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0019 SUNRISE ROAD - Health
i 9 Sunrise Road Centerville A=251 — 108 Snu *,,OCYC(E'DC Z� UPC 10259 No. H_ 163OR HASTINGS MN TOWN OF BARNSTABLE LOCATION ff"-2 SEWAGE # O®J"7reo' VILLAGE � ASSESSOR'S MAP & LOT—A"/ ®� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER G O'i�—'lf--4 PERMITDATE: v Q COMPLIANCE DATE: � �� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) % Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i "„ �Ci°'4�®C•°G/� i �� �� G ��o � � � � ��" �I � � �� �� � � ��� � �, �' � 9 ���� � � �a No.0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for 0i5po5ar *p!tem Com6truction Verntit Application for a Permit to Construct( . )Repair( grade( Abandon( ) ❑Complete System El Individual Components Location Address or Lot No./$? ,,, ,0 /jer ;� �"// Owner's Name,Address and Tel.No. Assessor's Map/Parcel CP Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. .g ,412 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ��`P No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flower gallons per day. Calculated daily flow -�© gallons. Plan Dater$--®r, Number of sheets 1 Revision Date Title Size of Septic Tank ><i J';rI AI o�eaa (9!$� Type of S.A.S. vZ Description of Soil_ s-Q_V_ ��� Nature of Repairs or Alterations(Answer when applicable) .Q Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y th' Bo d of Health. Q�Q Sign Date �.. Application Approved by Date Application Disapproved for the following reasons Permit No. J� `J Date Issued C� Na. /5 ( ';1s.. -F Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for ;Digpooal bpotem Cott!5truction Permit, Application for a Permit to Construct( . )Repair( LfUpgrade(, Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.,/f fWAo55. /_rK ^0 Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. aN7� S Type of Building: Dwelling No.of Bedrooms 'Z' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Ot**4 J' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �jC;, gallons. Plan Date_ _S�'�•- /9�-d� Number of sheets .0' Revision Date Title. Size of Septic Tank �`.�Ci�J'T�/1t�9 �G'O'O 4)4� mType of S.A,S. "�� C ,'r(�� Description of Soil v Nature of Repairs or Alterations(Answer when applicable) 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system ' in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi=i cate of Compliance has been issue y th' Board of Health. Sig ed 2 Date Application Approved b n Date C/ Application Disapproved for the following reasons Permit No. r 00 5 Date Issued � THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS T^CERTIFY, that the On-site Sev,,agc Disposal Systcra_Constructed Repaired l i P( aired I ~7"jogrQdvd )tt Abandoned( )by Cf'�-/79 .��G�'/,.►',��F 0 at / SG J+� ocol�j'� r.,o Ce o-,, has been constructed in ac/cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. >y 5 a 5,r dated 9.1. 0 Iy 5 Installer J107 „ 114�40 E101 " Designer� �.�i4�AA??Y The issuance of this permit sha not be construed as a guarantee that the s, ate 1i'1:-(function as designed. Date 41/t,I n S Inspector � No. c-�--� � � .ill --------------------------Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi5poe;al *pgtem Con.5tructon permit Permission is hereby granted to Construct( )Repair(&1fjpgrade(Abandon( ) System located at f .f'G� �,l"� -4'�Q C t�"�-✓7. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction in t be completed within three years of the date of this p..rtnit. Date: ` cJ Approvd�by 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, 12 ,hereby certify that the engineered plan signed by me dated Q� ,concerning the property located at �(IACmeets. all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The,bottom of the proposed leaching facility will-be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) O B) G.W.Elevation +adjustment for high G.W. DIFFERENCDBEN and B SIGNED : DATE: Z Z (J NOTICE Based upon the above information, a repair permit will be issued for —3 bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. q ASeptic\percexemp.doc L 1 aWn•Oi narnstabte Regulatory Services s Thomas a�aasrsst,e• • F. Geller,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyanhis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 411 Or Designer: 1>' � ��• Installer: Address: Po. 601c �� 3 Address: �/ �c"� '" On was issued a permit to install a (date) (installer) septic system at 19 JtJNeIu'r ,OO • D,r11�� based on a design drawn by )(address) dated (designer} I certify that the septic system referenced above was installed substantially according to the design, wfach may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. DAVID (Installer's Signature) 0 D.FLAHERTY, JR,m' No. 1211 Ap�G/STEREO v& "NITAR�Pa (Designer's gna ) (Affix Desi amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY T1EiE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form FAILED INSPECTION �l `2- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTA �� P OR TECT[ON� u��T _ iAAP NOV 0 8 2004 PAKEL,, 1 Of ) TOWN OF BARNSTABLE LOT 18 HEATH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 19 Sunrise Road Centerville,MA 02632 Owner's Name: Paul Lorrain Owner's Address: Date of Inspection: October 20, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford E Mailing Address: P.O.Box 49 =' OsterviUe.MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT = I certify that I have personally inspected the sewage disposal system at this address and that the'informationreported below is true,accurate and complete as of the time of the inspection. The inspection was perform�d based_on my;-- training and experience in the proper function and maintenance of on site sewage disposal systems. I A*DEP6tD approved system inspector pursuant to Section 15.340 of Title 5(310 CAM 15.000). The sys em: rq, C Passes Conditionally Passes Need urther Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: October 21, 2004 The system inspector sh\sut 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: 19 Sunrise Road Centerville,MA Owner: Paul Lorrain Date of Inspection: October 20, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Sunrise Road Centerville, AM Owner: Paul Lorrain Date of Inspection: October 20, 2004 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 CNIR 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) Property Address: 19 Sunrise Road Centerville,MA Owner: Paul Lorrain Date of Inspection: October 20, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a.design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 Sunrise Road Centerville, AM Owner: Paul Lorrain Date of Inspection: October 20, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 Sunrise Road Centerville, MA Owner: Paul Lorrain Date of Inspection: October 20. 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 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): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 4 years aQo-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ 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: Approximately 1970s-per owner 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: 19 Sunrise Road Centerville,MA Owner: Paul Lorrain Date of Inspection: October 20, 2004 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: 2' 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: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" 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: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs o 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: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Sunrise Road Centerville, MA Owner: Paul Lorrain Date of Inspection: October 20. 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 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: 19 Sunrise Road Centerville, MA Owner: Paul Lorrain Date of Inspection: October 20, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit had 4'ofliguid on the bottom. The scum line was up to the top and solids were above the pipe The pit showed signs ofpast failure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan). Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Sunrise Road Centerville, AM Owner: Paul Lorrain Date of Inspection: October 20. 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Q � l 6 o a r 3olal 6 a 33 ay 3 3 qa 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Sunrise Road Centerville,MA Owner: Paul Lorrain Date of Inspection: October 20, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- 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:topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ` Using Barnstable topographic and water contours maps the maps were showing approximately 30'+/ to Around water at this site. This report has been prepared and the system inspected and failed 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 1 COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A Y d DEPARTMENT OF ENVIRONMENTAL PROTECTION A F /f a° 5�. David B.Mason,R.S,Certified Title V Inspector,508-833-2177 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 19 Sunrise Road,Centerville,MA Owner's: Precourt Owner's Address: 19 Sunrise Road,Centerville,MA Date of Inspection: May 10,2008 Name of Inspector: (please print)David B.Mason Company Name:—N.A. Mailing Address: 4 Glacier Path East Sandwich,MA 02537 Telephone Number: 508-833-2177 a c -4 CERTIFICATION STATEMENT .f 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 Pia r- training and experience in the proper function and maintenance of on site sewage disposal systems. I am arDEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The si m: �' > X_ Passes - } _Conditionally Passes w 7 Needs Further Evaluation by the Local Approving Autho ity C!1 t- Fails C� ca rat 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. Notes and Comments: System as inspected appears to have operated based on occupancy level. Increase in occupancy may cause hydraulic failure.The information as identified represents only the condition of the system on May 10, 2008 11:30 AM. Maintenance pumping is required. ****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: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent..System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titles 5 Tnenartinn Rnrm All 5/)nOA 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 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: The primary cesspool is not a typical configuration for a cesspool. It appears to be a pipe cylinder with an inlet pipe and outlet pipe with tee connected to a pre-cast 4'deepx6'diameter leach pit with stone. Permit on file with the BOH for the pre-cast leach pit. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title;Tncnartinn Fnrm 6/1';0001) 3 Page 4 of 11 PART A CERTIFICATION(continued) Property Address: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or. cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. T1t1P S Tncnartinn Rnrm Ail vMnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ' CHECKLIST Property Address: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X _ Were any of the system components pumped out in the previous two weeks? _X Has the system received normal flows in the previous two week period? _X Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X _ Were all system components,excluding the SAS,located on site. _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X _ Existing information.For example,a plan at the Board of Health. _X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Titles G Tnanr rtinn Rnrm (./1 5/7f f) 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2(per assessors records Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (330 gpd capacity) Number of current residents:_0 Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): 2007: 104,000 gal. 2006: 122,000gal. Sump pump(yes or no):No Last date of occupancy: (current) COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Barnstable Health Department Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: Requires maintenance pumping TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system(2-500 gallon chambers with 4' stone) _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no) (if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 4/21/05 Were sewage odors detected when arriving at the site(yes or no):NO OFFICIAL INSPECTION FORM—NOT 6 FOR VOLUNTARY ASSESSMENTS Title G Tnenarfinn Fnr A/1 VIA N1 f Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 BUILDING SEWER(locate on site plan) Depth below grade: Approximate; 14 Inches Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_NA comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage. SEPTIC TANK: N.A.(locate on site plan) Depth below grade: 8"to riser Material of construction: X_concrete_metal_fiberglass_polyethylene_other(explain)_ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Typical 1000 gallon tank Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 14" Scum thickness: 2.5 inches Distance from top of scum to top of outlet tee or baffle: 15" Distance from bottom of scum to bottom of outlet tee or baffle: 12.5" How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.) Pre-cast outlet tee in good condition,PVC inlet tee in good condition,Effluent level with outlet pipe. GREASE TRAP: N.A. Depth below grade _ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Titles Iq Tnenartinn Form Ail';0000 7 i Page 8 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 TIGHT or HOLDING TANK:—N.A.—(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X_(if present must be opened)(locate on site plan) Depth of liquid level even with outlet invert:liquid level even with outlet pipe 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.): no indication of solids carryover. D-box 12 inches below grade to risers._Effluent is level with outlet pipes. PUMP CHAMBER:,(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title G Tncnartinn Rnr OV1 S/'7000 8 Page 9 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number —X_leaching chambers,number: 2 500 gallon chambers with 4 feet stone. —leaching galleries,number: — leaching trenches,number,length: _leaching fields,number,dimensions_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etch Probed stone area. No sign of hydraulic failure. No damp soil.No excessive vegetation growth.Probing soil around SAS does not indicate ponding or saturated soil. 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 or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N.A._(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Titles S Tnenartinn T:nr A/1 rtl')OM 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: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. W C II REAR B O ❑ DECK E ' 0 El F AD 33' O BD 24' BE 21.6' BF 27' BG 30' CE 29' CF 34' CG 30' Title C Tnenartinn Fnrm (,/1 S/�(lfl(1 10 a Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Sunrise Road,Centerville,MA Owner: Precourt Date of Inspection: May 10,2008 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water_20_feet Please indicate(check)all methods used to determine the high ground water elevation: X_Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain: Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography does not indicate ground water to be within 5 feet of bottom of leaching facility. Utilized groundwater contour map. Titles G Tncnanfinn Pnr All S/')f1M 11 No.... 1 ... Fps... .................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® HE T ........0 F........ ,Nwiration for Dispasal Marks Tons rurtion Vrrufil Application is hereby made for a Permit to Construct ( ) 0. Repair ( ) an Individual Se age Disposal Syst t tion-Addr e 1 C. -- o Lo v VZ Own. Address w Instal er Address Q Type of Building, Size Lot._---? .2.l-d.._._Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a d Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria Other fixtures _______________ ---------- W Design Flow__r.....................�4.._--__ Mons per person per day. Total daily flow............... ___.._...._-_.--__gallons. WSeptic Tank. [ Liquid capacityJ-... _gallons Length................ Width----------...... Diameter---------------- Depth----_----__----. x Disposal Trench—No........ ........... Width_..,_ .. _ Total Length................... Total leaching area---__c�amj-__... sq. ft. Seepage Pit No._____.j___._...... Diameter/.. ...'Depth below inlet...._.-..-._.. Total leaching area_4�__ ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date_------------------------------------- Test Pit No. 1.....2� _minutes per inch Depth of Test Pit.................... Depth to ground water__________-____------._. t� Test Pit No. 2................minutes per inch Depth of Test P• ................... Depth to ground water--______-___-__--__---. ** ------------- -------------------•- ---------------------------------------- 0 Description of Soil ....��1` -• - -------- ------ ------------------------------------------------------------- ------------------------------ x w UNature of Repairs or Alterations—Answer when applicable--------------------------------_...............____________________________1--__---_--_-._----. .....-•----•-•-••--•---•------•------------------------------------------•-------------------------------------•-•---------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sim ----------- . ............................................................. ........- - ................................ Date Application Approved By ,yl 1 /� to ��Date Application Disapproved for the following reasons----------------•-------•--7........................................................................... -•--•-•---------------------------------------------------------------------------------------------------------•--- --•------------------------------------------------------------------------------- Date t PermitNo........................................................ Issued........................................................ Date No.•-- ----- ----- Fiicim.-. ...... ............. .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... � Apptiration for Disposal Works Tonstrnrtinn Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Se age Disposal S st 't V. - j y4#6 ell p t) Loc�ition Addre � ,5 Y ' 's -'fa. ' .,.___ .'cy.. D"e ?', ..................' � - -.f:. _., td,•Address ..,yc ...------.. W I.s Owne v'A'� a PJ Insta)3ei Address U 'Type of Building --- Size Lot_ _ ;._ _s"'+ -----Sq. feet Dwelling 2 No. of Bedrooms............... _........ _________-----------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------•---••----------•---•-••-•••-----------•-------------•--•-----•-----•-----------.._._....__...-•••----------------...•---•-----••-•--.._.._.. W Design Flow........................rtk ,..__..gallons per person per day. Total daily flow___.._ .s 41 "_---gallons. WSeptic Tank I Liquid capacity allons Length................ Width---------------- Diameter................ Depth---------------- x Disposal Trench—No.____________________ Width_____,_-. �,.�a^' Total Length______._._____._ Total leaching area.___.. ._._..._._._sq. ft. Seepage Pit No......_�........... Diameter/__�" '�____-_:°De'pth below inlet_______ __________ Total leachin-area_-- ___ "___:_ ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date---------------------------------------- Test Pit No. 1.....`"�..minutes per inch Depth of Test Pit____________________ Depth to ground water-__-_-_--_____--_-_-__- 4.4 Test Pit No. 2................minutes per inch Depth of Test Pi,t.................... Depth to ground water------------------------ 9 •---- f------------------------•----.......................-----•••----------•--------•---- O Description of Soil___-___ , ,-_ + -:• r � ------------------------------------------------------------------------------------------- x U ........................-..................................................... -=--------------=---------------------------------------------------...-•----------------------------------------------. 14 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------------------__________. -------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed �3f - --••--•------•-•---•--•---•---•----•---•-----••------ ................................ Date Application Approved By.� Vim.. = ' '` - ---------------- _ r r _ _Date Application Disapproved for the following redsons___________________________ ---------•---------------------------------------------------------------------------------•-•••-•_._.•-----•••••--•------••----•-•----••-•-•-•-••------------•--•-•-----------------•••-•------...... Date PermitNo......................................................... Issued---_-_--------------------------•----------------•-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OjFy HEALTH rdtf iratr of TuunpliaArr � TS IS T9 CER,TFY, That tidividual Sewage Disposal System constructed ( ) or Repaired ( ) e i at /�[ y r1 �a nstaller � *' --^'-•---••---3#'""+ •Yw;ka';'"�v"An+-":^_ --•- •-*-�. •-•r---------- V --------••--°---•-••--•----•---------------•-------------•------------- ha been installed in accordance with the provisions of Article XI of The State Sanitary Code as desc,bed in the .- . , r r4 e� w_ application for Disposal Works Construction Permit No................. '__ _a _._._.__ dated.'..___--_,._,, _ _ -- - ^' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF" HEALT ..... ...OF.. `y,'� ��. r 9..... � �°r? ----------- ` No. Ir,•-•-_... FEE- . - Disposal nrk : To lrn fiat , rrotit� Permission i ereby granted------ r � _ ., to Constr orepair ( ) ""individual Sewage DIP Sy ------------- 4140 as shown on the"application for Disposal Works Construction P -rlait NoDate'_._; �• r Wit.__ """' .......... . Board of Healt DATE------------------------------------------•--------•----••••....---•--•------• FORM 1255 HOBBS & WARREN, INC:, PUBLISHERS a� OF �dU�1dfYTlt9� GENERAL NOTES T _ x FT lquilmom Rory rsu z O"t�,OO 1. REGULATIONS FOR THE SUBSURFACE DISPOS L CONFORM OF SEWAGE.E.P.TITLE 5 AND THE TOWN'S RULES AND 2. CONTRACTOR SHALL VERIFY THE LOCATION OF UTILITIES,SEWER INVERTS AND EXISTING SEPTIC J co E It 1 0(1l f Pi(�PIP£ �A tm/(NQ 5w) t r RE Q�1 t R � SYSTEM COMPONENTS PRIOR TO INSTALLATION. 3. EXISTING LEACHING COMPONENTS TO BE PUMPED,CRUSHED AND FILLED PER TITLE S. `INST L4.E10 MIN.pi t(,14 �8' P6�, FT. 2!1 L lL� OF 4. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6 INCHES OF FINISHED GRADE. i J' 1191, *'0 1/ If S. ALL NEW COMPONENTS OF THE SEPTIC SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING plP£ E 1 �r S ,f(' UNLESS THEY ARE UNDER OR WITHIN 10 FEET OF DRIVES OR PARKING AREAS OR GREATER THAN 3 FEET L/��� )�rN• _ I� �(��,J� BELOW FINISHED GRADE. 00000 H l�f'' �� FT, V U1 6. NO WETLANDS WITHIN 100 FEET OF PROPOSED LEACHING. Yet� I U 14AK - 7. ALL PIPING TO BE 4 INCH SCHEDULE 40 AT 1/8 INCH PER FOOT PITCH UNLESS SPECIFIED OTHERWISE. Flow`'n!L ! MAY ` , '-,l S. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE GRINDER. 1 i 9. NO DETTERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. ,� III�IZI—II� /71N _ �Q o o / �� fi 10.UTILITIES SHOWN ARE APPROXIMATE ONLY,EXCAVATION CONTRACTOR IS TO CALL^DIGSAFE"AT Q v' - I t ' L4,y�l.. ° ° Q�Q (� 6 °. 0 3` l/L C v ^/ 1-888-344-7233 AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE. 1 .3 // z avg� W-45 ��U•_ �� /. _ ��,$� (7 J�lI' � -1;�v. - � 'b3 ��� �� ° � `� 11.CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS SITE CONDITIONS PRIOR TO o B�BAFF LGE ,! F/�£E OP F11W S ¢ 510 , COMMENCING WORK ON SITE.ANY VARIATION IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN 7 DISTi216tIrt O/v ENGINEER IMMEDIATELY. 4A d ' " 12.THIS PLAN SHALL-BE USED FOR SEPTIC SYSTEM INSTALLATION ONLY AND SHALL NOT BE USED FOR To Q wAFv--.?resTl 10 2- " 0 d� Cli/NG- Gr �6M$ PROPERTY LINE DETERMINATION. 1 000 GA, , ^A / A00 plev(flo �A F/l1N W iz# t/'lS f GNt IN AQ. 13.LOT IS SHOWN ON ASSESSOR'S MAP 251 AS PARCEL 108 I i 14.PARCEL IS IN FLOOD ZONE N/A S&�T/C r�� - 12•�x 25 xz' �'�.�!cN �or��lt�yt�crl: � ---- ___ t V.= g ; 'SOIL, 6soRPtro�,l ��vclSr�li/�� <$ ) DESIGN CALCULATIONS M (S40 etb/p"5710 S�i4-6,&_D 15(k) 4 L 5 Y57-F v1 PPT I�,� z I5' Ado vffe I.4AJC F S TO NUMBER OF BEDROOMS 2 CNp"r 10 ScA'f WO ��f�GF M OF Ii 4XV 310 C/"` lc, I 000 GARBAGE DISPOSAL UNIT NO i � C� TOTAL ESTIMATED FLOW I Y, 4 I. Lo(� '"L Minimum Design:(110 GAL/BR/DAY X 3 SR.) 330 GAL./DAY �''-y�� JU t '� O/U �C Q(✓'G �, REQUIRED SEPTIC TANK CAPACITY 660 GAL. S T ACTUAL SIZE OF SEPTIC TANK(EXISTING) 1000 GAL. SOIL CLASSIFICATION i \ � DESIGN PERCOLATION RATE <5 MIN./IN. r I EFFLUENT LOADING RATE 0.74 GAL./DAY/FT2 I � LEACHING AREA 471 FTZ (12.8'Wx25%x2'd) At P LEACHING CAPACITY(AREA X RATE) 3448 GAL./DAY PROVIDED:2-500 GAL LEACHING CHAMBERS W/4'STONE AROUND E (� SOIL TES S i ( DATE OF TEST: SOIL EVALUATOR: a \\" _ - L�jvCi+MA-�dC.: T0� a�' �tJtlntAfr7tpr�1 CADIZ r 6) QJ„ r�N 6� OBSERVATION HOLE 1 ELEv.= O t � 1 PERCOLATION RATE t+ MIN./INCH 9l.F oSOH DEPTH HORIZ TEXTURE COLOR MOTTLES OTHE o, APPROVAL. loVr SCK l, DATE: - 30 C M 5 �•�y � O o _ - O o o O ' WA ER ENCOUNTERED AT IYb rr ELEV. PIT CC�f ') to' S 1P, l 31 SITE AND SEWAGE PLAN - �� ` ✓ FOR � Z �i PAUL LORRAIN 19 SUNRISE ROAD ' CENTERVILLE, MA 02632 FLAHERTY ENVIRONMENTAL SERVICES P.O. Box 363 Yarmouth Port, MA 02675 508.362.1657 Phone 508.362,1590 FAX Date: y /9/OS., Scale: P=20' OF ray s AVID ` Revised: a D. Job No. 05-123 - FLA RTY 1211 sT'-- SA�JI7AR\h� Sheet�Of . Revised: