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HomeMy WebLinkAbout25-27 SOUTHWINDS CIRCLE - Health 25-27 Southwinds Circle Centerville P A 226 160 -bt 11 o�d NO, 1 521l3 ORA ° � 10% Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2015 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms � on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 �577w`12/2015 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 sy tem will perform in the future under the same or different conditions of use. t5in:o-3/13 Title 5 Official Inspection Form: ubsurface Sewage Disposal System-Page 1 of 17 P 4 Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 25-27 Southwinds Circle I Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2015 w page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) a 4 Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: The dwelling located at 25-27 Southwinds Circle Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, 1500 gallon pump chamber, distribution box and a 2 lateral raised leach field 14'x 45'. The system was found to be in proper working condition at the time of inspection. 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 u f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 25-27 Southwinds Circle Property Address Robert& Connie O'Connor& Erin Bertrand Owner Owner's Name information is Centerville Ma 02632 3/12/2015 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for :very Centerville Ma 02632 3/12/2015 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 1/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments tI wM 25-27 Southwinds Circle € Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is Centerville Ma 02632 3/12/2015 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts m Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2015 page. City(rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 333 gpd provided t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts m Title 5 Official Inspection Form I _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 P F. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is , required for every Centerville Ma 02632 3/12/2015 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 1998 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: .2 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 611 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts k V�w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information in required for every Centerville Ma 02632 3/12/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank needs to be cleaned soon for routine maintenance and should be done again every 2 years to prolong the useful lifespan of the system . Water level was even with outlet invert, tank was not leaking and was structurally sound. Outlet tee was intact and in good condition. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M s 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments zl M 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information i:a Centerville Ma 02632 3/12/2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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.): Pump chamber was in good condition, pump and alarm functioned when triggered manually. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 14'x45' ❑ 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.): s.a.s. consists of a raised leach field. No signs of past hydraulic failure were present. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of.scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,�.�''- 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owners Name information is required for everyCenterville Ma 02632 3/12/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i 8, to NAr c f5 E c ip fa+k �. ly >�- 3a iy • PVMP t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25-27 Southwinds Circle Property Address Robert& Connie O'Connor& Erin Bertrand Owner Owner's Name information I!, required for(:very Centerville Ma 02632 3/12/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 5 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: 4/9/1997 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: Design plan dated 4/9/1997 states that groundwater was encountered at 5.6'. Leach field is a raised system and is designed to have a seperation of 5' between bottom of s.a.s. and adjusted high groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i i Commonwealth of Massachusetts IW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 25-27 Southwinds Circle Property Address Robert&Connie O'Connor& Erin Bertrand Owner Owner's Name information is required for every Centerville Ma 02632 3/12/2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for.very Centerville MA 02632 03/10/13 page. Citylrown 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 cursor-do riot Michael Kellett a OU use the return Name of Inspector key. Aardvark Environmental Inspections Company Name PO Box 896 Company Address East Dennis MA 02641 Citylrown, State Zip Code 508-385-7608 S13742 Telephone Number License Number ,a w B. Certification I certify that I have personally inspected the sewage disposal system at this address and that tha..3 information reported below is true,accurate and complete as of the time of the insp n.The i*ection n was performed based on my training and experience in the proper function and mae ance of of site sewage disposal systems. I am a DEP approved system inspector pursuant to S on 15.34(�of Title 5(310 CMR 15.000).The system: ti `Cl t k;;Cll ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority a„t 03/12/13 Insp or'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 4 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. i t5ins•11/10 Title 5OfFcial In orm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for every Centerville MA 02632 03/10/13 page. Cityfrown state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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): i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for every Centerville MA 02632 03/10/13 page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) 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 wins•11f iC Me✓Offlliciai inspection Foam:Subsurtace Sewage Disposal Syslem•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form <la. Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for evary Centerville MA 02632 03/10/13 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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'h day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for every Centerville MA 02632 03/10/13 page. Gtyfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria e)dst 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 tailed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-11110 Me 5 Of trial fnsped ion Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is Centerville MA 02632 03/10/13 required for evory page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 P R Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for evi:ry Centerville MA 02632 03/10/13 , page. Cityrrown state Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date CommerciabIndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: t5ins•t 1/10 Title 501iicial Inspection Form:Subsurface Sewage Deposal System•Page 7 of 17 Commonwealth of Massachusetts ug Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is Centerville MA 02632 03/10/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes,attach previous inspection records,if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Tide 5 Oftial Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann - Owner Owner's Name information is required for everyCenterville MA 02632 03/10/13 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 01/07/99 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.3 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): Depth below grade: 0.2 p g feet Material of construction: ® concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,500 gal 3" Sludge depth: t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for every Centerville MA 02632 03/10/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28n Scum thickness 2' Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 1 6'r How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form h& Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy� 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for everyCenterville MA 02632 03/10/13 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): r Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for every Centerville MA 02632 03/10/13 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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 box was level and tight with no sign of 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.): The pump,Chamber and all Appurtenances were in working order. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurrace Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Flame information is required for every Centerville MA 02632 03/10/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ® leaching fields number,dimensions: 1@14'x45' ❑ 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.): This system has two lines in a 14'x45'stone field.There was no sign of ponding or failure in the stones. 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 t5lns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form +� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for everyCenterville MA 02632 03/10/13 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): i Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is required for everyCenterville MA 02632 03/10/13 page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 32 front 14 2 4Y�l t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is Centerville MA 02632 03/10/13 required for every C City/Town page. �Y State Zip Code Cate of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 3.9 feet rPlease indicate all methods used to determine the high ground water elevation: i ❑ 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 augered to water at 5.6 feet. I adjusted to 3.9 feet. Bottom of leaching is just above grade. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 'd Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25-27 Southwinds Circle Property Address Daniel Mann Owner Owner's Name information is Centerville MA 02632 03/10/13 , required for evi:ry page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 - Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 17 of 17 ---- Cosn;&u',W by:• HIGH GROUND-WATER LEVEL COMPUTATION Location a r a Z S a�`1"� y,► t�e7� Lot No. ner Addres' ttracior. - WS: EP g *Mae dewh to Vdawr tale Doe ,7• to newt ilia ft -FP 2 U.sm4eWd amw?A ase!hvWx Wed Kw kocate E; Wam4syd range zone rEP3 twng monmy repon-Qmrm ` iftw Resmmes - TEP 4 I -Ta bb 3#Waver4evel 11eI3uwrenz t j,w index my(STIEp 2A).cusmit depth javmw IeM*w mdex sAH�TEP 31• 1�7 ITEP 5 by suboadhV the vmW- kvd add MTEP 43 �tme 13. i 2 4- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENT -l-P O(TE-JL MAY 3 0 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25127 Southwind Circle Centerville, M4 02632 Owner's Name: Dan Mann Owner's Address: 128 Devon Lane Marston Mills. MA 02648 Date of Inspection: May 9, 2003 Flame of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map:226 Idailing Address: P.O. Box 49 Parcel: 160 OsteryUk,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority a'ls Inspector's Signature: Date: May 15, 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: 25127 Southwind Circle Centerville, MA Owner: Dan Mann Date of Inspection: May 9, 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 0.303 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 14D 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 14D explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25127 Southwind Circle Centerville, MA Owner: Dan Mann Date of Inspection: May 9. 2003 C. Further Evaluation is Required by the Board of Health: __ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PnDperty Address: 25127 SouthWnd Circle Centerville, MA Owner: Dan Mann Date of Inspection: May 9, 2003 D. System Failure Criteria applicable to all systems: Y(a must indicate either`des"or"no"to each of the following for all inspections: Yes No __ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool __ ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool __ ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool __ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow __ ✓ 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 ooliform 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 CUR 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 gpd- You must indicate either`W or"no"to each of the following: ('Me following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well I1you 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25127 Southwind Circle Centerville, MA Ovrner: Dan Mann Date of Inspection: May 9, 2003 Check if the following have been done: You mast indicate"yes"or"no"as to each of the following: Yes No v_ 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? _I/ 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: 25127 Southwind Circle Centerville,MA Owner: Dan Mann Date of Inspection: May 9, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2002-81,000 Aals.;2001-92,000 Qals. Slump Pump(yes or no): No List date of occupancy: Currently occupied COMMERCIAIA NDUSTRIAL 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: Pumped every year-per owner Was system pumped as part of the inspection(yes or no): No I r yes,volume pumped: sallons--How was quantity pumped determined? F;eason for pumping: 7CYPE 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 7199-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: 25127 Southwind Circle Centerville, MA Owner: Dan Mann Date of Inspection: May 9. 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: At grade 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: 1" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" 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: 12" How were dimensions determined: Measiffing stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels a:;related to outlet invert,evidence of leakage,etc.): Ae tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. 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: Uistance 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: 25127 Southwind Circle Centerville, MA Owner: Dan Mann Date of Inspection: May 9, 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: Ccmunents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Di;pth 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 leikage into or out of box,etc.): The D-box was level and clean. No solids were present. The D-box was at grade up in a mounded S.A.S. PUMP CHAMBER: ✓ (locate on site plan) Pumps in working order(yes or no): Yes Alarms in working order(yes or no) Yes Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): .r'he liquid level was at a normal height. The pump was in working order. 8 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25127 Southwind Circle Centerville, MA Ov finer: Dan Mann Date of Inspection: May 9, 2003 Sad,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: _V, leaching fields,number,dimensions: 14'x 45'-per as built card -- overflow cesspool,number: _— Innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): T Me leach field wns a mounded system. There were no signs of failure. The stone was clean. 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: Ivlaterials 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: Ilepth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I 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: 25127 Southwind Circle Centerville, AM Owner: Dan Mann Date of Inspection: May 9, 2003 Map:226 Parcel: 160 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or baichmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 8_ la: Fromm F 11 - ✓(VJ'� ��IMP 10 • Page; 11 of 11 a OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25/27 Southwind Circle Centerville, MA Owner: Dan Mann Date of Inspection: May 9, 2003 SITE EXAM Slo..pe Surface water Chick cellar ShE11ow 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: Ycu must describe how you established the high ground water elevation: Dw S.A.S. is up in a mounded system approximately 2'higher than street elevation. 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 JAN-13-99 02 :31 PM BENNET&O'REILLY-INC. 508+896+4687 P. 02 { a ]BENNET T A O 'R Engineering, Environmental & Surveying Services I573 Main Street Sanitary 21E/Site Remediation Property Line PO Box 1667 K:e Acvclopment Hydrogeologic Survey Subdivision Brewster. MA 02631 Waste Water Treatment Wxtcr Quality Monitoring Land Court O 508-896-6630 Watcr Supply Licensed Site Professional Trial Coun Witness 508-896-4687 Fax B097-1494 January 12, 1999 Mr. Thomas McKean Barnstable Health Department 367 Main Street Hyannis, MA 02601 Cow RE: 25-27 Southwind Circle, Unit ) Centerville, MA Dear Mr, McKean: As per the requirement of the Massachusetts State Sanitary Code 310 CMR 15.02I0). BENNETT & O'REILLY, INC. has conducted an on-site inspection of the newly installed sewage disposal system at the above referenced property. At the time of our inspection, 1/8/98, the system installation had been completed tidith the exception of back filling and final grading. Our observations were limited to the top of the S.A.S.,the observation manholes for the pump chamber,septic tank and D-Box and the soil conditions above the S.A.S. Soil conditions around and below the S.A.S. were not observed. Based on our observations, the sewage system was installed within substantial compliance with the approved plan dated 4-9-97 and revised on 1 1-12-98,as filed.in your office. This letter represents BENNETT&O'REILLY's inspection prior to backfll. No warranties or guarantees are expressed or implied for the future operation of this system. Please contact my office directly with any questions, comments or for any additional information you may need. Very truly yours, BENNETT&O'REILLY, INC. L John M. O'Reilly, P.E. Principal JMO/tsd JAN-13-99 02 :31 PM BENNET&O'REILLY-INC. 508+896+4687 P. 01 A 13ENNETT & O'REILLY, Inc. 1573 Main Street P,O. Box 1667 Brewster, MA 02631 (-`;08) 896-6630 (`;08) 896-4687(FAX) FAX TRANSMITTAL (508) 896-4687 NUMBER OF PAGES TO FOLLOW: 1 FAX NUMBER: 508-790-6304 DATE: January 13, 1999 TO: Mr. Jerry Dunning RROM: John M. O'Reilly REGARDING: Certification Letter-25-27 Southwind Circle, Centerville, MA MESSAGE: IF THERE ARE ANY PROBLEM WITH THIS FAX PLEASE CONTACT US AT(508) 896-6630 BARNSTABLE COUNTY DEPARTMENT OF HEALTH AND THE ENVIRONMENT Z SUPERIOR COURT HOUSE • T d POST OFFICE BOX 427 V BARNSTABLE, MASSACHUSETTS 02630 • • Phone: (508)362-2511 Ext.330 �lA 5 E.7 Public Health Administration 333 Environmental Health 383 r Water Quality Analysis 337 Mr. Paul Lebedevltch TDD 362.5885 P.O. Box 636 Centerville, MA 02632 Dear Mr. Lebedevitch, At your request a Risk Assessment was conducted at 25 South Wind Circle in Centerville on March 27 , 1996. A complete report is attached along with a list of licensed deleaders and loan programs available. The following is a summary of abatement required for compliance: *Room 1: B and C windows must be fully abated, window wells and parting bead areas covered *Room 2 : C1 and C2 windows (same as room 1) *Bathroom: B window (same as room 1) *Kitchen A window (same as room 1) *Hallway Al and A2 fixed windows-make all loose lead paint intact fully abate window sills 4 r *Exterior All loose chipping and peeling lead paint must boa made. intact. (for full deleading compliance window sills less than feet in height must be replaced or scraped to bare wood) If you or your licensed deleading contractor should have any questions regarding work required for compliance with the Lead Law call me at (508) 362-2511 ext. 371. Sin erely, v� J e Crowley #C2829/#Q2829 cc: Christina Kuchinski, Barnstable Health Dept. CLPPP Lead Inspection/ Risk Assessment Form Risk Assessor/Agency Page)of-�-= Rnrnstnhle County Health anal Method Used: Fnvirolsmerltat iJeRartrr�Lr; L9'�Ia2S expiration date "-Ray Fluorescence License#Superior Court House Model YK3Serial# 7 yb Barnstable, MA 02630 Address� Q �-q Apt.# City 4 14 "I /-)I I M/9 Ce,,17-1e,,t/, 'Mo Child's Nanrie (Last, First, Init.) Parent/Guardian's Last Name ndrent./C� wrdiaz's First Name Pe-F&Kr Single Family ❑ Owner's Name: paol ZeA Multi-Family Owner's Address: Number of Units _ x 63 6 �Prv� //e M - KEY: CAP capped Remarks/Calibration: cov covered DIP dipped oum'F/- l pP lxe g Y /� ENC encapsulated MI made Intact NA not accessible Yty�/d lL- Code NEG negative _ POS positive PRE repared �l/ �eCid 1nS�e� , �,2J j.S' .6y C RE removed `✓ CCU��j LLYrt S T /��/ REP replacement REV reversed SCF. scraped to bare substrate SFG safeguard in place Floor# — Floor# I I 1 1 1 I ICI I ! 1 I I I I 1 I I I I I C I I I I I I 1 r - r - I- - r - r - r - r - T - T - T - T - T - T - T - ' - - r - r - r - r - r - r - r - T - T - T - T - T- T - T - I I ! 1 t l 1 1 ! 1 I I 1 ! r - r - r - r - T - T - T - T - T - T - T - - r - r - r - r - r - r - r - r - T - T - T - T -- T - T - I I Y I ! I I I I I ! I 1 ! I I I I I I I I I I I I I ! - r - r - 1- - r - r - r - r - T - T - T - T r - r - r - r - r - r - r - r - T - T - 1 — r - r— r - r— r - r - T - T - T - T - T - T - t - 7 - - r - r - 1 - r " r " r - T - t - T - T - T - T - t - I I I t I I 1 I ! ! f f I I I I I I 1 I I I I I I I 1 I - I. - t - t - t - t - Y - - - F - r - r - r - t - t - t - t - t - t - t - t - t - t - t - 112e 7 - t - - I I I 1 1 I 1 I I I I I 1 1 — r — r — r — r — r — r — r — t — t — t — t — t`— t — t — BI - + - + - t 1D B I I I 1 I 1 1 I I 1 I I I 1 p + - - 1 I I ! ! 1 I I I I ! I I I I I I I I I I I I 1 I 1 J - ► - ► - F - F- - r — t - t - - + - t - t - t - t - - - t - + - + - + - + - t - t = t - I 1 I I ! 1 ! I I 1 I ! I 1 I I I I I I I I I I I I I I I I I 4 I I I I 1 1 I 1 I I I I I I I I I 1 I I I 1 1 1 1 I 1 I I�I I I I I I I 1 I I 1 I 1 I I I I I 1 1 1 1 I 1 I I I I I I I I 1 + - + - + - + - } _ 4 _ I 1 I I I I A (street side) A(street side) Pb (lead) more than 1.2 mg/cm2 with x-ray fluorescence or positive with Na2S is Dangerous. RISK ASSESS.DATE I I Urgent Lead Hazards? Interim Control Data (YorN u sk Assessor Risk Assessor REINSP'. DATE Lead Hazards? (Y or N) Recertification Date Risk Assessor Risk Assessor t.incompliance REINSP. DATE 1.Incom Nance REINSP. DATE 2.work In progress 2.Work In progress Full Compliance Date 3.reoccupancy 3.reoccupancy 4.failed 4.failed Inspector Did you Complete a surface assessment for encapsulation? YorN Risk Assessor r , 1 - �s r, Lead Inspection/ Surface Assessment Form - AMERI . - HOME HOME ' tie 1 or ENVIR NMENTAL - — . Method Used: . ®'NaiS expired«,dat 1'.O.Ros I(X'1t nrclnllr.`.tauchncln 12G12 s00 i(i4o}7; O X_RayFlWrescence License N 118 4 3 Model serial fr Address ApL i City 017VeW4e Child's Name(Last,First,lnit.) Sex Parent/Guardian's Last Name Parent/{Guardian's First Name 7Owner's l I U f Single Family p Nam:: chi e V IT—C P+ Multi-Family ess: (0 Co Number of Units Cc t e A- : r!- 83 -�7z w- -r ►� co yb�( KEY: CAP allow Remarks/Calibration: o1Pv Covered �Z�IjGf?edT �fPl l}►2 Cdalnsdl� n dgVed enca",nw M1 NA M accesstft fkre-NEG negative Scales:Iamraa of 0 or l pas w"s d2 W: C�I POS =:d Suety Saeallrt" 4`` REM remove0 O.ropa+Wtlpaxll ausn t..M2846,4mrd Z-10%Aa ear Yllata ,\ °� D.rloe spar ZotOKnnAI w0ak 1N -REV reversed X-c Two Tan O.roPMftwMa I.M Oaullaemne 2oV10'ena�111aw0 ,/ n SCR aerapeC ro bare substrate xLla Tap°Tw a ro Oa.lt gel°Ne t. _ �aWllaelon0 alaVte'ytla awlae0 U,O•pA•q�- �� Floor M t sr Floor aY I- I I 1 1 ICI 1 1 1 1 1 1 -r-r-r-t• -r -r- r-r- r- T- T-T-T -T- - -r.-.r-r-r-r-r-r-T-T-T-I I I 11 I I I I I I I I I 1 I I- 1 1 1 1 1 I I 1 ( 1 r-r -r-I• -r- r- r -T -r- T -r-T-T-T- -r- -r-r-r-T-r-7-T T( 1.._.1. 1 1 1 1 r-_r-1'.-..r.-r- r- r -T_T-r _T-T-T_ 1 1 I 1 . -r- ................T- - -. I 1 I I ' I I ' I I I I I 1 1. '•1 1 1 1 1 I 1 1 1 1 I 1 -r-r -r- r-r- T- I 1 1 A I I I - ,,, 4; .. T'T-y- ' _ I I 1 1 r 1 1 I 1 1 1 I B _ 1L-tall + ' T-y-'-y- ' _""n_-' _ ` 6�i 'D B I 1 1 I 1 1 1 1 I 1 1 1 1 I p r � l D_ _ _ _ _ +- 'r-r-r-r.-r-r-♦ ♦-*-y-y-y-y-y- I 1 1 1 r I 1 - _ �' - - - L - • r rAI • I` -, L p_L_p-p-p_1_p_a-i ♦-J-.�_J_ - 1 1 - I I -L _L _L ♦_ 1 _ ♦ _ a _� _ _ _ A(street side) A(street side) Pb (lead) ITiore than 1.2 rng/cm 2 with x-ray fluorescence or positive with NazS is Dangerous. INSP. DATI-� LeaOHataros 1 �oellvs.rn { Inspector REINSP DATE I z REINSP. DATE --Vk �!-�-_-r- Z..onlnpopn.° .. Ll — , — REINSP. DAl � 2 aa..,Wop... Futl Compliance Dat J r.ocn,o.,c, .Irw rhd You complete a lurface a°scasntent for encapsulation' Y Inspector i � . LOCATION/ �� ' ' _ • ®®� � . . r►�r��ii��iii� �i�ii■� �r���i��ii■ii�ii�ii�i�. Mr.���i�i�ri�i �ii�■i • • PM- MM. Ei-�iii M. • mmi� Mii � • • • ran-- Li�eiii ��� • �r.��i�ii��■i�� �i�ii� ■i�ia�ii� ��� = : : �n�ii�i■i�is� ��� ©�i■i�iii —�� LOCAT ION/ INS mmoMMMIMMIMMIN • • . • � ,, . tom/ = G■__��■■ ®�� ION o■■■■��■■■ _ems -- �■■■■�■■■■ ®■■■■ INS mo■■�■■��■■� ®■■■■ ONE ONE 11MMISIM �'� • ' rmlPm1■■®®■■■ ®e®. rm■■■■■■lllMlM■■ Ml �■�■■■■■■ ME 11001 ME! Ml ME! E ■■■■■■■■■mmm 111M 11001 11001 Ml ■M■■mpMIgEE i■■11001111M -11M ■n■■ 111M ■ 111=1110� 001001■■ 110011M■e I ■MI� 1 ■ LOCAT ION/ SURFACE M■■■■■■■■■■■■■ ■■■■■■ =■■■■■■■■■■■■■■ ■■■■ . . .■■■■���■= ■�_ ...cam®® ®��■■�■ ®■� Mmmm ■■■■ mm �■i� . ... �®■�■■■■■■�■■ ter■■■ I SURrACE • Chairrail �� • ®� v walls ©•.. �IiCi���ii �i� ®• iiCi���ii �i� •.. . . . .ii�is��ii �ii. _ ... .• ■i���ii ®ice . `L ■i���ii �i� . .. �• 19Ci��®ii �i� ••-I�I�.�1®i®��ii �i� K4-. [mom ' ' [i• iCis��ii i��i� .. vmimi��=== MIMI . .��i■i��iii ■�i� . .. ��ili_��ii ■�i� •. . ..l�iCi���ii �i� ® LOCAl ION/ COMMENTS INN mm SURFACE CON ME SEEN MINE n�■�■■■■111011■■■■ Win sash/Mullxom-vs • rm©�i■■■■■■■■ ��� ■�■ ■■■■■■■■�ii■■■■■■ _��® Up wallsk Dw walls Baseboarcs/Chait r MEN IM MIN MIN IM Door MIN MIN IM --[)or"m Dix,r ca,ing/ja �tiriii�i����IM D �i i oor MIN Door casingirjamb 11001 IM 11MINNE 111M NIMMININIM IMINE MININIM 111M IM MINIMINIMIM IM m�IM��Mi� NIM IM • RIMMININIMMI MI ®ice rmmMIMNlIMIM IM IMIM IM FM 111M 11001 NIMMININIMMI MIN IMINIONNIMINIM IM 11001 NIMMININIM IM IMINIMINIMMI IM ME! NIMMIN! IM INS NIMMINI IM 11001 MOMINIM IME MNIMMEMN 11MIM NNIME MININIMMI 11001 11001 mom 111M MIN MOMINIMINMIM IME mom ME IM MIN MOMINIMISIMMI ii�MINIMI mom IM 11001 is �iiii� 11001 �c�iii��� NINE NINE IMIN MI IM �i�i_ 11M IMINIMISIM INE ME MINIM AMEKI 'A,N 1710ME LEAD INSPECTION/ s Page of i ENV I R ��I ENTA L SURFACE ASSESSMENT FORM f Douglas L . Williams Address of Inspection: o2j/>7 `� wr��sti2-�� —Apl#-- - - — airy EXTERIOR SIDE LOCATION/ LEAD L OWR DLR SRF COMMENTS DELEAD DELEAD SURFACE ABT? PREP? DATE METHOD Siding E•. Cornerboards �— i Lower inm C17 Upper trim tJ Door tie r Door casing/Jamb Threshold .� Door- Door.casing/Jamb tx Threshold Door Door casing/Jamb �1J Threshold a �— Door Door casing/Jamb Threshold Window sill � ✓ 6 i Window casing PC5 Win sash/MuBions 0 A 4Window sill 3 Window casing / Win sash/Mullans r! JAM C�6QS Window sill r/ Window casing r/ Win sash/Mulbons 14 111 r iS6� AWindow sill b pb> (1 Window casing pC>5 �1 Win sashlMullions /v ( 4- ✓ f � C:etlar win units Cellar win units �+ Cellar win units Cellar win units Ab Foundation Allej Bulkhead 13 Fences N iynatur��r,,,� _ ] i s tJ I1843 ��=,�-- date c.-./,j,- 1-_3. ` x L� �-{1 V 1v1 i� LEAD INSPECTION/ E1eTVIp SURFACE ASSESSMENT FORM P age �f r� t� r_�Q ENTA I, Doug l.,ns L . Williams , Address of Inspecil,on:p2s/,,'� city EXTERIOR C' � SIDE LOCATION/ LEAD L OWR DLR SRF COMMENTS DELEAD DELEAD SURFACE ABTA PREP? DATE METHOD t Siding 71 -8ci5 Cornerboards / �r Lower trim Upper trim /!'qq .. Door J ff Door casing/Jamb J Threshold r Door. i Door casing/Jamb Threshold Door Door casing/Jamb Threshold Door Door casing/Jamb Threshold Window sill OS Window casing ps r— Win sash/Mullions S r Window sill D Window casug Win sash/Mullions dS 1'Vindow sill zWindow casing aS ✓ Win sash/Mullions o5 a5 Cj Window sill _ .3 Window casing Win sasNMullions Cellar win units Cellar win units Cellar win units Cellar win units Foundation ' Bulkhead Fences i s i gnatur-e �, v� 1 i c 0 11843 date 'I 1}i 1V�i 1"�l 1 A N I-I��1Vt LEAD INSPECnow Pam o� Q2� SURFACE ASSESSMENT FORM F N V I R(N7K4 EN TA I_, Oauglas L . Wi. l ,l .i.ams Address of Inspection. City / 'ITT I"✓+/ l Y", EXTERIOR SIDE LOCATION/ LEAD L OWR DLR SRF COMMENTS DELEAU DELEAD SURFACE ABT) PREP? DATE METHOD Siding Cornerboards Lower Inm Upper Inm Door IDoor casing/Jamb Threshold Door Door casing/Jamb Threshold Door Door casing/Jamb Threshold Door Door casing/Jamb Threshold Window sill .� Window casing � Win sash/Mutlrorts p p window tilt L(J window casing p3 7! Wm sash/Mullpns pS r Window sdl SWindow casing d Win sash/Mull*m of p S fi Window sill O f Window Casing r Win sash/Mull*ns MW OS Cellar win units Cellar win units Cellar win units Cellar win units 6C Foundation ,vey Bulkhead Fences s i gnature l i c !t 11843 date "'AN .1 I V m E LEAD INSPECTIONI '4 , ` '' Page.dL of E1 v V I R r E N 1lA 1_, SURFACE ASSESSMENT FORM DougtaE,w7 L . Wi11i.ains Address of lnspectim v2>%27 sayt"4 ,,,o," e we(e Apt# -- City EXTERIOR �c�>,i nT a►ri �lQ, .:r% - SIDE LOCATION/ LEAD L OWR DLR SRF COMMENTS DELEAD DELEAD SURFACE ABT? PREP? DATE METHOD Siding Cornerboards Lower trim Upperinm Door Dear casing/Jamb Threshold Door Door casing/Jamb Threshokd Door Door casing/Jamb Threshold Door Door casing/Jamb Threshold Window sill 5 Window casing 65 Win sash/Mullions Window sill p5 (� Window casing 5 Win sash/Mullions PCS VD5 Window sill Window casing Win sash/Mullions Window sill Window casing Win sash/Mullions Cellar win units Cellar win units Cellar win units Cellar win units Foundation- Bulkhead Fences signature l i c tt I 1843 —�_ date `AMERI BAN t�T�)I�E LEADINSPECnow `? Pa��. of f F', V v -[R (E t V I,A L SURFACE ASSESSMENT FORM. DouglEis L . Williams Address of Inspection: ,���> > ��,r (-Apt# city � 1 EXTERIOR SIDE LOCATION/ LEAD L OWR DLR SRf COMMENTS DELEAD DELEAD SURFACE ABT? PREP? DATE METHOD Siding Cornerboards Lower tnm Upper trim I Door Door casing/Jamb I Threshold Door Door casing/Jamb Threshold Door Door casing/Jamb Threshold Door Door casing/Jamb Threshold Window sill ` Window casing Win sash/Mullions QS ✓ Window sill Z Window casing Win sash/Mullans Q VWndow sill 6 l75 Window casing A05 Wm sash/Mullans 111114PIA ✓ J w Window sill I 1>05- f _ f Window casing OS _ Win sashlMullions (� �f Cellar win units Cellar win units Cellar win units Cellar win units Foundation Bulkhead Fences 14, (U rnJpch-u S r ✓ vj`,X )04 C hs•k w , 5 ll �C_3 aa s�CAS-P I S Ns 0 l c tt I 184,9 - date/ii;i Lead Inspection/ Surface Assessment Form ` i AMEIZI 'NH HOME EN V I R N� ENTAL I��r�no.d(u:cda L;I)4.'S I�flp - rya expiration dale kq 1 I'll It— Ilv•,l :nln. ..I.v .I,..c.nn4,1: 400.;(A-0)45 0 X-RayFkwrescence Licenser I 1843 ---- — model serial Address �p Apt•• City : 1 ��iU Child's Name(Last,First,Init.) Sex Parent/Guardian's Last Name Parent/Guardian's First Name I U (/ _1 ej E ���e I I( Single Family U Owners Nzme: Ao� FPEU fry FH' Multi-Family Owner's Address: Number of Units a �O Co Cr--warrwt e Md r/- 83 -0-7z w- -► /- co ybr( KEY: cov upped Remarks/Calibration: ►I�C-A5 �}2E ('V>m I"^A cov capped 5:,e7�2roft DIP dipped ENC enceasussied ('t1 r- C�c�e- F-4- e- --D 2 1YI&TIVi 1 4e?e- MI toade nt&CI NA 101 accessble NEG negs"e Scalm(mom 010 or 1 past.scoraa of 2 erg: ' POs posdtre PRE 1)'"Ied &01.cv 5ue.l.l.re 0-4 pelt/10 pare toad I. nt OMANOW b+I0a A1.la�Mtl REM remo.ed REP repwitoenI Sei�' p•ron le<<to%a"MW 2.s10a dads law REV taloned tr&WW.Too 0•rop.ee le"O"d 1.<VIrroadmosod a vw MM lased SCR aeraped to ben Uostrate aGe Tap TOW 0.rop.re wew+ed le<WrpiW"Nee S-VWPMMWAd Floors 151" Floor n d k C, I 1 1 ICI I I I I I I -r - r -r - r - r - r - r - r - I r- - I I I I I I I I I I I I 1 I 1 1 1 I 1 1 1 1 1 t 1 -r-r -r -r- r- r - r - + - r - , - , - ,- ,-�- -r-r-r-r-r-r-r-t-T-T-T- I I I I I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 -r - - r - r- r - r - r - r - . - , - , - ,_•- �_ -r-r-r -r-r-r-r-r-r-7-r-t-�- I I 1 1 I I I I I 1 1 1 I I 1 1 1 1 I 1 1 1 -r T - - -C 6D D g. I I 1 1 1 1 t t 1 1 1 1 I D LU *I I I 1 1 1 1 I 1 I 1 1 I 1 1 -4_N-F_L -F_V_F_ 4 _ ♦ _ _ ♦ 4 _ 4-J_ r1( art t SI(tl') A(street side) Pb Head I Inure th;ul %k ith x-mv fluorescence or positive with Na2S is Dangerous. �-----INSP DATE --� I REINSPLe.r1 Hatentr'' 1 ��� �.rerY n propre.. DATE rnsnnr,tol IiF:Ir•L;I UArE I I RE - - - El = _... EINSP. DATE . HEINSP 4T Full Compliance Dat /IW. Ir1aDe010P Did you cornplele a surlact uuntnent for erlcapsulallm Y fr N•. • Door casiVJamb�mmlm__mmm mm • mlmmm__mmm mm Ml�elm, pmlm__mmm mm vmmlm__mmm■ mm_ I==mm__mmm mm_ rnm-irmqpmlmmm__mmm 1 mm_ mwmm��mmm mm MFBEM�■■=== mm XGFDIAPM- Ilrmlmlm__mmm mm_ " mmm��mmm mm pmmlm��mmm mm� r ml, mm��mmm ME®R �11PI"=Fmopm rm, M. rm. rm. "Emmm��mmm m M-Immm ■■■mmm mm■� mlm� mmm • MIMM -- �o■■NIMMO■■■■ ■■■■■■ IMM I rMrM. M■IMM_■■■ MIMM ME /M■■■IMMIMM■■■ �MMIMM ME /M■■■IMMIMM■■■ IMMOMME IMM ■■■■IMMM■■■ ISM /■■■■IMMOMOM■■ HMO ■■■■■ MEMO■■ MEMME IMMME ME ON IMMOM ME MINIMM ON ■■■■ ME ME ME MINI■■■■ MOM■■ ��� RON mom =mom =mom mm =mom M, mom Imm. sm MI. 9 mmmm��Mmm m Mll mm��Mmm .............. • © .. . ISO 00110111 0111011101111 ON 0011011100111 0011000011 01111 ® �.. 001mom MEN 011101111 011111111101111 0111101100111 011110111111111 00111111 mol mo. m� 011111111111111 00111=00111 rormollOWN111 011010111101111 0111=111111 IMMINIUMN 000011110111 MO!= 00110110001 NMI= R.,#In 10 0 001 SEES IMIMMI 000100100101 UJIFL, 11.10=0111111 01111011111111 110,91110111 mm 11001=00101 IMISNINNN SON! 1111121111 • • �mmm ■■■� • 1111111011 111110111101111 =�= 001110011 011110111121111 Ext sode sash immmmm ■■■■mmm =mom ■■mm 0101010001 M. IMIENNI M1011MINSIM MINIMISIM mrm. 0011 0111111110111111111 01110111 [m- mm, 011111111111111 M. cum �mmm 001110111011111 SON SON! SON r-11111mmom 00111 mm Ceilirgr,kysel ceiling OM mmmm SON! 0111101111 ME Mlmom IME SEE • • SURFACE I OF Y OW FINE MEN MEN MEN r�■i���■■ ■r■■■■ r�iii�■■��■■■ ■■■■■01 .. i■■s■i■■■ ■■�■■■ ■■■■■�■■■■■■■■■■■ ■■■■■■ r■a■■■■■■�■■■ ■r■■■■ MOMMINIMMINI MINE ..��■■i■■■■■■■■■■■■� ■■■■■■■ mm • ■�u■■s■■■■■■■ ■■■■■0101 o . . �i■■�■■■■■■■■■■ IMMO■NNIMI MEN ME MEN 11001 m MEN 110101 �/ ■■■■ ��O �■_� � ■■■i ��� IME ■■■I INNI MINES mom Max 1Nl Elk I A N 11 1 01vi I., LEAD INSPECTION/ Page of.--: SURFACE ASSESSMENT FORM ENIVIR INICiENTAL nnip I I ,v--, I- W i I I i ;i m!-. Address of Inspection Apl# City (i�414/11 4_?CP�/r FXTERIOIR SIDE LOCATION/ I AU L OWR nLR SRF C0MMFf4T!; DREAD DILLEA0 JPF AC L ABTI PREP) DATE ME71100 Sidng Cornerbwrds ✓ Lower trim Upper trim tj LA Door Door cwmq,/Jsmb Threshold /k� Door Dw casing/Jamb /,)e I Threshold Door Door casing/iamb p)42 I IV(2q Threshold IDoor Door casing/Jamb Threshold Window sill Window casing Po Win sashlMullions, /0> Window sill 1)13 Window casing Jf Win sashiMullions C Window sill r. Window casing Win sash4Aufl*M fqf, Window sill :6 Window casing p05 Win sashlMullions; �Cella,win units ICellar win units ICellar win units ICellar win units IFoundation 113ulkhead Fences date AN 11, LEAD INSPECTIOW page; of F SURFACE ASSESSMENT FORM P 'JNVIR NM ENI-'AI Dor.tcp i i- . w i i i i ams Address of Inspection:0Zs/2- AD"I C (cApt# City EXTERIOR SIDE I OCA T ION/ LEAD t 0WR Ot R SRI (-,OMMf li I f,� OVI I AO N I f AD SURFACE AST? PREP? DATE ME I f 40D I)tcjj Sid g Comprboards Lower frim A 13C 1) Upper I"m Door Door casing/Jamb Threshold I 000f Door casing/Jamb Threshold Door Door casing/Jamb Threshold Door Door casing/Jamb Threshold Window sill Window casing Win sashiMulljoris Window sill JP, Window I Win sash/Mullions Window sill Window casing /?(55 Win sashtMuIIKM Window sill Window casing /er? Win sash/Mullions Cellar win units ICellar win units_ Cella,win units �Cellar win units �Foundation I IBulkhead IIFences Wf jq- t- MI E R 1 AN 1. 10 M E LEAD INSPECTION/ Page/(,of SURFACE ASSESSMENT FORM EN V I R )N I,N`IA1, t)our 1 ;r, L_ . .W i. I I i ;,ins llddross of Inspection. <, / _������ ),r.4S ( �, '���. -Apt# City � - t C.,- .:� EXTERIOR SIDE L(.XA,TIOhJr fA.lr 1. OWR DLRSRf COMMENTS DELEAD DREAD SURrAC(- ABT? PRFF? DATE METHOD Std nq Cornerboards Lower Inm Urper Irim [rn!v • Dcr�r casinyrJam,, T hreshold Door Door casing/Jamb Threshold Door Door casing/Jamb Threshold Door Door casing/Jamb Threshold Window sill Window casing Win sash/Mullions C, p Window sill f Window casing 05d Win sashlMullrons r Window sill 0105 SWindow casing O Win sash)Mutllons w Window sill ,0 Window casing 6 Wm sash/Mullms ) dS Cellar win units Cellar win units Cellar win units Cellar win units 6C Foundation �Jey Bulkhead Q Fencesdate /v e s i rlr crt;ur _ I i s l! I 1t343 AM I;l� l♦ A N j 1(. )M 1, LEAD INSPECTION/ Page�_�_ o1 SURFACE ASSESSMENT FORM ENV IIz )�KI1 N'TAL � Dt�ur1 I ;is L_ . W i I I i :tni / /f Ackiressoflnspcx;h �;>on ,�5 "/ `,;-��j(� ram'„ �.� (°�vC(t�. Apt ► - City (M,7-�:n:��,I C. EXTERIOR SIDE KY,AI10fit LFAD I OWR DLRSRI COMMENTS DE LE AD DELEAD SURFACE ABT7 PREPI DATE METHOD Sickng Cornerboards E ower trim Upper trim Dmr D-'+ir casing/Jamb T Dirt shold Door Door casing/Jamb Threshold Door Door casing'Jamb Threshold Door Door casing/Jamb Threshold Window sill 5 Window casing 005 Win sash/Mullions IJ Window sill p� Window casing (� Win sash/Mullions Csj DS Window sill Window casing ' Win sashMiullions Window sill — Window casing Win sash/Mullions Cellar win units Cellar win units Cellar win units Cellar win units Foundation Bulkhead .Fences 5i Jr7atur� I'r its L.,+�J�.�It ".J L is 1! I184 ' date < �y''.. r / y t\M.1 K 1 O A N 1. 1 U M 1'; LEAD INSPECTION/ r' P890�-of SURFACE ASSESSMENT FORM EN-VIR TK4' I:;NT'AI, L. . W i I I i :imp / Address of Inspection f'.5 `•, y)E1 l.u, r. L Ant# City (- EXTERIOR �tDf IOCAIION/ F.AD 1 DWI? DLR.I?f COMMFWTS UEIEAD D(IEAD SURFACE ARTS PREPS DATE METHOD Siding Cornerboards Lower in Upper trim I ()oor 1 D.-.0'casmq/Jamt• Thiest ld Door I Door casing/Jamb Threshold Door Door casingf lamb Threshold I Door Door casiVJamb Threshold Window sill. ✓ Window casing Win sash/Mullions * l,✓ ^ Window sill window casing Win sashlMullions OS ✓ Window sill �. window casing 05 Winsash/Mullans �� ✓" J W M� Window sill iJs f Window casing � ._ ✓ Win sashIMullions PC5 16 Cellar win units Cellar win units Cellar win units Cellar win units Foundation Bulkhead �a Fences fn1 5 r vj fj-4 W C As-2 vJ r H,lFpa S A%k o K iw si.11 X3 L c �Fsc wrv.. S T:4 siytw3ture_\ ' Tl� �L.wt 1 is lJ I1C34� date/i4-/ -�Jr r � TOWN OF BARNSTABLE f LOCATION J" oZ� QvA(mj-► . G L QG&. SEWAGE # -f o --7 3 VII LAGS CQ^ erV►l ASSESSOR'S MAP & LOTG ��Od INSTALLER'S NAME&PHONE NO. SEPTIC`TANK CAPACITY �SGt� G.S,T- /50o G.Puoh LEACHING FACILITY: (type) t"�d�Z (size) NO. OF BEDROOMS y BUILDER OR OWNER /.)AA .MAri:n 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 leac ng facility) Feet Furnished by 0 FO i 13 yS E c !tA $ a� p r44k i � E .- ty 3a �y arh P uy TOWN OF BARNSTABLE i 1<OCATiONo� ; SEWAGE # `J 1—V1dAG kkA— E ASSESSOR'S MAP& LOT;L a 6 - II®D -INS i ALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I^�®�At—• 0' LEACHING FACILITY: (type) t-\Zl� 'T(size) X 5 i NO.OFBEDROOMS BUILDER OR OWNER PERMITDATE: f COMPLIANCE DATE: — : ± Separation Distance Between the: , Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by J BSI �C No. l31 Fee �,•�i/ THE COMMONWEALTH OF MASSACHU S Entered in computer: i Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS RppYiratiou for ].D:i5pogal *proem Couttruction Permit Application for a Permit to Construct(: )Repair( grade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. — �t.L»Wb Owner's Name,AddreUd T I No. Cam LQC4 van vq- I * �A \2. C� btbe7 A.sessor's Map/Parcel f 32 y "gQq_ In<„taller's Name Address,and Tel.No. 171 167A4 esigner's Name,Address and Tel.No. Aj 5 q %A&_s 101:P1 M , a rn Type of Building: '` Dwelling No.of Bedrooms�_ Lot Size t(64 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs orA terations(Answe when applicable) 1Xy�n^� �- -0l �i DESIGNING ENGINEER MUST S Date last inspected: INSTALLATION AND CERTIFY pi vVRITINO Agreement: THE SYSTEM WAS INSTALLED IN STRICT a CC€JRU�INCF TO PLAN, The undersigned agrees to ensure the construction and maintenance of 1�lte a ore escrt ed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has beenogelLky thirBqm3l of Health. Signed Date 0 Application Approved by - ->. c Date Application Disapproved for the following reasons a Permit No. q F— 4 Date Issued �� l� No._� 4 / l - F �a• ' _M �/ (f" � �Feed ate` — Entered in computer: THE COMMONWEALTH OF MASSACHUSE S Yes PUBLIC HEALTH,DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Applicat"on fori5v aYp4tent CongtructfottPermit Application for a Permit to Construct( j Repair(/ r tg ade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. OG•.J — t%*Z!s)W 1, Owner's Name,AddreUanBd Tel.o. Assessor's Map/Parcel _ l�� 3��) R�n��-�Q ' , r�• 1Aa a • Installer's Name Ad ress,and Tel.No. 1()-$ _Designer's Name- Ad-dCress'and Tel.No. V to zft�plpfdlr i Y � I F> I lM I� Type of Building: 1` ' Dwelling No.of Bedrooms Lot Size �`�,� sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures I Design Flow gallons per day. Calculated daily flow gallons. Plan'bate Number of sheets Revision Date l IlTitle Size of Septic Tank Type of S.A.S. ' »' ` Description of Soil , $ •I Nature of Repairs or A terations(Answe�hpplicable) it Date ilast inspected: - Agree 4 -- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage dispo�al system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a C'e`'rtifi- catecif Compliance has been 'ssue y thM-1f Health. i Signed Date 10 Application Approved by . Date _ Application Disapproved for the following reasons S i Permit No. 9,6 " Date Issued �f � I � THE TgMMONWEALTH OF MASSACHUSETTS B NSTABLE, MASSACHUSETTS ertif irate orf§,omp1iattce THIS IS ERTIFY,that O -site Sewage isposal Syst m Constructed(,, )Repaired( VfUpgraded( ) Abandoned( ).by at_'' `� - - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this ermit shall not be construed as a guarantee that the syste , will function as designed. Date Inspector IL No.- T �7,��--------------------------Fee so I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION'- ARNSTABLES MASSACHUSETTS tgpogai �pterit Con5tructfottPermit Permission is.hereby granted to Constru t( )Repair( )Upgrad Abann) ( ) System located at � 'a� LI.R-l\ � \V . �al.,l • I and''as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to cornply with Title 5,and the following local provisions of special conditions. ProAded:Constructiog must be completed within three years of the date of this pe i Date } 3/�� Approved by —ZL f l0/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works I, , construction permit signed by me dated concerning the " property located'at!W3 -a meets all of the following criteria: if • There are no wetlands located within.100 feet of the proposed leaching facility • There are no pl-ivate_wells-withi`150 feet of the proposed septic system • There is no increase in flow.and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: / A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) �Q=� B)Observed Groundwater Table Elevation(according to Health Division well map) SIGN DATE: t!Of(C? LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER f [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. e�IPEBVISE DESIGhtnlr, EevrlN!<F_R M!JST t �UN V: ;IT"iNG INSTA -_ 1 :<' nv IN�i,: f.LLED IN STRIe:T ACCORDANCE TO PLAN- q:health folder:ccrt e � y lu � t 1 �xcS� t ?NE TOWN OF BARNSTABLE �F ;��� �P o OFFICE OF = BAM9Te L BOARD OF HEALTH y rasa 00s,1639" `e0 a MAX367 MAIN STREET 'F ► HYANNIS, MASS.02601 November 16, 1998 Erik Broman 62 Monomoy Circle Centerville, MA 02632 RE: 25 & 27 Southwinds Circle, Centerville Dear Mr. Broman: You are granted multiple variances on behalf of your clients, Edgar and Linda Lizotte, to construct a replacement onsite sewage disposal system at 25 and 27 Southwinds Circle Circle, Centerville, Massachusetts. The variances granted are as follows: • CMR 15.203 To allow a design flow reduction of 24.3% • CMR 15.211 - Distances: (A) To install a soil absorption system five feet away from the property line in lieu of the required ten feet separation. (B) To install a soil absorption ten feet away from the cellar wall in lieu of the required twenty feet separation distance. (C) To construct an impervious wall surrounding the soil absorption system in lieu of the sloping requirements of Title V. (D) To construct a soil absorption system 27 feet away from a vegetated wetland in lieu of the fifty feet separation distance required. (E) To install a pump chamber tank five feet away from the property line in lieu of the required ten feet separation distance. (F) To install a pump chamber tank seven feet away from the cellar wall in lieu of the ten feet separation distance required. broman • B.O.H. PART VIII, Section 10.0 -To install a soil absorption system 27 feet away from vegetated wetlands in lieu of the required 100 feet separation distance. • B.O.H. PART VIII, Section 10.0, 1.15 - To utilize an application rate of 0.74 gallons per square feet per day in lieu of the required application rate of 0.5 gals/sq. ft./day. These variances are granted with the following conditions: (1) The septic system shall be installed in strict accordance with the revised plans received on November 13, 1998. (2) The designing engineer shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in strict accordance with the submitted plans. (3) This dwelling cannot contain more than four(4) bedrooms. Dens, study rooms, finished attics, sleeping lofts, and similar type rooms are considered bedrooms according to DER (4) This dwelling shall be connected to town sewer when/if it becomes available. These variances are granted because the existing septic system failed. There will be no additions, restorations, or other reconstruction work to the dwelling. The physical constraints of this property and it's location relative to wetlands make it impossible to meet all of the State Environmental Code and Board of Health Regulations. Sincerely yours, Susan G. R R.S. Chairperson Board of Health Town of Barnstable SGR/bcs broman 1H9 DATE: I 4 = FEE I J OP A13 eA715�ink S�LS .r.t �A t6?9. � Town of Barnstable REC. BY TEO pA�� Board of Health 367 Main Street,Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAY.: 508-790-6304 Sumner Kaufman,M.S.P.H. Ralph A.Murphy,M.D. VARIANCE REQUEST FORM LOCATION / Property Address: 5' 7 S d UtuW 1 ND S Ci>Z C/E C�av ran L�l�/E Assessor's Map and Parcel Number. ZZ{p— l<o Size of Lot: e 1/ Wetlands Within 300 Ft. Yes Subdivision Name: No Business Name: APPLICANT CONTACT P&RSQN Name: 6�P6k112, -j� Liryf)lj 4%7077-4_ Name: Erg $mnnen ai6�7 � Address: 3). 00.3�dL j�6 XitK 0ke- M W 2-. Address: G i%nOf!eh G r-C& C91►(�JVbi& Phone: S-D? 757 5'5 6 3 Phone: Z 1 1— N FAX: SJ 7 7S`7 FAX: VARIANCE FROM REGULATION(List Reg.) FOR VARTANCE(May attach if more space needed) 0 to CMg 15 'Za3 --19,es1Z?, l'7,oW 3 0 y ica ro 0_=77 " e rr[)uc6 M . t — A a io lf�o.ti, eel wall �l�lfi�,� v,��s wnl( P 1e ''r/est f s s 2.2CiS�-t�S� Sr f}tS r7I , tneeTtQntt N C7 0 I7 �t4V)� t7r co c S / 5. —nw)e. 5' yPo- ry ),ne �Ql�PD_-ecQ to o,/AS' --krs �I..rP its, l"F S,T�3tV K cv lt!c✓' t( &6D�,-1.Orh Checklist li (to be completed by ofcestaff-person receiving variance request application) i ,op S,A"f n Four(4)copies of plan submitted(including septic system plans and/or restaurant floor plans) ,f t p(13[Tt 6- Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting Gr,,lr&-Q�t date at applicant's expense(for Title V and/or local sewage regulation variances only) �s Full menu submitted(for grease trap variances only)�S S Variance request application fee collected(no fee for lifeguard modification renewals,grove try variance renewals[same owncAeasee only),outside [� 100 dining variance renewals[same owner/leasee onlyl,and variances to repair failed sewage disposal systems(only if no eaparoion to the building proposedn 1" 0f- Variance request submitted at least 15 days prior to meeting date © ��, r VARIANCE APPROVED Susan G.Rask,R.S.,Chairman 6,01 G _ NOT APPROVED Sumner Kaufman,M.S.P.H. 5��7' P ?REASON FOR DISAPPROVAL V9.I, tCCd,on / Ralph A.Murphy,M.D. Oro."( ;,,54c4 OF 0.5 Q:/WP/VARIREQ October 19, 1998 Dear I am writing to inform you of our request for variances from the State Environmental Code Title V,and from local Board of Health Regulations in regards to a proposed replacement soil absorption system with a pump chamber at 25 and 27 Southwinds Circle Centerville,Massachusetts. We are requesting variances from the State Environmental Code,Title V and from Board of Health Regulation as follows: (1)310 CMR 15.203 -A design flow reduction of 24.3% (2)310 CMR 15.211 -Distances: A. To install a soil absorption system five feet away from the property line in lieu of the required ten feet separation. B. To install a soil absorption ten feet away from the cellar wall in lie of the required twenty feet separation distance C. To construct an impervious wall surrounding the soil absorption system in lieu of the sloping requirements of Title V. D.To construct a soil absorption system 27 feet away from a vegetated wetland in lieu of the fifty feet separation distance required. E. To install a pump chamber tank five feet away from the property line in lieu of the required ten feet separation distance. F. To install a pump chamber tank seven feet away from the cellar wall in lieu of the ten feet separation distance required. 3)To install a soil absorption system four feet above the maximum adjusted groundwater table in lieu of the required five feet separation distance 4)B.O.H.Part VIII, SECTION 10.0-To install a soil absorption system 27 feet away from vegetated wetlands in lieu of the required 100 feet separation distance. 5)B.O.H. PART VIII, SECTION 10.0, 1.15 -To utilize an application rate of 0.74 gallons per square feet per day in lieu of the required application rate of 0.5 gals/sq. ft./day. The Board of Health meeting will be held on Tuesday,November 10,1998 at 7:00 p.m.,or as soon thereafter as practicable at the Second Floor Hearing Room,New Town Hall, 367 Main Street,Hyannis, MA. The letter is to serve as an official notification to abutter(s). Sincerely yours, Erik Broman (508)771-6284 J:bro PAR'r -m i: ONSITE SEWAGE DISPOSAL REGULATIONS SUCTION 10.00 ONSITE SEWAGE, DISPOSAL CONSTRUCTION ADOPTED 6/11/91, BECAME EFFECTIVE 6/11/91, REVISED 2/11/92 BOARD OF HEALTH riut i6J9. 367 MAIN STREET HYANNIS,MASS.02601 ON-SITE SEWAGE DISPOSAL CONSTRUCTION The Board of Health, Town of Barnstable, Massachusetts, in accordance with, and under the authority granted by Section 31, of Chapter 111, of the General laws of the Commonwealth of Massachusetts, hereby adopted the following rules and regulations after public hearings of the Board of Health were held on May 14, 1991, June 11, 1991, July 23, 1991 , January 14, 1992, January 28, 1992 , and February 11, 1992: Purpose: On-site sewage disposal systems designed to meet 310 CMR, 15.001 The State Environmental Code Title 5, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage have not proven to be adequate protection from viruses, pathogens, and other contaminants of groundwater and surface water particularly in areas where there is a lack of filtration due to the existence of sandy materials tested to have fast percolation rates. Scientists have observed virus entrainment in groundwater to distances of greater than 200 feet from where they were introduced to the subsurface through a conventional onsite sewage disposal system. In saturated or groundwater flow, viruses can travel unattenuated In medium-to-coarse sands. Human consumption of viruses, pathogens, and other contaminants which enter shellfish resource areas, swimming areas, and/or within zones of contribution to public water supply wells can place the public at risk to disease. SECTION 1.1 General Requirements. 1.11 Application for Disposal_ Works Construction Permit: An application for a disposal works construction permit shall be submitted to the Board of Health and must be accompanied by a plan of the proposed onsite sewage disposal facilities. Any permit Issued subsequent to this application shall be invalidated if conditions different than those set forth in the application are found prior to, during actual construction, or within a reasonable time after construction of the onsite sewage disposal system. 1.12 Plan of Onsite Sewage Disposal System: The submitted plan must show as a minimum: the lot to be served, location and dimensions of the system (including reserve area), design calculations, existing and proposed contours, location and log of deep observation holes, location and results of percolation tests, location of any streams, surface and subsurface drains and wetlands within 300 feet of the sewage disposal system, known sources of water supply within 200 feet of a sewage disposal system, location of any proposed well to serve the lot, location of water lines on the property, maximum ground water elevation in the area of the sewage disposal system, and a profile of the system. The plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans. 1.13 No person, company, corporation, entity, trust or firm shall install an onsite sewage disposal system leaching facility within one-hundred (100) feet of a Watercourse, as defined, in 310 CMR 15.00: THE STATE ENVIRONMENTAL CODE, TITLE 5:MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE. Section 15.01 Definitions. 1.14 No person, company, entity, trust, or firm shall install an onslte sewage disposal system leaching facility within two-hundred and fifty (250) feet from a watercourse with the bottom of the leaching facility less than fourteen (14) feet from the maximum adjusted groundwater elevation unless said person installs the leaching facility in compliance with the application rate as follows: Percolation Rate Application Rate Minutes/ Inch Gallons/ Sq. Ft./ Day 6.0 or less 0,75 or less > 6.0 0.50 or less (The application area needed to achieve these rates shall be calculated using the formula given in Section 1.2.) Maximum adjusted groundwater elevation must be determined using one of the following methods, or a method approved by the Board of Health: 1) using ESTIMATING HIGH GROUND-WATER LEVELS FOR CONSTRUCTION AND LAND USE PLANNING-A CAPE COD, MASSACHUSETTS EXAMPLE, by Michael 11. Frimpter and Martha N. Fisher, U.S. Geological Survey, Water Resources Investigations 83-4112, September 1983, or; 2) performing an observation test during the wet season as determined by the Board of Health. In marine coastal settings, observation tests must be performed over a complete tidal cycle, excluding "minus tides" defined by a standard tide table. A variance may be issued if a competent source demonstrates that no portion of the contaminant plume from the proposed septic system will intercept any watercourses. An application for a variance from this section must include a site specific hydrogeologic study commissioned at the applicant's expense. 1.15 No person, company, entity, trust, or firm shall install an onsite sewage disposal system leaching facility subject to Section 1.14 of these Regulations where the bottom of the leaching facility would be less than five (5) feet above the maximum adjusted groundwater elevation. if a variance from this section is approved by the Board of Health (allowing a separation distance of four (4) feet), the proposed leaching facility must be designed such that the application rate does not exceed 0.50 gallons per square foot per day (gal/sgft/day). 1.16 No person, company, entity, trust, or firm shall install a leaching pit, galley, flow diffusor, chamber or other leaching facility unit subject to section 1.14 of these Regulations unless each leaching pit, galley, flow diffusor, chamber or leaching facility unit and every ten (10) feet of leaching pipe length in leaching trenches, fields, beds or other pipe oriented systems is fed by a separate line from the distribution box (see Figure 2). However, systems dosed by a pump, reliably producing charges large enough to fill the system, need not connect each 10' length of leaching pipe separately to a distribution box. 1.17 No person, company, entity, trust, or firm shall Install exit pipes In a distribution box with unequal Invert elevations. It Is recommended that all exit pipes be fitted with an invert leveler cap. No person shall install exit pipes which convey unequal flows. Onsite sewage disposal systems subject to Section 1.14 of these Regulations shall be constructed such that the equal flow is accomplished by one of the following methods or a method approved of by the Board of Health: 1) the distribution box must be Installed on crushed stone which is at least six (6) Inches deep or on eight (8) inch thick concrete masonry units or (cinder-blocks) which has a surface area equal to or greater than the base of the distribution box, or; 2) the use of a balance-pan spill type distribution box. A balance-pan spill-type distribution box fills a one (1) to two (2) gallon pan, with effluent before "spilling" It out to the exit pipes, or; (3) the use of a siphon or pump chamber. (This Section 1.17 only applies to those systems which have more than one (1) leaching facility unit.) 1.18 No person shall install an onsite sewage disposal system leaching facility subject to Section 1.14 of these Regulations with an effective width which is greater than twelve (12) feet. SECT1 ON 1.2 Calculation of Application Area: The application area (AA) fot a leaching structure shall be the effective bottom area plus six (6) inches around it for lateral dispersion (see Figure 1). The application area required to satisfy the application rates as stated in Section 1.14 can be calculated using the following formula: AA REQUIRED (sgft) = FLOW (gal/day) / 0.75 or 0.50 (gal/sgft/day) where, Floc► = Gallons/Day as Determined By Title 50 Section 15.02 0.75 or 0.50 = Required Application Rate From Section 1.14 or 1.15 Above SECTION 1.3 Variance and Enforcement procedures: 1.31 Variances may be granted only as follows: The Board of Health may vary the application of any provisions of this Regulation with respect to any particular case when, in its opinion (1) the enforcement thereof would do manifest injustice; and (2) the applicant has proved that the same degree of environmental protection required under this title can be achieved without strict application of the particular provision. 1.32 Every request for a variance shall be made In writing and shall state the specific variance requested and the reasons therefore. Any variance granted by the Board of liealth shall be in writing. Any denial of a variance shall also be in writing and contain a brief statement of the reasons for the denial. A copy of any variance granted shall be available to the public at all reasonable hours in the office of the Town Clerk or the Board of Health while it is in effect. 1.33 Any variance or other modification authorized to be made by these regulations may be subject to such qualification, revocation, suspension or expiration as the Board of Health expresses in its grant. A variance or modification authorized to be made by these regulations may otherwise be revoked, modified or suspended, In whole or in part, only after the holder thereof has been notified in writing and has been given an opportunity to be heard in conformity with the requirements of 310 CMR 11.00 for orders and hearings. 1.34 Each section of these rules and regulations shall be construed as separate. If any section, regulation, paragraph, sentence, clause, phrase or word of these rules and regulations shall be declared invalid for any reason, the remainder of these rules and regulations shall remain in full force and effect. 1.35 The provisions of Title I of the State Environmental Code (310 CM1t 11.00) shall govern the enforcement of these regulations. SECTION 1.4 Penalt 1.41 Penalty for failure to comply with any provision of this regulation shall be governed by Massachusetts General Laws, Chapter 111, Section 31. Each day's failure to comply with an order shall constitute a separate violation. 1.42 Further, the Board of Health, after notice to and after a hearing thereon, may suspend, revoke, or modify any license issued hereunder for cause shown. This regulation is to take effect on June 11, 1991, The revisions (additions of the new sections 1.11 and 1.12 and revisions to Sections 1.15, 1.16, 1.17, and 1.18, and Figure #2). are to take effect on July 23, 1991. PER ORDER OF THE BOARD OF HEALTH Joi eph C. Snow, M.D. • Ch ilrman S man G. Rask 6 rian R. Grady BOARD OF HEALTH TOWN OF BARNSTABLE TM/bcs A: 1.)1-411?1. MINING A11PLICATION .AREA. (A.A�) For,Rectangular Shuctures A A - (L1 + L2 + L3 +,L4 + Ls + fft.) x (WI + W2 + W3 + 1fQ ' Top View 21 3' Slone 14 1,I414 L2 ►}' i� �-- L,- Lsj I For Circular Suuctures ' AA = ((WI + D + W2 + 1 ft.)A)f x (3.14) Side View Top View Stone WI D W2 I W1�►I� D stone!. ' r �bigl 2 RECOMMENDED DISTRIBUTION THROUGH FLOW DIFFUSERS maT.HOD NOT ALLOWED UNDER SECTION 1.16 Two S•Type Clow Two •' Plow birru�crs � biffuser! b•[lox From Septic Conk ii rr r , • rr rr � r r �r � r � r Two t Tyro flow Two now Diffusers Di[[usets t 1.14 No person, company, entity, trust, or firm shall install an onsite sewage disposal system leaching facility within two-hundred and fifty (250) feet from a watercourse with the bottom of the leaching facility less than fourteen (14) feet from the maximum adjusted groundwater elevation unless said person installs the leaching facility in compliance with the application rate as follows: Percolation Rate Application Rate Minutes/ Inch Gallons/_S . Ft./-Day 6.0 or less 0.75 or less > 6.0 0.50 or less (The application area needed to achieve these rates shall be calculated using the formula giiven in Section 1.2.) . N:aximum adjusted groundwater elevation must be determined using one of the following methods, or a method approved by the Board of Health: 1) using ESTIMATING HIGH GROUND-WATER LEVELS FOR CONSTRUCTION AND LAND USE PLANNING-A CAPE COD, MASSACHUSETTS EXAMPLE, by Michael li. Frimpter and Martha N. Fisher, U.S. Geological Survey, Water Resources Investigations 83-4112, September 1983, on 2) performing an observation test during the wet season as determined by the Board of Health. In marine coastal settings, observation tests must be performed over a complete tidal cycle, excluding "minus tides" defined by a standard tide table. A variance may be issued if a competent source demonstrates that no portion of the contaminant plume from the proposed septic system will intercept any watercourses. An application for a variance from this section must include a site specific hydrogeologic study commissioned at the applicant's expense. 1.15 No person, company, entity, trust, or firm shall install an onsite sewage disposal system leaching facility subject to Section 1.14 of these Regulations where the bottom of the leaching facility would be less than five (5) feet above the maximum adjusted groundwater elevation. If a variance from this section is approved by the Board of Health (allowing a separation distance of four (4) feet), the proposed leaching facility must be designed such that the application rate does not exceed 0.50 gallons per square foot per day (gal/sgft/day). 11.16 No person, company, entity, trust, or firm shall install a leaching pit, galley, flow diffusor, chamber or other leaching facility unit subject to section 1.14 of these . Regulations unless each leaching pit, galley, flow diffusor, chamber or leaching facility unit and every ten (10) feet of leaching pipe length in leaching trenches, fields, beds or other pipe oriented systems is fed by a separate line from the distribution box (see Figure 2). However, systems dosed by a pump, reliably producing charges large enough to fill the system, need not connect each 10' length of leaching pipe separately to a distribution box. P , row No........ i F� :..f..... �?....... . THE COMMONWEALTH OF MASSACHUSETTS V 3�0 5ti BOARD OF HEALTH ik 0 W. ................OF.... r'in S bl......................................... 1` AppIt"ration for Dispnoal Wilds Tonstrnrtion Errant Y4 Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal System at: k &Lco���o..n h-A ddess / r Lott.•-•._-• ...................••-••...--••-••••.._..._ ....1.�..... ..... � ner Addr ess fdl.......�_../. G..... ........ Type of BuildingAddress `jc, •----------------•___._.....--.Ex Expansion Attic Size Lot.-G e...............nder feet Installer / �.. Dwelling—No:�of Bedrooms..____.. p t ( ) Garbage Grinder ( ) aOther—Type Other fixBuresin---------•------------•---•-----.No--of persons - - .. Showers " ( ) Gr yP g Q P Cafeteria W Septic Tank—Liquid pacityl®o®gallons Length. g2-. Width_. �'Z-�.. Diameter................ Depth. �lo Design Flow................ .....................gallons per person d y. Total y flow..__.........._..___...____ lEg F-• . W Disposal Trench—No....:.... Width _.-.._ x 1 7-•-- Total Length.........f..... Total leaching area....................sq, ft. Seepage Pit No..................... Diameter_.12.CM..- Depth below inlet.._CO... Total leaching area_4 : sq-ft G� Z Other Distribution box (X) Dosin tank ) Percolation Test Results Performed by... .. 11 ........................................ Date. -�. _ .a .l......._... Test Pit No. ......minutes per inch Depth of Test it....1_"4 yr.. Depth to ground water.._12'0' "e.....- G4 Test Pit No. 2................minutes per inch Depth of Test Pit.....120..... Depth to ground water..... ............................._•----•.....: O �'�. 1 : O - l o`er �cs0.rr SQ ZC., m�c� C QYN%"- a @-,c� cast Descri tiori of Soil._.......... ;r ..........a... . i• ....• �.' -------•----_•--- q ••••--one.�....�.o�nSal.ie��.�.�...-50.r _ , 12.0 t-o v e, t �a` .►�►n c R Ae-NE� LA U Nature of Repairs or Alterations=Answer when a livable....... ....... . .....--............._.............� ........._ '__-.______.. ,R ......................................... Agreement: The undersigned agrees to install /br4edescrilbed Individual Sewage Disposal System in,accordance with the provisions of L I:LL 5 of the State Sanitary Code-The undersigned urther agrees not to place the system in operation until a Certificate of Compliance has been i d by the b and ealth. • /'21Y Signed....:--•- ... ......... .......--•._.....---=--------•-•-_••---Application Approved By-•••-••-•--•......-••••--••• • •-••_.. . .. .�........--•--- r '............ ate Application Disapproved for the following reasons:................... ............................................................................................ .......................................................................................•---•.----------•----..._...................••-•.....•••••-•••....-•-•--••---•---••-•••-----••-•......----.....� •ate r ....Permit No.....it..__.10--o'D-•----------------------- Issued...... �-�---•---�� Date_..^----•----•--• •• . ................. No..... ( .�........_ THE COMMONWEALTH OF MASSACHUSETTS ,r ✓ ,L BOARD OF HEALTH Y Appliration for M-4p sal WorkB Ton.itradion FPruti#, Y Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal �1PP Y ��) P ( ) g P Systein at: Lot 4� P1 QwY,, c Goo Pc1.42 YLo anon-Address ...•....__.....•Lot N •.................�,........... _.. Owner Address Installer / Address 2. o 1 Type l� Building Size Lot...2........ ........` Sq. feet U Dwelling—No. of Bedrooms....:�................................Expansion Attic ( ) Garbage Grinder aOther=Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------•----•------ ----- -•---•--•-•----•--••--•--"---••-•---•••--- .••. Design :Flow ....�� ...._. __.. .gallons per person per day. Total daily flow. "�� ,._.,..gallons` K P!p9 Diptoi--Tank=Liquid capacltyl gallons Length _. Width ' ' � _.. Diameter:....._..._. Depth.'. xW p sal Trench-:Jo..._.. Width Total Length Total leaching area..................sq. ft. Y tl ......•• . ... g ....••. .... Seeps,ge Pit No....... Diameter.�2., ; . Depth below inlet. ..E' :Total leaching area"42�'_ sq Oft. Z Other Distribution box { ) Dosing tank ( ) Percolation Test Results Performed by.... . G- �. _ Date.�'�-•?.� ...."........ aw---------------------- 14 'Pest Pit No. l---- .......minutes per inch Depth of Test Pit.:_, r -�f-. Depth to ground water.... 44 'Pest Pit No. 2................minutes per inch Depth of Test Pit.....VZ1...... Depth to ground water.....�r•Qu��e-r- ... --•-••----- - --•-•- O I � 1 Q ` ,emu know, '�V�tSol Go 0 Description of Sotl......:A.....�........ ......... ...----...... _....._..�_.:_Y1n2c� Y15 t�a't .c� aY,c� c a�`� w+'►X. 1 2�- c, V Y'rge:c.,___.Gc�Y15o�)c�a' e�......- .. _C.�a!-1;--vr1� ............' °-��C� gr-0,14 '� �U�vti� � Goo' i h_ '11 Nature of Repairs or Alterations—Answer when applicable r -V--- Ct�� P l-:� ............. .__, IC ............................................................. ------•. Agreement: /2The undersigned agrees to install a oredescribed di ideal Sewage Disposal System in accordance with the &ovisions of T I T LZ 5 of the State Sanitary Code The undersigned urther agrees not to place the system in oper�ition until a Certificate of Compliance has been d by the ealth. I Signed..... // ?IK /a;e �!. ......�.... APPil.ication Approved BY - �. ..:..,'� 2 ------•---••-- � L . . I` z. /D Application Disapproved for the following reasons:.... . ......... •••-..................................................................................... M� .................................................•-••----._.......------.........---•--------•--------•-----•"------------------•...-•--••••---•••••------_..._... ._ --.--Date Permit No.....q. In (P', ... Issued.. ............................ � ... ......... ate r.l.. .. y THE COMMONWEALTH OF MASSACHUSETTS BOARD OP—HEALTH ,.............................................. (irrfif tiab of ( vm11ftr.ttrtrr T----S I TO CER IFY, That the Individual Sewage Disposal System constructed ( <r Repaired ( ) by -- .:+��............�✓s.......f-"-•.................•--------•------ ------......---•- ....................... E at d, _✓h s has lbeen installed in accordance with the provisions of TITI!fcf5-O'oTh&,State Sanitary Code as described in the � application lication for Disposal Works Construction Permit No......................................... dated__..._x....................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A:GUARANTEE THAT THE K SYSTEM WILL FUNCTION SATISFACTORY.DATE......................ir �a Insector.. � F r ........................................... .. -h..... --�,m.. ----- - _..�1 i — THE COMMONWEALTH OF.MASSACHUSETTS BOARD OF HEALTH N ^,VD v ..OF............................................. ...................................... Nd, --........ FEE........................ Disposal Works notrttrtiun rrutit �/ L•,� c,ai✓ Permission is,hereby gra>i ted-•-----------------�..-----------•--.....-----•--•--------------•--------•---•--/-..........-----•--- to Construct ( o 7pair ( ) a V/ dual SewaKe Disposal Sys ����'fd✓ *, .- at .Vo.......... •=••-•--•---•---•--------------•-••-••---, •-•-� --•-- ---•----- •-•-----•----------------------•-----------•--•----•-- {� Construction Per Street as shown on the application for Disposal Works mit t ----- Dated------------------I_....-.---•........ .. . �- ..----•••-•........ Board of Health DATE...................... ! ----.. . ti tFLOCATION SEWAGE PERMIT NO. Y ILAGE C F,i �,c �2 INST LE 'S c. E ADDRESS k:�5 a- s P 9 U I L D E R OR OWNER DATE PERMIT ISSUED `-0 -1 � DATE COMPLIANCE ISSUED - t rrKf+rvT .�Y�ST/Y1l'Fw'Sl6wl d�n9r ,�x4i��LEACNIN6 �cigFNa`�-� .� Sri Zt4F_T r , N SEPTIC,TANK — _ „D,.BOX,-- LEACH r {:= TOP OF'FDN s ✓ ' - .FO(.�� . i (MSL)eOw1[r/6 .AaJ UwnSu,T/kPyl$ t+efFCLZtTryti. �1.teraileFf�Y6D 2 OF!rsTO4s /' �F' xLP X WASHED STONE fF C i ♦i' ,�• • • V•tI-YjirM IA �fM-. ia'Ac.sf.,t'G C3wsT'IC•�' �.E.o.C..M A.R;.E�^• A••w.alf' ,�,_, ,l`µ G.l.e:'A4s.J i C[�Ao2,Jeitr, -SAub• _.•--.. \ '.,;t f ., oe Ao i !N- _ s' OUT, _.{j, � •.dr �x / IN= SEF J61 ®r -TAN1"'yl. "'7 til..C«is�:</'., Ccs •'�...(. ,� ., 3y.':,i. ., ' I p ✓p, ELEV, ELEV ELEV. ELEV.N, 61 y ELEV. ELEV. ` 4 — Q.p,:.ir+ Ayfid!/\. i y^j� — +)F{f % 2 �� (� 4 •--- OF 3'a.r. IHz WASHED STONE . ' BEST,:MOLE LOG _ . t L: E•-CL_F Y ' •'r40..111a41 13,�2ot TA►Cyi4 + ! = 2� �:` E ; .�'� yi ti` µye TEST BY . x WFTNE$ (- ` TEST DATE �I ` S 'DESIGN' BEDROOM HOUSE r' —_ ' or , ELEV.'EV. GfJ` EL1V. IOT '' ". PERC DISPOSER DISPOSER !p ! . - RATE � MIN/IN.. t� .l� `4'' FLOW RATE 336 (GAL./DAY.) r .e.•" j 1' Cl''� r•'.� �'i, \"`''' -f r .�, .f «. r j 1 SEPTIC TANK '3�0 11.5)= < �r�v© / ,. ,.,«be`�D° .. rn�•: I,.•e .-+✓v G7CJt� ,�.: `�'n�,..1 � f f �`��r (r ✓� ��+. ''``°,tia,� �� _ �,� �,, Ni D, l RE&O SEPTIC TANK SIZE 1 I LEACH `FACILITY ( f _.,.. 1* '• _ t ;, '..j ;.. [4 '-- EI,4- SIDE WALL,64)C>CG = ZG. , ( S.i,�S ) Q 31.`t.�? G/D. ` BOTTOM' Iz'f/d.� t53•q �o.�3'! G/D. / �� • _ /� \ } T O~T A L \' {> USE:, pG LEACHING I I - - t4A'I-'�.._ 'tl.•y.�. _ l�1-' e'� c �.�-. 'rt l,' .:r �j"�'�• S? >�i � - �. _ _ WAT f4 E �OIMNTE ED, _E C NOTES (UNLESS" OTHERWISE NOTED) _._.__-�..__QUAORAIVGtE MAP !' 1.DATUM(MSG)+TAKEN FROM.-•-•--- _, tt♦ 2.MUNICI PAL WATER .._- 15_---___-,_-_.............:AVAIL-ABLE �. dr Rl 3.PIPE PITCH:.44"PER POOT. i � �.p '4 DESIGN"LOADING'FOR ALL PRE-CAST UNITS:AASHO• •44 �' �. I ` S.MIN.GRbUND CO VER.OVEil LL SEWAGE FACILITIES (1),FT. � ��?(� �/� � A,RNE H. DISTANCE AS CERTIFIED'- r 6,3016E JOINTS SHALL BE MADE,WATEA T GHT I{, �+� OJALA• 17.CONSTRUCTION DETAILSTO•BE ACCORDANCE WITH COMM:OF MASS. "r C OSA�:AtvlL` y r SITE, ' •PL:AN; r STATE ENVIRONMENTAL COOS TITLE'S, ` y2g3Gg [yq, p7$2 / _ k Gi LO uS. �T •6 r .. su Ed.PROF. R /. REF:`G«©"E' L` � j 4� 7i.GC � -s • - I � = '. � , _ .. •'' p PtiEPAR . . . . . . � _ '•a{!ow�r� cape en,�i�ee�r�g� o :r f1 fi L ENGkNE€RS ,•, , r k (� -- _ ". ♦..• ' � 1 _ .%. __.. ' -•^" � '•.«•r—« 1..�,y l-` '""-' fat;;,- BOARDOFHEALTH RE LANDSU'RVEYOR `. �' �+Z.� �LJ to a2d"Yt�f1�$t.' SDALF '• �. .. . (EXISTING) - -• - - .G"+�R.r!�! ` �'`It .. ..4.�.. - - �,'c" 'CONTOURS A1?PROVED DATE N)A x + ` , RR POSED)—O O- -0- 4 I3AFE s.0 ( O t « . - + d DEEP I,xr P �. � , , , � . „.: . , : :,.,m•.CALCULA"IO GENERAL NOTES then A) Neither drtrtmay nor parlors ar +� are allowoe ` pop ,»------- T�sB Nola th From ,ail Horizon Soil Texture Sall Color Soil Mottling 4 �2 Fxastlrsg Contour a� � t (USDA) (munselI) (5trucfur@, i ` �' over ss tiG stony a na' o t9- Q components are raged. 2. p ed Ccrnlau01 r utniier Sur fate inches) � . - w~» ._ ., ,�. �. ., p --.--� bra or fancy, an y,%GrNi s- � .. .. �.». ` )The easi nor will not be responsible for the% stern+ � u ii ++ , .. fancy,%Grcvei ) -w.,...�, ..w�. '� r � 2�x� E�lstln� '�p��s! Grade •�s� os eesignae unions constructer' ens shown,Any chonoms Proposed Spot Grade O , CF �al.t. T -- �_ - -- G Basis cat Design ,{ rh?ill be ea roved in wrltint,. T�l �l•(,.�� � .. .. 1' ?�?� tawtd? � ... ....., .... ...:. ..� .,.. "t. e" Contractor IWI kto responsible jQr rerlt n the ` Water' service .. .. .. • fit? t'�. 'umber mf edro 1s �) p � g ---.•,ahu-._.•, Ovorhead Utility ( ) r__ Lino ar -� warcu� L. I.7' ( $i� r i tarottian o4'all und,arn�raund and rertae d ulilltloo --� u Undorground Utility Line(s) � ` � ��G,e•t� Now" MV .� ,nt _ prier rrar nt of rror"�, ►tt. Geri Lino ,� to aearnrnenr e _ ? ' DY 'j a�;Mi �, ».. -.. .)Design Daily Sewage Flow, �° !. ,~ � 1 l-L � Tit Test hole and/or ftearinq Location ._ N .M✓ir L+'4,•w 'S• J� .. .....M. , .. .r. .. ,. «. r 1. .. & $ �. w ?�� � �l N^e�'�m.O d'� _ .7/ it 1 tai CBS Required,ioyn ° � p GCS. m T. ate. -z: m rta^�ide,dI .... ' ..., 5. '��� .0 istrc 'aan_ Wi �, + +"� "\ � O.S.Ca.F3 �Istrlbutton fox , i4 _ 5al�??', t��a�+ ✓ .. ... . . . 4.)S011 Absorption ystf�m C�PncitY �� � f ��� �.r�.�. Soil Absorption ���ro�, . . a< ma t ., CRD, r r KEY MAP n® scct6f� _ (✓�' _ _... .C! 4.rw.J ' Io %$ �? _ Feat - ? ; Cs�+«�sht �/ lo�. eaA®r+rp�t for 5ystenn wig cry . t FtoVle° -. «:. ,• �* »__ � p 1'u"', � Utility polo .,....�..-. ! ` L1✓ ll S C�-ear . `� i cr- c . Catch 8�tsin Plan Moak .. -..... 1oaft.. M>t LOY4 > A 45y,10 L IA i,ir, iK l l,i 4 _ :_- S ti _. ' . ?Y I�m ' . , . °. .. . . .. .... .. ... ..... ..... . .. . . . ... s• , ; wS A . i F'i Fy drone d oak `7oa n ?" .. '"..... ...Gr..1#5. .. . . . lwr .. Y '� V g 45x its 3'.74 6MIA1 t;C .- �g rs Dead Peg .....m7...... -� C 1 7 w1d+ ~rsa+ Well J w> . tx� ,. . ►,�� R '. _ ... . rr s� o,' _ . ._... m? � � �" � ` ✓1�r �slr�sar� t�ap,��'.Pe�rce@• l�c�.., .... �' pascal i ......., p+�rmItr id w/t',Vn df,.,19n, i 11•i use Soil Class ..�. . atatis ® _ _ Test . ..... . .' -Z'7-`�7 - PLAKP, (L �► t Y1=l� ` . /'� pore. rote at iess than iaet'COAOfIOCI fat@ L" .4�' ! !^l.r-a1. a►l Min./in. for a loadine� rote of W i:'76XUA )If Iiv� 1� , , , Ci LAY S . . •7' ,GI'C I3 f. / --- �s— Witnessed by — J r IOW Cat, MAX. 6 VA z t ' - xr n►a c c� Top of Foun4vtion � •�' .�., �, { __�._ ,.�°'�' � '' •-�,�" ' ''�.- s''' � '� .� �`� - Elravoti4n ..,t .0 t rade - Finish Gr®de_ _ ..... ... _ -- Finish G ----- �- ®777X- 0-7 .- �., - w R 36 max. i�,l.J*r "1'KC g"min. ��," nnox, I �• -. \ � �' r #love tine �� e- _, .. ''` „». _ �h m, ex. \ ~ 's:.. to"'resin, i4M I e. .;l'. t F :.", ' .. ` ` ' �, i. y`"`a..,.» ....""` .-',y �.. /,,. 1 ''�'.. °•,r —•�. 4" , 6.7 m , ..�.; � . (�l CIS p�^y Y,/ '°°a � � '� .;: ,,g�.sw�.ise.A'L"'"�:!� u-.,..r:,..,.y,�,y�- > ,. ��} '� ........,•., �i 4 icy� "�° r/ ,�° � . �• � � �w*—off -�' � � 'yC Gal Se iJistnbdon Boma 1 �- �».......... Septic Tangy � � + .....L", �:,��'. �1.,�„� ('�? � ''� "�'". - �.�''� � ter' 1 ,� • � - " l rj CAL s ! p,+ 9,�a � )j/�//.� �/''`vCUL- �{1, JAI' IA:a'fw7S:^s5t.pf'^.'�`rr4.RT.'tl7GY x,.t.✓SAs•,.Fn ";� � !to- � ,es �• •4 E, �. - t 6- :" � - "� O TI ONOTES >~. � ;roz¢� � r J ..� _4 f9rtw `ice W. , A�RJ 0�. � � Tb� �/ tw)All eas�+etrur�tlan atPaall q�+nftararn to tt�o a la) Faso raggrsQot® for isach�tg facility slsoil I�A.� C tol coo,'111% 5, and the resgWromonts of consist rat V, 4 to i•i/� double washed starse trod � l4 r (. .r ttbe loyal Board of th. at Iran, fines and duet and shelf lees Installed from e � & sate crown of that elistrlbu"Ion line to a bottom d � �` � T"V-' _,U( " 1 ° �' �� w It);.baptlo took(s), trap(s),dosing chomber(s)� Asia h c i�� �� �'�� lt� �Ll. � �. � «�`� �. � � `� _ �� of rhs sratf ahr rptiar, system Aso aggrsgate shall �". _` .. �;f . attd d�etribution baet shall be set eat a level sto to with °°to er of lib` to Ii "loss? le " s t6 UG"I 1-0 DPAIL W.- 1", '�"i-•�",� ��'•)w;"� # � „ �10 �, � � m .tOHN I1. be covered a ys + �' ` rai t� a ptteewtotch has been ate► er0tlg osarn; , od, Qr on wosahod stone free of Iron fines and east. 0.) I> E e� )"'lT fi � tt °� � 1Fs � � � � _y. _..l'r.tl ��, ,"� rIi irnop rhrul►ed otear►ea boeall. ¢ < 4att„Ir tw: �t1 �' TF T Ii.) Vent soil absorption system why, distribution ���- . -iISE ` �i�l "� � gyp' ', �,. : " '� � ; .•t a° t- 3.)t)tiepNo tank(s) shall meet ASTld standard C Idnss axcooe4 �C feet, taon leaa�oet oith�r In his �l"�Gt.�t T" � "'i � � A ar ,a � � fir^ s� � �PL gip. g/ y '+ 'aM1.✓ re,,.. �ere.w. > .- /.°' ! �6.^'�llr.w e r' gj , � , p W y� a, It27,_03 atnd shall have at least t/arte �? rliorn�isr or In port under e3rlra�sr�ays, perking, turning srocta, � $P' � The �,lnitrauaa from the be of IC#��' ,�,' t �L 16 :•; � '� M'a 49e� a at other lm ervious material or when dosAd. Impervious ' r to k t+o f low Ilne %%a I I b e 1`�� f � m � � Gal �_.�t� ynrmr'a�uw.w,�w,:mzaurrT�cm�w!.�r�wc.., �Tt it.)Sean e+b arpticrn s sea n a call lag ca"rsrar with a " 4 1 r."a t �-'s° r r' rv"-*N"6r- `'0 . fi '-�a +tj.) lbeedatie 40 Pelt;inlet and outlet tees shall �) minimum at 9,of clean mo ven%and (excluditbrf � s -� � �t�P�l2. � � �I* �'- 6 1� y� �i �ji��(. �. eatteet►di a tg►lorirnaarra► of 41"abiks ttte floes tine of theL L cal li :... wm •,•' -,.- = m ,. topsail) w _ -T�4i� "..t", i •15��6 /�p Y sook tarok and eh+gtl bps Installed an ttre cean�orline of #Ati.,t directly u th's sleeneaut mon%olos. 13,)finish grade stall be a ra+o�s+rnum of Sf,° aMor 41ae , � . � P ��) + 4:mI . 1 "!( » �It toop a,+wdr Otorm a*may cr"Ote t oludi this rto fog � I .. 531talee Drivers of the sept'Ic tank en'd d1stributlon t inn ~' . �''� T ip >"�' �� I,� ��'s, ° t� i °�.,�,. :� 0. t,-CT M D 0F°96a r-t,ow distribution bosom dosin chomw end soil aksorpt . a ° '"° r ' bps �tlth pro-cast concr®to Ksator tight risers oMsr � ' Sala�.,',� ;.. !. .. / l �`�'�_ � p f • s \ 6 lea' xactlo. system. .l�stic tanks shall laea+ra a minimum ce m 5. •�. 4D ( -r ,. ° t'd�,Wk tea/ .! �4t� � � Via°-,�"' igtet and otrtlot tea>tal! to "tttein iffi i•of finish h of �" rye' atc� a � Diet �•schedukt • Ci PVC 0r y a is t l .+rw 'w � !^t TA41 ��; � .,1�1�� I coed of e v isnt. Pt shslll la+s tale 0n a tatintraum 14.) From the data art Installation of tts+t soil ?�-'�� V �+,()b.�,� �� •- �t't ., � r. y ... . e b b m:° a� to a� PC. ... y �, o 0) e � at>orptlan system until rscealpt of ra C+trtifie;aate oC' _ rJ�"1`i"t„,b,'ta"t . ; � i ,. m trodal of net loss then I .. + t '" +;. """ m �,l � ! � . rr c C-offollance, the perimeter of the s;I obnorla ion ! a '"%Ab. 1 ' SYSTEM " i " x1DistribWlon 4lotee ter $011 d pt sreten► eyetoata shall a staked and .fPeas lee! Ira pre very! 9tae /fie pyw� 'TI ,e / p� aka ,, r: a g p r Vl ll,,.. c A'dr�Srw,y�'"«' & 4 R"5 +. .. a y*� 'fi F°�u ..,r w; ,^' b:", me' I E •d' 'a'�'n ^' i++4iw Y ' '� }.;+J es t lA ialhall bey 4"diameter haR+ tlto � PVC u Y t �f�.� � �, � ���� � �t f. t' �k��� Ts "a �- -�, � ." C aQ ) 0 use of such area for all a��taa!ities which rnlgl� V (old of 0.006 ft.M. Line shall be e ppod at domoge the system. � � • ," .9'2v':.RG.•m'"*ti,.�" 6'•";A° �, ,rho�'am v�r Iwo 1��, Y"m^ 4 �m '. $+ •Wr '�y ''• wail of, s Owed. r r 15.) The 9ootd of Hoolth -shall require Insloection of � �r - ill i. �+ e a" E d 0'REILLY, n0. llee I eo from -boat shall rerhoIM tevral for at S t f + l , x , ,. )"4e' t " . . it.1 tea f tt P r D all construction by seat f o the ward e a �'• ' ,�.�$ �„ .� � s I�?� �• .,r � ., . , •' � � a,�zn;�tticcrhts: tt�rauaaarratei . *Mars "• . tern. L 1 � a b-� ��wS,.' p " ' 4vn $ • pp toot bei`are feltotrMp to swell a pt10n sys (or the deoll raer If this t+yotgrn requires a +ra•loraccea) etnr� .� , , � ,r„, r r �. ,. ri.a w., A ", tom 1r ¢, 1tlataAt tipant D-box to asoarre str dIe'trlba�tleae+. ` rat re salvo .�u rim, �^ �' � person � rtlf� Insarttl �: all ` . ;. ,« $ d . r P.O. Box 1667 �► 0-ba + i he" a Ahtwoly at sump of eft sawrod mark beaota arafrleteat In vela selt�h a � s � �� �, p tlyw rsree►l r p i n: 1M r o a. �° ..�w ^ ) ® � y , ° ?t�seg5•bt':ttt OfrXt 9"ster. A 02631 t one app ovf6d,� � s. 4p hod 4 +d 4�� „ ' � �� .e ; ; e .A Er�'�•�. �es� 8�1�� ,rt `l .� � ul�' g If* 001st Invert. ;• v,r t . e, a. roe ce requa*W.., `� . 'F% t� eJw ,.• " _ . : ..:•, „^ ..�.- 2? r .r 'r � , ., :«w.. �;�• �""" a '+ '� ��. .. �lam. `�� ` -•-�� ___fit_ DEEP Test Hole OBSERVATION HOLE LOG SYSTEM DESIGN CALCULATIONS GENERAL NOTES LEGEND Kl d Depth From Soil Horizon Soil Texture Soil Color Soil Mottling Other A) Neither driveway nor parking areas are allowed �� �ks - Existing Contour Number Surface(inches) (USDA) (munsel1) (Struc`ture, over septic system unless H-20 components are used. 3, t,° 3 stones,Consis SYSTEM DESIGN CALCULATIONS -- Proposed cant 4 tency,%Grave l -- B) The designer will not be responsible for the system 24 x G, Existing Spot Grade e CIF t 1�<- _ __- o as designed unless constructed as shown Any changes Proposed Spot Grade 41 ,1> ____. T131 �* _--- ___.i -- -- ;,a�pY (oAAt1 lo7 5,( 0 �-- L) BaSIS of Design shall be approved In writing .... ._....-...._A --- w m •• ••• •- � - ( Water Service 4 - coo C1 loy►2 ��� r, _ M�iut1 Number of Bedrooms _ _ -_ C)Contractorshall be responsible for verifying the ---ohu Overhead Utility Llne(s) a! � wArre cp J-_L= Z.7: o _ Other location of all underground and overhead utilities - -- u - Underground Utility Line(s) ►� r�y� �'t~ACN _ __. - -- �_�_ . _ Tt,Z EL- 4,P)r q.:..aJ . . . . . .. ... _ _ . .. _�A+�DY !�ArR.- .� "_.. .....°, _ :___.�,._ .. 2.)Design Daily Sewage Flow= G.P.D. prior to commencement r L� i - �4c� r e tot wok ��, �' •- q Gas Line 9 loo t- <+A►.11. IoYR 7f� a i M€g �� ~'-�' N-•';h'- " �-- H. Test Hole and/or Boring Location .. - WptJ•- � T ems ,• $ --- - 3.)Septic Tank Capacity Required; .......6.t5c.:.. Gal. T �� %�'� ST. Septic Tank a A Lo,�Mv r? l6Y!' 4/4 I a Provided., lam?. _ Gal. C D� , „� Distribution Box 5.-. !4. . �.. . .... . Via.°T. LdAt^. . .... .. .- .`�!�.. .- `' - .._.. I 4.)Soil Absorption System Capacity V _ „`' ''S A S Soil; Absorption System �� � Q "' t� - a ci �j� IoYz bi a riv `�#40 � - wt)( � KEY MAP no scale ' G e 2G r ; 4 �- Requiredi ----. .. . GPD. Res Reserved for System Provided ._...�3.'?... . GPD. Flt�tti -AJY•� c I -PAC o utility Pole 6 - _o A L_oA IAY .eA►kD 10Y4. -/z �,... '^i Plan Book ��- ' T 5r8 - -- '�5k 10 LEAc"I"', FIELD GALL L�404 , CLEF[-eit�'•�L- �G ® Catch BasinPage GPD DEC __A OFIi 'Q' Fire Hydrant Deed Book 57vo Page..,Z')'7 _6--4Zz. c t hA11D Ioyp_ 4/to o VT _ �45xto X,?4 /SF 33 c4PI' 9 WATi"' L. + 4 3o FCK VAUr o►► Well H 5.)A Garbage Disposal is '.permitted w/th+,9 design, i,�. KAM� _ - r O� Assessors Map.z .Parcel..`�.. Q ---- Cv. Soo .�A L t PUMP C W ANC�E:Q w EFF. Date of Test 3-.Z7- 17 use soli " Icss ..� wltn c Mtu pare. rate of less than PUMP �USI- MYI'� 1�/1-12 /t N� �',-a4 ! Percolation Rate Z.-Z ll IN �" v-4 ; �I LAYEIk:S .... .... Min./in. for a load,ng rate of ce FauAL), *� ALAV_K .GPD /s f. PUMP Witnessed by M . FAeaEu- +- { ` '•. ' Ito ! (,!'�l t l� l�TAt Lt` Bo►1 A1;1TU 5TTA'W r - �`_--�` _ Z•� s" FLOW P 0 ! Est. K4, 60Dt 4DVAT� EL Top of Foundations s'+ �i\ ► -- J�` ��{,� \/ iE t �5 Elevation= . , ! +. Iv.o FL= IO.0 Finish Grade= 7_ Finish Grade 3n Mta - -- O36 �� t► mox. \ 9"min. IULL i ZEE +.1 ! I \ o ��k =_ti'!"<5 6 36 max. flow-- line � ' - 10„min. 14„ U gas baffle ............ Gal. Septic Tank Distribution Box �r ��� 2. ) 2 tl �, : . .� ,d: ��• �! , 51 CONSTRUCTION NOTES ` ��i y� � I 8 :4 tM� �La Virz L) All construction shall conform to the State 10.) Base aggregate for Teaching facility shall I(o) F}(t�Tl►�(a LE.�C� 11.1G FlLZ7 TG� t3E ,dt3Q�lt .tEc�. . .� - MELD �� _ y Environmental Code, Title 5, and the requirements of consist of 3/4" to I-1/2" double washed stone free -roc UEA ,j,w l_ i 1�fEl Ae, A FUTLA ZE. a" '' A REVISED PLAN the local Board of Health. e �� u,l� � _ / THIS IS of iron, fines and dust and shall be installed from c - � // o _ +I f., _ below the crown of the distribution line to the bottom �`,, x� ' '� `r C• my 2.) Septic tank(s),grease irap(s),dosing chomber(s), 17� TKE FyfZG� M>d1�1 11� LL Cz Z Lid � N /G /al1i c e W- •� 'S• REV. DAT E•�/ ( C f ' of the soil absorption s stem Base aggregate shal I f E:L_ �� S:. and distribution box(es) shall be sat ono level stable P y5.�0 +<•;� ... bass which has been mechanically compacted, or on a t be covered with a 2"layer of ;/g" to 1/2"double EF 6D0t 7ZucTiTU To DFAIJ F-AC TO -n-t1_ C1l1A t.ei e. Zx4 o b a 8` v t,�v : DISCARD ALL PRIOR PLANS washed stone free of iron fines and dust I8, TWE PUMP' TO PJE 4 MY97r�. WHIZ 5 (y2. "P) O _.__t__ Rl�'�•'S3 6 Inch crushed stone base. ) try No._ +10 11.) Vent soil absorption system when distribution d�. �E ALAM PAL _ �JE 'MEC> TO A :. IFP.4�TC ,F 1L ;�� �c 3.) Septic and shy shall meet least t standard G � lines exceed 50 feet, when located either In whole 1'lRCtdl'r T1.�d1,.1, 'T1-IE jj,(c�F'. �,1-t�tZf"� ;�1-11�1_L G�.'��,,,�1`:T f..s`F' /'� �Q� T1-..r�t� ,\'­�;rc� - ,•„- LAQ t127-93 and shall have of least three 20'diometer (,. L't I manholes. The minimum depth from the bottom of or t part under driveways, parking, turning areas � pgv wAvzh;It,16 ( IGw-r wl AL� Di 15L IF e_ELL t�p LC' `or other impervious material, �r when dosed ` septic tank to the flow line shall be 48'� lot•\ �O��L�A.(C� �E 12.)Soil absorption JJ p system shaft be covered with o � � � -"� .. � `.x-+`ilk � = ZO 4.) Schedule 40 PVC inlet and outlet tees shall DAMP C4f` eL;'F-' ; UFL1r7 = c)84a * t (�RAYtDED. I�rfeCx� � ���� _ extend a minimum of 6"above the flow line of the minimum of 9"of clean medium sand (excluding s _ VAir1A " R��(,�� "�` ` F04W S CAL.C 'D 0Q 177,1P Y •T4► L ►.10 c,:vca � C� utGFl \n/aTti iZ �: - � I septic tank and shall be installed on the centerline topsoil ) i DESIG!'41NI� ENGINEER MIJST QCIP5RW'1SE Aw�La�, i 5Z127/Ep E Y of the tank direct) under the clean out manholes. t �Edf�li3LC CAKPL.1Aa10E r ca' ill_ R�MDYIIL: � I`dST6�L�AT"SON AND CERTIFY IN �'�`�=i319�G y i3.1 Finish geode shall be a maximum of 36" over the � � THE SYSTEM WAS INSTALLED IN S"I-tR!� wA�- top of all system components including the septic tank �Y`- 1- ` ��t L- I, t 6) ��ALL O� F-EmcVop �o0 d �10 GMT 1`�tZC��j - Fll�b+l: 5.)Raise covers of the septic tank and distribution , + I � i ACCOFWANCE TO PLAN, box with pre-cost concrete water tight risers over distribution box,dosing chamber and soil absorption >ytc�c Afkiz OF 6/ -Q_ A" (,_IMITICI) �Y P{�DPrrt� Ty .;LJE r�{Z"i..lp 1} 6,46• !)OE--,, Lei- MEET �\D (�1w5(�� F(1�w system Septic tanks shall have a minimum cover } ? /eTla } Inlet and outlet tees to within 6'of finish grade, <�,A,�j, ADO DOWA/0 To T4-f�. MCDIUK '✓At._1D �t� 'f'zr- AOc, ,,, Of 9 '. �• PROJECT � � 6.) Piping shall consist of 4" schedule 40 PVC or DE GiE�� y�v C_LF_Ar..( __Ali?) ( oOMPACTV7I~ To 141"tMlgl / �/ _���� � 14.) From the date of installation of the soil t ��-2? OLt�Mwli la CI PI �►1-}� Zy;� F � (�,� ,16 equivalent. Pipe shall be bid on a minimum jT( i,1"(EJ.�j, Z) 6As, 1°� 110T )o of PIZOPIZZTY V41? REQD) continuous grade of not less than I %. aborption system until receipt of o Certificate of = Compliance, the perimeter of the soil absorption N RIMP �w 1�_i2 T� f:.r.� MAW,-_ /.4-'P kL776kT-.. PumpTITLE 7.) Distribution lines for soil absorption system system shall be staked and flagged to prevent the 3) `�•as 1�, + Zo eta�le ( �' vas. ) _ SEWAGE DISPOSAL SYSTEM (as req'd) shall be 4"diameter schedule 40 PVC use of such area for all activities which might AIL'{' G\�CL� 4 71Pf;��� A LA y w� A Io•�r Djc 110 Gv4L. � � g S,t1.5. 'Dn , I.IoT MEET APPC t�T.(WALL f'Cc>�Ft Eft,=` I d (�'1-�'' 1�<'r E_Xl STl*5,�, FA(C-FD L F-Af kA j laid of 0.005 ft./ft. Line shall be capped of damage the system. - ---.-- i � "�L� �, i� �7 cp �� WEZV4�D /Z�, VAlZ 2� p � • end or ds noted. Le>r -440VLt nor l5 BENNETT O'REILLY, Inc. 15.) The Board of Health shall require inspection of c � { , LoT 4 s`✓ DE►tr- �Ir~D 8.) Outlet pipes from D-boz shall remain level for at all construction by on agent-of the Board of Health T1it11� IL, ►.lbT to F 0 (�ZbP, ( a Y4Q aE p --- - C1 i�.4►1 ��Z I�5 Engineering 8; Environmental 5rrvices O least 2 feet before pitching to soil absorption system. (or the designer if this system requires a variance) and �'� d - �. 7,) 6Fj�7x TAk./tc f`� ;.(aT 4b! Q��. CELl.4iZ C V/�Q. 017 Water test D-box to assure even distribution. may require such person to certify in writing that oil � . 1 c ii G ` 9.) D-box shall have a minimum sum of 6"measured work has been completed in accordance with the terms 1'` '' I it r 8� Undrrpas� Rued P \ `_ `.. i �c}c �: .,10 CMV- 15. 2 Q, CR� Ca P..cu,'tDU/4-i •12: of the ermit and approved plans 4g hours advance t 4`if411t,1 ' P.O. Box 1667 a below the outlet invert. P PP I l;,d. a, Ic,� w(TIJI&,I pCU• OF W+£'�tA.+>,1� nH-Hy6 6630 Office Brewster, MA 02631 i08-R96 3687 hex Q notice requested. � \ ,� , � - � � J -- i r j V4kiA0ctr. .e.EQI> DATE y SCALE BY CHECK: JOB NUMBER: W + L 7 ti