Loading...
HomeMy WebLinkAbout0105 TARAMAC ROAD - Health 105 Tararnac Road Centerville A= 169-050 s M EAo® No.24IN R UPC IM smsad com • Mads le UM Commonwealth of Massachusetts " ^05- 0 Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Taramac Road Property Address Sara Norman Owner Owner's Name r. information is ✓ y Centerville required for every MA 02632 2-1-18 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When q. General Information filling out forms Sl* /d'ga?L— 111ltlltlffrl on the computer, �oytH OF/y�SSv use only the tab 1. Inspector: ;a`��; key to move your y cursor-do not James D.Sears '��� JAMES `N use the return key. Name of InspectorCo z -, Capewide Enterprises =* �V �'� � r. Company Name . � .,, 153 Commercial Street �''�i,,F 6 Company Address Mashpee MA 02649 CltyfTown State Zip Code 508-477-8877 S 1623 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 2-3-18 ;s;c!ft—sS,gnature 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 has a design flow of 10,000 gpd or greater, the inspector and'the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 a5ed xed dH 09:2 8602 V0 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c 105 Taramac Road L Property Address Sara Norman Owner Owners Name information is required for every Centerville MA 02632 2-1-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 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: The system is a 1000 Gal. Tank D Box and. 10 chamber's. 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): t5lns.doc-rev.Fl16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pepe 2 of 17 Z a5ed xLJ dH 05:6Z 81,02 t70 qaj N, Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required for every Centerville MA 02632 2-1-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cant.): ❑ 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 El N 0 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.doc-ray.6/16 Title 5 Official Inspection Form:Subsurface Sewage Dispose!System•Page 3 of 17 £ a5ed xed dH 05:6E ME t O qad Commonwealth of Massachusetts 19 Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 105 Tara mac Road Property Address Sara Norman Owner Owner's Name information required for every Centerville MA 02632 2-1-18 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, H 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 MORM is less than 6" below invert or available volume is less than '/2day flow 4tPCIliovi; t5insdoc-rev.6116 Tole 5 Official Inspection Form;Subsurfeoe Sewage Disposal System•Page 4 of 17 t7 a6ed xed dH 056E 860E V0 qad Commonwealth of Massachusetts Y i� Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Taramac Road Property Address Sara Norman Owner Owners Name information is required for every Centerville MA 02632 2-1-18 page. Cityrrown 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- 10,0009pd. ❑ ® The system fiillj'g,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 I I 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. t5lns.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 c, a6ed xed dH 09:2 860Z b0 qad Commonwealth of Massachusetts T11 Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Taramac Road Property Address Sara Norman Owner Owner's Name required o r e Centerville MA 02632 2-1-18 required for every 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 NIA) ® ❑ 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): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 x#of bedrooms): 220 P gpd ) 15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface SewaSe Disposal System-Page 6 of 17 9 a5ed XPJ dH 1,9:2 8602 b0 9a�J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required for every Centerville MA 02632 2-1-18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1000 Gal. Tank D Box and 10 Chamber's. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2016-154,00OGal 2017-60,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/scI t., 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.doc-rev.W16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 L a5ed xed dH 1,9:2 81,2 170 qaJ Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .� 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required for every Centerville MA 02632 2-1-18 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: NA 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 D E P approval. ❑ Other(describe): l5ins.doc•rev.6116 rile 5 Official Inspecion Form Subsurface Sewage Disposal System•Page 6 of 17 8 a5ed xed dH 65 6Z 860Z t0 qad i c Commonwealth of Massachusetts Title 5 Official Inspection Form `l Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required for every Centerville MA 02632 2-1-18 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: 2009 Permit # 2009-304. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"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,): Pipeing is 4"cast iron and 4" PVC SCH -40. Septic Tank(locate on site plan): 8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal, Precast H-10 Sludge depth: 1" t5ins.doc•rev.6115 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page got 17 6 a5ed xed dH Z9:2 81,0E b0 qad Commonwealth of Massachusetts kl Title 5 Official Inspection Form -I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v,v 105 Taramac Road Property Address Sara Norman Owner Owner's Name information a Centerville MA 02632 2-1-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 81' Distance from bottom of scum to bottom of outlet tee or baffle 17„ How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge 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 at working level. Tank and covers at 8" below grade. Inlet baffle,outlet tee. No sign of leakage or over loading. 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 151ns.doc•rev.U16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1D of 17 01, abed xeJ dH E9:2 21,2 ti0 cad Commonwealth of Massachusetts le Title 5 Official Inspection Form kverr" - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required for every Centerville MA 02632 2-1-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) 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.doc•rev.6116 Tte 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I,I, abed xe� dH E9:2 860Z V0 q@d Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 105 Taramac Road Property Address Sara Norman Owner Owner's Name Informrequired tlon s Centerville MA 02632 2-1-18 required for every page. CityfTown 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.): D Box is 16"x16"-26" below grade w/cover at 8". Box is clean and solid w/two lines out, No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doe•rev.606 Title 5 Offioiel Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Zl, abed YPd dH 69:2 860Z t70 cad Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -oil 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required for every Centerville MA 02632 2-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont,) Type: ❑ leaching pits number: ® leaching chambers number: 10 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ inn ovativelaltemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is ten biodiffusers (two row's of five each)Ck D Box and camera out.No sign of over loading. 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.doe-rev.6116 Title 5 Officia)Inspection Form:Subsurface Sewage Disposel System-Page 13 of 17 £6 abed xed dH £9:2 8102 b0 9ad s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required for every Centerville MA 02632 2-1-18 City/Town page. State Zlp 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.): 15ins.doc-rev.6f16 Tltle 5 MIA Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 �� abed xed dH t79:2 8 OZ b0 9ad Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r= i 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required for every Centerville MA 02632 2-1-18 paw cityrrown 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 13­1 - t r r, 3 14 t5ins.doc-rev.6116 Title s official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 11 56 a5ed xej dH b56E 860E 170 qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�� 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required For every Centerville MA 02632 2-1-18 pap. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells fW 11.'6" Estimated depth t high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 9-10-09 Date ❑ Observed site(abutting propertylobservation 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: T.H. on Design plan 9-10-09 11'-6" no G.W.. Before filing this Inspection Report,please see Report Completeness Checklist on next page. 15ins.doc•rev.U16 Title 5 Official Inspedor Form:Subsurface Sewage Disposal Svstem-Page 16 of 17 96 a5ed xed dH 179:2 860Z ti0 gad Commonwealth of Massachusetts a Title 5 Official Inspection Form r, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 105 Taramac Road Property Address Sara Norman Owner Owner's Name information is required for every Centerville MA 02632 2-1-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary; A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed E System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 �l a5ed xed dH b9:IZ ME t O qad i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is required for ma 02632 every page. Centerville Zip Code 4/26/2012 City/Town MA Date of Inspection State 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: A. General Information When filling out forms on the computer,use 1. Inspector: 1 � only the tab key to move your Wayne Archambeault cursor-do not Name of Inspector use the return key. Company Name box 914 Company Address Hyannis MA Zip 01 Co CitylTown State Zip Code 508-775-1362 355 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 4/26/2012 Inspector's Sig re Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. lZ d t5ins-11110 Title 5 Official InspecftF. ubsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville zip Code 4/26/2012 City/Town MA Date of Inspection State B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•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 �M 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 Cityrrown MA Date of Inspection State 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, t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 Citylrown MA Date of Inspection State 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 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 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 M 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 Cityrrown MA Date of Inspection State ❑ ® 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 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 Cityrrown MA Date of Inspection State ❑ ❑ 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. 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)] t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 Cityrrown MA Date of Inspection State D. System Information Residential Flow Conditions: 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 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d na 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 4/26/2012o Date Commercial/Industrial Flow Conditions: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments z 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 Cityrrown MA Date of Inspection State 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: D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner 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 t5ins•11/10 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 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 City/Town MA Date of Inspection State ❑ 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. 11. Other(describe): D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: SAS installed 9/21/2009 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.): Septic Tank(locate on site plan): Depth below grade: 1 feet t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form- _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is mafor ma 02632 every page. Centerville Zip Code 4/26/2012 Cityrrown MA Date of Inspection State 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: 8.5'x5'x5' Sludge depth: 3" D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 38" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? measuring rod Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): inlet and outlet tees at proper hieghts on sign of failure or leakage t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form- _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 CityTrown MA Date of Inspection State 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 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 Cityrrown MA Date of Inspection State 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 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.): box level and water tight flow equalizers at same level Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville zip Code 4/26/2012 Cityrrown MA Date of Inspection State Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 32 ❑ 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 Citylrown MA Date of Inspection State 2 rows of 6 biodifusers in sand Tx 32' no signs of failure in either row 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 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 *t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 CitylTown MA Date of Inspection State Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 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 t5ins•M10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville zip Code 4/26/2012 Cityrrown MA Date of Inspection State D. System Information (cont.). Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Taramac Road Property Address Jeremiah Schreyer Owner Owner's Name information is ma 02632 required for every page. Centerville Zip Code 4/26/2012 Cityrrown MA Date of Inspection State ® Obtained from system design plans on record" If checked, date of design plan reviewed: 9/17/2009 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 plans on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. 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 Form:Subsurface Sewage Disposal System•Page 17 of 17 - r AA � No. oa -30 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes T[pplication for Migozal *potent CCon.5trUction permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 10 S 1'11-1-4 on 4.0 Owner's Name,Address,and Tel.No. Ye c C.n 0I L, S e,(q_Q c Assessor's Map/Parcel Sf a . Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. oT`! Type of Building: Dwelling No.of Bedrooms Lot Size 2 O��iO p Fr sq.ft. Garbage Grinder ( ) Other Type of Building cS t C ^" No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 610 gpd Design flow provided 3 6 5 gpd Plan Date Cl t S_ — 2,00st Number of sheets Revision Date Title 10�_ T�A-0Z Size of Septic Tank 1 boo tQ XZ 1 Type of S.A.S. 5tzn_e(t,�} T—tzc/- ci Description of Soil 6D n 0 Nature of Repairs or Alterations(Answer when ap icable) t Cytk�> ngn4 .n-3 —b 2 S. C T-r C .3 0 cqwd,,,_F 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 Certificate of Compliance has been issued by this Board o alth. Signed Date Application Approved by Date (7 ' a(W Application Disapproved by: Date for the following reasons Permit No. 00 8 V Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of COmpliauce THIS IS TO CERTIFY,that the On-site Sewage Disposal `System n Constructed ( ) Repaired (� ) Upgraded ( ) Abandoned( )by C A 4P-�-I� (.�l p /� t'c( 1//�) 5 �.. —C at (� l-Wt Oc /L a jAJ K ,y kr I-)(( P has been constructed in accordance q with the provisions of Title 5 and the for Disposal System Construction Permit No. p©o,'3 o q dated 1 ' 17-6 07 . Installer G O r�.e C n ,#y- 5TS Designer -co — ir( #bedrooms 71 Approved design flow Z2 o gpd The issuance of this permit shall not be construed as a guarantee that the system�11 ctibn�as designed / Date (a 1 /U Cl Inspector r -------��--- ---- ---_----_--_----1—` ------ No. !t d 0 Iq _ J2 0 (I Fee f t✓ --- ( THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS Mi5 p0ar *p5tem Con.5truction Permit Permission is hereby granted to Construct ( ) Repair (/ ) Upgrade ( ) Abandon ( ) System located at C LC j,41 &h1go�C fio 4j 6-�4-� (('t 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 must be completed within three years of the date of this permit. oo ps Date q — 7' Approved by No. �ya( y lW � t Fee 4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: • �'�.PUBLIC HEALTH DIVISION - TOWN BARNSTABLE, MASSACHUSETTS Yes Application for dig ozal *pgtem Cow5truction 30ermit r Application for a Permit to Construct( ) Repair(y) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components " Location Address or Lot No. 10 S T-A/'A rrt A C. R v� Owner's Name,Address,and Tel.No. Ye(r-M­b L-. e" 17t Assessor's Map/Parcel ' b D 5 `C.. Installer's Name,Address,and Tel.No. L$_ �{oL 6 Designer's Name,Address and Tel.No. 614pt,t.,)IC1 C e-),�Cr f.,,,e �0 N3a•c -7 3 Ce f It. t'�3 i✓,h,f/c � Type of Building: Dwelling No. of Bedroom's _ ---- Lot Size 4rCtU p 4' sq. ft. Garbage Grinder ( ) Other Type of Building r �>! �r✓�'"u� No.of Persons Showers( ) Cafeteria( ) T Other Fixtures Design Flow(min.required) a O gpd Design flow provided 3 6 S gpd Plan Date Cl - i j - 2 o 09 Number of sheets Revision Date Title /J S i ervr-o Z Size of Septic Tank 1600 C,l4 ( W;') h, � Type of S.A.S. 57r2� (fps Description of Soil fru2o Ji►as., ' G F� 3 0- 3(-` ' Nature of Repairs or Alterations(Answer when applicable) ti/k')dnt J 00,:;:, 1141 f?9-1 4 Date last inspected: S�?2C7 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 Certificate of Compliance has been issued by this Board of alth. Signed Date Application Approved by Date + f 7 ' a-OO Application Disapproved by: Date for the following reasons Permit No. �� 6 L Date Issued Town of Barnstable Regulatory Services Thomas F. Geiler,Director Public Health Division 161 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer&-Designer Certification Form Date: CI' 21 - Zook D: : Q Avg Ct�v�rlhN�w=:t2 R Int ) r: +� c 10✓�S eS Designer.. . Address: 43 TP I WGLi-: Q9CLV- Address: .(20 -7(�o`3 SM4QY to u. M A 0250 VK A On 9-11— O`fi e . CC'XWvI5,es was issued a permit to install a (date) (installer) septic system at ( p �.a,(e4 nA^C— (LAP,cl based on a design drawn by (address) C co -- -T c.L. dated (designer) V I certify that the septic system referenced above was installed substantially according to the design, which,may include minor approved changes such as lateral relocation of-the distribution box and/or septic tank. I.certify that the septic system referenced above was installed with major changes (i.e. grpater-ttian 10' lateral relocation-.of the SAS or any,vertical relocation of any,component o the septic sys#e i) but in accordance°with SCate &Local Regulations. P..revision or certified as=built by designer to follow. Sp OF Mq D. ( ler's Signa re) CQUGHANOWR y No. 1003 TLw� NI7ARI PN (Designer's Signature) (Affix.Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLICHEALTH DIVISION, CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. .Q:Health/Septic/Designer Certification Form TOWN OFF B ARNSTABLE LOCATION ��m iaC P4-0/ SEWAGE# '.�00l- 3t4 VILLAGE eQ hyt 16 ASSESSOR'S MAP/&PARCEL I&9-S o INSTALLER'S NAME&PHONE NO. e�cvja(g yZ g Y02S SEPTIC TANK CAPACITY /QQ() /-//0 LEACHING FACILITY:(type) S1q> EEC (size) 62) 3X 2 7Z.o NO.OF BEDROOMS .3 p.K OWNER rN F r PERMIT DATE: .q s J -®�( COMPLIANCE DATE: -Z.\ -20 00, 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 C AQAA,3 i f 141 47 55- i3 `1 c�T 2 3Z a�°s �f s Town of Barnstable P# y oE� • Department of Regulatory Services MAft Public Health Division ^200 Main Street,Hyannis MA 02601 Date_ - Date Scheduled ° U Time d F 11 U Fee Pd. Soil Suitability Assessmentfor Sewage Disposal asposal Performed By: DC,vidl D. Cod"4 4 0 W QS Witnessed By: 2 LOCATION & GENERAL INFORMATION ►�[ l �VVV--=�yy [Location Address ff jvOwner's NameAddressO1 FIrA,ryeq�sscssor'sMap/Parcel• (' (pcy" ®�'� _ Engineer's Name �1pLwd yr .� NEW CONSTRUCTION - REPAIR D - Telephone# S'09^ 4Z1 _ 4-22 f Land Use —E 5I�.C-M4,141 Cl) Slopes(%) Surface Stones Distances from: Open Water Body 100 ft possible Wet Area _ft - Drinking Water Well Drainage Way 50 -t ft Property Line f(] ft Other ft SKETCH: (Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity ty to holes) PG pA� I GROUNDWATER ADJUSTM ENT I� rP-2 (�rP-1 I it EXISTING GROUNDWATER LEVEL ® BASED ON TOWN OF BARNSTABLE tiW/ I m GIS DEPARTMENT RECORDS. INDICATED .GW 26.00 m INDEX WELL SDW-252 ZONE p ( READING DATE AUGUST. 200r7 READING 247.0 .8 ADJUSTMENT 2.B ADJUSTED GIN 30.6 I Parent material(geologic) Ill) 6clr-f l 00 wer5 h Depth to Bedrock In 0 4� Depth to Groundwater. Standing Water in Hole: Y 1 0 h(� Weeping from Pit Face V1 D Estimated Seasonal High Groundwater Se� ©0 P DETER IINATION FOR SEASONAL HI ' WATER TABLE Method Used:SSA �{`bp ye Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: tn. Depth to soll mottles; Index Well# In, Groundwater Adjustnient tn. Reading Date: Index Well level ft• AdJ,factor— Adj.droundwater Level Hol Observation j PERCOLATION TEST butt: elllo/6`1 Time- Ib 4 M Hole# — Time at 9" Depth of Pere Time at G" V\ �] Start Pre-soak Time @ �D;�� - Time(9"•6") i End Pre-soak Rate Min./Inch L,VnQ j Site Suitability Assessment: Site Passed__ t ;.: Site Failed: Additional Testing Needed(Y/N) .,i:/ ,Origi,al:'Public Health Division Observation Hole Data To Be Completed on Back----------- r- � ***If percolation testis to be conducted within 100' of wetland,you must first notify the,•N Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTiC\PERCFORM.DOC SOIL TEST LOG r TEST PIT 1 NO PARENT GROUNDWATER NCOUNTERED MATER AL:EPROGLAC AL OUTWASH t PERC AT 56 in — 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 48.30 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 0-6 FILL j 8-10 O SANDY LOAM 10 YR 3/2 NONE FRIABLE 10-14 A LOAMY SAND 10 YR 4/4 NONE FRIABLE 45.47 14-34 B LOAMY SAND 10 YR 5/6 NONE FRIABLE 36.80 34-136 C MEDIUIM SAND 10 YR 5/4 NONE LOOSE NO GR TEST PIT 2 PAARENOTU MATERIAL:EPROGLACIRALO OUTWASH 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 48.30 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 1 0-10 FILL 10-12 O SANDY LOAM 10 YR 3/2 NONE FRIABLE 12-14 A LOAMY SAND 10 YR 4/6 NONE FRIABLE 45.30 14-36 B LOAMY SAND 10 YR 5/6 NONE FRIABLE 36-138 C MEDIUIM SAND 10 YR 5/4 NONE LOOSE 36.80 --— — — r_ _ DEEP OBSERVATION HOLE LOG Hole# T f Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Co i to c %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten I Flood Insurance Rate Mali: Above 500 year flood boundary No— Yes .V/ Within 500 year boundary No V Yes Within 100 year flood boundary No ✓ Yes Depth of Naturally Occurring-Pervious Material - - Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? `C e 5 If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,,expertise and experience described in 310 CMR 15.017, H OFMgssq Signature �• Cam, — Date �ep+ ZD� �o� DAVIQ. cy�� o D. -, COUGHANOWR Q:\SEPTIWERCFORM.DOC �O �'CENSE� Q o FVAL�P� I NOTES CONTOURS ���v DONEGAL INSTALLER TO LOCATE EXISTING EXISTING - - - - - - - 50 0�'p SOIL ABSORPTION SYSTEM AT TIME 46 47 48 171.$7 Ft MINIMAL GRADING PROPOSED v�oP T�� LIMERICK n OF REPAIR AND TO PUMP. FILL AND / � -7�-- Q ABANDON IT. -- -- -- -- -- -- -- _— -- ''S couRr A P29, \ / t �c rn- 0 m P R � LOCUS GARBAGE GRINDER j N LIETRIM CIR IS NOT ALLOWED GAS Q WITH THIS DESIGN. GATE �\ PAV D DRIVEWAY SOIL ABSORPTION SYSTEM I CENTERVILLE. MA / —� -SEE DETAIL ON REVERSE I LOCUS � I GAS LINE �`v� WATER l rP-I qOp I NOT TO SCALE / ' \LINE 20 Ft TP-2 0160 14-D Fq z uj X , LEGEND OM F9 (f� I m EXISTING �� 0 m 1000 GALLON � (— 18-D m SEPTIC TANK p% I + O z O Z SH I EXISTING LEACH \ Z I PIT/CESSPOOL • - ❑ TEST PIT ® D BOX 1 \ / HYDRANT (D DRAIN I I DECIDUOUS CONIFEROUS / j I TREE �q�p TREE 1 ; L D T 33 \ I -NUMBER REFERS TO DIAMETER IN \ 1 \ I INCHES. LETTER DENOTES TYPE. 1 -- -- -- -- -- \ /AREA = 20900 SF +- 44H O-OAK M-MAPLE P-PINE C-CEDAR 46 4 7 217.74 f"t -- — — -- -- -- �y�N �MASSq �SN aF MASS DAVID C'SG� o�o�� DADVID q�yGNm FLAND. U CDNo.H1093 ANOWR N U COUGHANOWRALL FIFE SOLE: 1 1n = 20 FL �F�� s 4/CENSE°FLON PROFILE EXPRESSED LINV DECIMAL FEET NOT FEET AND INCHES ATIONS SPECIFIED ARE INVERT ELEVATIONS S S T N eV AL L C 20 0 20 40 Ni A � � SC RAISE COVERS TO WITHIN SCH 40 PVC AND TO 0 ALL PIPE TO BE 4 10 20 Se pf��" der �' ' ZDOq TOP OF FOUNDATION 6 in OF FINAL GRADE PITCH AT .01 Ft/Ft MIN. EL =49.74 +- 1 I[ 48.6 i ��®� Te�� SEWAGE DISPOSAL Gw SYSTEM PLAN BENCH MARK 0-BOX 3. INSPECTION PAINT SPOT ONEST. JEREMIAH & BETTY ANNE SCHREYER / PORT (ONE OWNERS OF RECORD 3" DRO MAX PER TRENCH) BULKHEAD CORNER * 10.. = 14 45.64 _ -- _ BARNSTABLE GIS DATUM 1995 �� CENTERVILLE. MA 46" GAS-� I ®N�� PROPERTY ADDRESS EXISTING BAFFLE 46.60 6 in - -__-=__=_____-__===_=________=_____=-_- ASSESSORS MAP 169 PARCEL 5J D STON _---=-_ 43 TRIANGLE CIRCLE L45J.38 - BOTTOM OF SANDWICH MA 02563 PLAN BOOK 223 PAGE 139 EXISTING 45.55 BASELEACHING SOIL ABSORPTION EXISTING SYSTEMr,�' 08 364-D8J4 DATE. SEPTEMBER 15. 2mmJ 1000 GALLON L44.31 GALLERY SOB #ETE-3231 IFAGF1 OF 2 VERSION: 5.00 Ft+ THIS PLAN IS BASED ON AN INSTRUMENT SURVEY AND IS INTENDED SEPTIC TANK SOLELY FOR INSTALLATION OF THE PROPOSED SEPTIC SYSTEM EXISTING 14 FL o7 4 ft -SEE DETAIL ON REVERSE p 67 13 ft 30.8 = ADJUSTED DEPICTED HEREON. FOR ANY OTHER CHANGES TO PROPERTY INCLUDING wp SEASONAL HIGH PLACEMENT OF ADDITIONS. SHEDS, FENCES OR SWIMMING POOLS, OWNER GROUNDWATER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. } SOIL TEST LOGDATE TEST: SEPTEMBER 10, 2009 DESIGNCALCULATIONS SOIL EVALUATOR: DAVID D. COUGHANOWR. R.S. WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. PERC NUMBER: 12694 DESIGN FLOW: 2 BEDROOMS X 110 GPD = 220 GPD TEST PIT 1 NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 220 GPD X 2 DAYS = 440 GALLONS PARENT MATERIAL: PROGLACIAL OUTWASH USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL CONDITION. PERC AT 56 in - 2 MIN/INCH IN C SOILS IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET D-BOX. (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING SOIL ABSORBTION SYSTEM: INSTALL 10 ADS HIGH CAPACITY BIODIFFUSERS (160OBD) 48.30 0-8 FILL 10 UNITS x 6.25 ft / UNIT = 62.50 L.F. 62.50 L.F. x 7.90 S.F./L.F = 493.75 S.F. 8-10 O SANDY LOAM 10 YR 3/2 NONE FRIABLE 493.75 S.F x .74 G.P.D. / S.F. = 365.3 GPD 10-14 A LOAMY SAND 10 YR 4/4 NONE FRIABLE USE 10 HIGH CAPACITY BIODIFFUSERS AS CONFIGURED BELOW - Vt = 365.3 GPD > 220 GPD REQUIRED 45.47 14-34 B LOAMY SAND 10 YR 5/6 NONE FRIABLE REFER TO DEP APPROVAL LETTER TRANSMITTAL n W000052 FOR CERTIFICATION 34-136 C MEDIUIM SAND 10 YR 5/4 NONE LOOSE OF ADANCED DRAINAGE SYSTEMS BIODIFFUSER SYSTEMS. 36.60 No T TO NO GROUNDWATER ENCOUNTERED LEA CHI NG GA L L ER Y SCALE 10 M DONS AND SEPTIC TAW TEST PIT � DIMENSIONS AND DETAIL NOT T O PARENT MATERIAL: PROGLACIAL OUTWASH CONSTRUCTION DETAIL USE EXISTING H-10 UNIT SCALE 2 MIN/INCH IN C SOILS USE ADS HIGH CAPACITY BIODIFFUSERS (#1608BD). GRAVELLESS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER INSTALLATION - USE DEP APPROVED INSTALLATION PROCEDURES. SEPTIC TANK IS TO BE PUMPED DRY AT TIME OF INSTALLATION AND IS TO 48.30 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 31.25 f t ,, BE EXAMINED FOR STRUCTURAL 0-10 FILL � INTEGRITY. INSTALL NEW PVC OUTLET TEE EOUIPPEO WITH A GAS BAFFLE. 10-12 O SANDY LOAM 10 YR 3/2 NONE FRIABLE o 1 In 12-14 A LOAMY SAND 10 YR 4/6 NONE FRIABLE N TAPER 45.30 c 14-36 B LOAMY SAND 10 YR 5/6 NONE FRIABLE o o -�I C 36-138 C MEDIUIM SAND 10 YR 5/4 NONE LOOSE Lb � o o � 36.60 m 0 J GROUNDWATER ADJUSTMENT DISTRIBUTION BOX 31.25 Ft_ N Lo EXISTING GROUNDWATER LEVEL DIMENSIONS AND DETAIL USE SHOREY DB-3 H-10 1� BASED ON TOWN OF BARNSTABLE GIS DEPARTMENT RECORDS. .INDICATED GW^ 28:00 12 in CROSS SECTION VIEW ti INDEX 'WELL• SDW.=252 NOT TO SCALE MIN INLET OUTLET Z ON E D COVER COVER READING DATEJ'AUGUST. 2007 FROM —' 41n USE H-20 O ' J READING_ .' 47.0 O TANK TO 16 RA TED UNITS 3 IN DROP ADJUSTMENT 2.8 co SAS 11.3 in —> Il FLOW LINE J", t -'• .� - y ADJUSTEDj GW;) 30.B O O (� In EFFECTIVE FROM 10 in - 14 TO DEPTH BUILDING to t e E D-BOX 6 in STONE BASE CROSS SECTION VIEW 34 in (2.83 f L) 68 In (5.66 FL) 34 In (2.83 f L) LIQUID GAS LEVEL BAFFLE NOTES 1n 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK: CROSS SECTION VIEW 2) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. SEWAGE DISPOSAL SYSTEM PLAN 5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED OR REMOVED. -TO SERVE EXISTING DWELLING 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE. 7) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES JEREMIAH & BETTY ANNE SCHREYER AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. 105 TARAMAC ROAD CENTERVILLE. MA 8) ,SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT ` PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. ECO-TECH ENVIRONMENTAL 9) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 43 TRIANGLE CIRCLE SANDWICH MA 02563 STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. ETE-3231 SEPTEMBER 15, 2009 2/2