POCKET LL
2'-0" 4'-6112"
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(n d m N
BUILDER RESPONSIBLE FOR COMPLIANCE WITH DO
LIVING ROOM + Q y s
SECTION R312.2 WINDOW SILLS OF THE 2015 < t0
c ) = a m
IRC TO BE DONE ON-SITE IF APPLICABLE O N - Room Sq Ft: 161.02 � `r' r-
( ) z �p I J Light Req: 12.88 LLI
O
BUILDER IS RESPONSIBLE TO O
� � � t0 � Light Provided: 58.46 -
SUPPLY AND INSTALL GAS LINE co DEN C?
cn N Vent Req: 6.44
LOT LINE SET BACK FIRE-RATING/SEPARATION 1 Room Sq Ft: 124.46 Vent Provided: 71.5 N
NOT REQUIRED UNLESS SPECIFIED OTHERWISE r' Light Req: 9.96 FOYER
Light Provided: 35.2 PFS STATE 3" DRAIN &
g LA L �
IT a
NOTE: STRUCTURE DEPICTED AT THIS SITE Vent Req. 4.98 2-3/4" SUPP. o J >
ADDRESS TO BE DEMOLISHED BY BUILDER Vent Provided: 18.5 S/L FROM 2nd STORY y F z a o
AND REPLACED WITH THIS HOUSE P.E. CA/ a
-MECHANICAL VENTILATION ON-SITE 8 �' gp o a
BUILDER PER N1103.6 n 00 ch P.E. o
n
DUCT TIGHTNESS AND BLOWER DOOR 14'-0" ' 20'-7
TESTING ON-SITE BY BUILDER AND r
CERTIFIED BY STATE
m
HEAT REQUIREMENT AND SYSTEM IS TO BE z u m
DESIGNED AND INSTALLED ON-SITE BY Q m � o
OTHERS. HEAT SYSTEM TO BE INSPECTED 3052 - 3052 _310-EXT 3052 3052
AND APPROVED BY LOCAL BUILDING 4'-O" 10'-O" 18,-0" 26'-0'
INSPECTOR TEMPERED 32-� 36'-0"
HDR:3-2x6 HDR:3-2x6 HOR:3-2x HDR:3-2x6 HD - x6
CODES: SPF#2 SPF#2 SPF#2 SPF#2 SPF#2
MA SINGLE & TWO FAMILY DWELLING CODE (780 CMR)-9TH EDITION 00 0) 0)w
MA FUEL/GAS/PLUMBING CODE oN oN o
2015 INTERNATIONAL MECHANICAL CODE W/AMENDMENTS Q N
2015 INTERNATIONAL ENERGY CONSERVATION CODE W/ AMENDMENTS C4
2017 NATIONAL ELECTRICAL CODE W/ MA AMENDMENTS CHRISO 4/22/2019 9: 13: 54 AM o
SOLAR READY ZONE PER AU103
NOTES: 1. *-DENOTES ADDITIONAL COLUMN IN BASEMENT 5. 8'-0"CLG. 9.
2. 2X6 EXTERIOR WALLS 16"O.C. 6. STAIRS TO BE 8 1/4"RISERS AND 9"TREADS. /1
3. 2X4 MARRIAGE WALLS 16"O.C. 7. MW CLG BEAM OVER LIVING ROOM/DINING ROOM: (2)2x10 SYP#2(PER UNIT)(STACKED) 10. a '{J
4. ROOF RAFTERS 16"O.C. 8.*5/8"CEILING GYP MECHANICALLY FASTENED* 11. a •
z o
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Q M
W < �`
>
7'-5" 19'-10" 29'-3"
36'-0"
HDR:3-2x1 3" RADON VENT HER: *TEMPERED* HDR:3-2x1
SPF#2 3046-2 2" FUTURE VENT Lj
SPF#2 2846 SPF#2 2846-2 m a _
PFS Corporation C0 Q 9
Northeast Region 0 o
a Z Ln
13'-10" 7'-11" 12'-4" O 0 �
APPROVED \ '� 00 (n
O < m z O
H Raup - 3 _
i0
I = CO
4/22/19 N ~
x BATH #1 �
Approval limited to o BEDROOM #2 --2'-8" N >
co a
Factory Built Portion N `� I
N °° m w =
\ Room Sq Ft: 145.83 J a
p Light Req: 11.67 =N co� Y N
Light Provided: 33:03 \ D iN� W O
o Vent Req: 5.83 2'-0" and L,�� Vent Provided: 17.34 'n W� > z o -t
;, "';�yo BEDROOM #1 oz _ coco
N 00
LIN D IRoom Sq Ft: 212.75 m 3 0
STD TRI Light Req: 17.02
216 Light Provided: 48
116 POCKE Vent Req: 8.51
Mc
STD TRI DRAIN PAN Vent Provided: 25.5
SDp v/ PLB TO BSMT pip z
I - P.E. HALL PAN fCD,
QK PE 310 310 N uj
W-----------722"x30" -------
7t2� CLO R
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LABEL OMIT 3'-11" SECT TRIM SIDEBOARD O �cS'F c
CLG & WALL GYP SA OMIT 3'-11" SECT r Lj
N 2-2x4 FSZI
2 NEEDED CLG & WALL GYP 2-2x6 FS a w
7'-5 1 2' STUD GRADE L Win
c
STUD GRADE / 3-� STUD GRADE
NLL_ nMaL�
------------ -- - ------ ------ (/)>
m o cs
z
J= STD TRIM ��P�(N OF Mgss9c O W a w
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�0 210 210 0� ti� �cn 0 5 >�
POCKET DAVID T. a- m N
7'-51/2 4'-6" o FEENEY Q
SITTING AREA Z o �' NO.54747 G' y
M N a m
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Room Sq Ft: 142.06 n N ,� g 9�
z Light Req: 11.36 - �� mw O G/87�P
BEDROOM #3 Light Provided: 22.02 I O - �� FSStONAIEN�'
Cr) N Room Sq Ft: 148 Vent Req: 5.68 - it NZ =
I Vent Provided: 11.56 Q Qo o N
Light Req: 11.84 \
M Light Provided: 22.02 3-1 m o m
Vent Req: 5.92 o CA
Vent Provided: 11.56 1 L > d
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210 � 4-22 19D.Feeney Z z
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P � a
T OCKE
P.E. � U a
OSTD TRIM co
P.E. M OC-5
WALK-IN
I CLOSET
11'-5 1/2" 10'-5 1/2" ; , 1/2" FS STATE 5'-6" m
LABEL
Z
0 0
Q M :2 U
3046 30ER R 3046-2 0" 3046 ' 3046 0
4'-0" "- .
TEMPERED* 18'-0' 26'-0' 32' 36'-0"HDR:3-2x6 HD HDR:3-2x1 HER:3-2x6 HDR:3-2x6
SPF#2 SPF#2 SPF#2 SPF#2 SPF#2
ao rn �
Li 0 04
0
Q N\\
O
in \\\
O CHRISO 4/22/2019 9: 13: 54 AM Q
NOTES: 1. DENOTES ADDITIONAL COLUMN IN BASEMENT 5. 8'-0"CLG. 9.
2. 2X6 EXTERIOR WALLS 16"O.C. 6. MW CLG BEAM OVER BED1/HALL: 1-1.5"x 9.25"LVL(PER SIDE) 10.
3. 2X4 MARRIAGE WALLS 16"O.C. 7. MW FLR BEAM UNDER BED1: 2-1.5"x 9.25"LVL(PER SIDE)(STACKED) 11. 0 L
a
4. ROOF RAFTERS 16"O.C. 8.*5/8"CEILING GYP MECHANICALLY FASTENED* 12. a •