HomeMy WebLinkAbout0073 TELLEGEN TRAIL - Health 73 Tellegen Trail
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2ppfication for Disposal 6pstem Construction Permit
Application for,a Permit to Construct( ) Repair,( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. '73 Te j(e P r ra I L- ner'�e N e,Addres d Tel.No.
c, e�gn �lLT
y
Assessor's Map/Parcel ,ilr( 2 U j l 5Ci Ct t-#tJ l le T 3 7 g 0
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Bt6 Excctvatton 4J77-0&5n R9ane r�i1�,Ll�?�j(5 y-1I-53t.3
Type of Building: �j � — — T-
Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 1
Design Flow(min.required) G 1444 Q gpd Design flow provided gpd
Plan Date I I I b 10 1 Number of sheets Revision Date
Title 4-t f e fn C f o-CUL.
Size of Septic Tank UoG Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of 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 Health.
Sied Date I (p 1,0
Application Approved by Date 0
Application Disapproved by Date
for the following reasons
Permit No. ^ I / Date Issued
No. .2Fee i 0'/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplicatlon for Misposal 6pstent Construction j3erutit
Application for a Permit to Construct( ) Repair(r) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. '73 Te((e -r�Q I L O ner's,JName,Address and Tel.No.
CI f p. � 1F\derbOlLT X44 j .
Assessor's Map/Parcel '2 l} ff f f e 1 156 Im Ci r i V l d P i N 3 7 W U
`— Installer's Name,Address,and el.No. Designer's Name,Address,and Tel.No.
13j(3 Fxt(kvctktun �f�, �;(,5 �'r% lc)e ((TJ 4--jrlc5
Type of Building:
Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures Design Flow(min.required) Ll gpd Design flow provided gpd
Plan Date 7 11(n I U A Number of sheets Revision Date
Title P 4 ! /.C,ER C' f 5 l
Size of Septic Tank 60 t' Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of 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 Health.
SFgned A Qbo A+ Date 7 I1(0 (U!; µ~R
Application Approved by Date
r
Application Disapproved by Date
for the following reasons
1 I
Permit No. Date Issued 7 t
-------------------- -. - --< -- - -- - - - -�--- ---- ---------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by 1 i3 Le ri v r, { (e)
at 7 A) I �e C(if'n !C Fi ( ( has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. UA— 1ttdated �// 7
Installer .1 I h A4 Designer Tn rz( e 1,, i,���,�� /)4 t(
#bedrooms >� — j Approved design 11 `q l} gpd
The issuance of this permit sh 11 not be construed as a guarantee that the system will f5hetio as designed.
Date ] rJ Qj InspeCtoY
_. . _ - -- -- ----- -- --�- ----- . -
No. {,�GI C� Feed—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION .BARNSTABLE,MASSACHUSETTS
Misposal 6pstent Construction 3pertnit
Permission is hereby granted to Construct( ) Repair( ✓) Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Constru tion must be completed within three years of the date of this permiti
Date / /� 4 Approved by ('
l v (
t- =t
(
TOWN OF BARNSTABLE
LOCATION '73 -rc-)Ic9cn Trc6; J SEWAGE#Poo 9- ,PJy
VILL,/,GE Ccr)1 c r u;l /G ASSESSOR'S MAP&PARCEL a30 - ISO
INSTALLERS NAME&PHONE NO.B E 3 E,Xca✓a-)i O r1 5�77 DGS3
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) - Gcac{.o'n!!j -_)rcnchrs(size) x 3 x y3
NO.OF BEDROOMS y
-OWNER VQnC1Cr 5V; ) 1 /7-)0rJCk!QC.
PERMIT DATE: 7-17-0 9 COMPLIANCE DATE: 7-a 7 -0 9
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
D -DECK
BI 'Za o '
A
T
3 Z .�y6
13 3 - . Q � From �wc11 ti�9
4,o z
C3
0
TOWN OF BARNSTABLE
LOCATION 7 SEWAGE#
VIT.LAGE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) CST (size) /do
NO.OF BEDROOMS V
OWNER lC�-n/�t/ET/i DUGhES�V.�Y
PERMIT DATE: 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 Leachin Facility If any wetlands exist
within 300 feet of leac.' cility, Feet
FURNISHED BY
r -
�r
�rCQNT f
o Poi h
Fe,oN 7T
TOWN OE.& a STABLE
LOCATION �I SEWAGE #
VILLAGE ASSESSOR'S MA�k%
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMUDATE: 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
I� Furnished by
EA
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AA I`I
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TRANS. NO.:
CITY/TOWN:
APPLICANT: o--
ADDRESS: -7 2, r Ce
DESIGN FLOW: gpd
REVIEWED BY: iiku- Mc C +-,Le P DATE: ^? 1 09
N/A OK NO
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7
Legal boundaries denoted [310 CNM 15.220(4)(a)]
Street, Lot, tax parcel number and lot number noted on plan [310
CMR 15.220(4)W]
Locus Provided [310 CUR 15.2204(t)] ✓
Plan proper scale? (1"=40'for plot plans, 1 '= 20' or fewer for
components) [310 CMR 15.220(4)]
Easements shown [31.0 CMR 15.220 4 b L/
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]-if not, a variance is required 310 CMR 15.412(4)]
Location of impervious surfaces (driveways, parking areas etc.)
[310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR
15.220(4)(c)]
Location and dimensions of system components and reserve areas.
310 CMR 15.220(4)(e)]
System Calculations 310 CMR 15.220(4)(f)] ✓
day flow
septic tank capacity (required andprovided)
soil absorption system(required andprovided)
whether system designed for garbage grinder
North arrow 310 CMR 15.220(4)(g)] ✓
Existing and ro osed contours [310 CMR 15.220(4)(g)]
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)]
Names of soil evaluator and BOH representative [310 CMR
15.220 4 h and i ]
Location and dale of percolation tests (performed at proper
elevation?) 1310 CMR 15.220(4)(i)]
Percolation test results match loading rate? [310 CMR 15.242] /
Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] ✓
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR LI/
15.220(4)(n)]
Address Sheet 1 of 9
5 a
n
N/A OK NO
Location of every water supply, public and private, [310 CMR
15.220(4)(k)]
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case
of private water upply wells
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. 310 CMR 15.220(4)(1)]
Water lines and other subsurface utilities located [310 CMR
15.220 4 m (if-water line cross see 310 CMR 15.211 1 1
Profile of system showing invert elevations of all system
components and the bottom of the SAS [310 CMR1.5.220 4 0 ]
Stamp of designer [310 CMR 15.220 1 and 310 CMR 15.220(2)] ✓
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CNM 15.102(2) or as
approved for an upgrade under LUA at 310 CMR 15.405 1 k ]
Test hole adequate to demonstrate four feet of suitable material?
310 CMR 15.103 4
Test Holes adequate to confirm adequate groundwater separation?
310 CMR 15.103 3
Benchmark within 50-75' of system P10 CMR 15.220 4
Materials specifications noted? [various sections of 310 CMR
15.000]
System components not > 36" deep (unless Local Upgrade
Approval or LUA requested) [310 CMR 15.405 1 b
Address Sheet 2 of 9
L
N/A OK NO
Size OK? 310 CNM 15.223 1
Inlet tee located ten inches below flow line [310 CMR 15.227(6)] ✓
Outlet tee 14" or. 14" + 5" per foot for increase ft depth [310
CMR 15,227 6
Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)]
Note regarding installation on stable compacted base [310 CMR �I
15.228(l)] ✓ 7iX S�' 1�^�``'
Separation between inlet and outlet tees (no less than liquid depth)
310 CMR 15.227(2)]
Inlet/Outlet elevations at least 12" above high groundwater
(except as descried 310 CMR 15.227(5)) or permitted for
upgrades under LUA [310 CMR 15.405 1 k
Minimum cover 9".(Tanks buried more.than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1) and 310
CMR 15.232 3
Three access covers (inlet and outlet must be 20" or greater) -
middle access at least 8" 7/07 [310 CMR 15228 2 ]
Access to within 6 of grade - one port for systems<I 000gpd,
two fors stems>1000 gpd [310 CMR 15.228(2)]
All at-grade covers secured to unauthorized access? [310 CMR
15.228 2
> 10 ft from building foundation [310 CMR 15.211 1
Buoyancy calculation Required/Done 310 CMR 15.221(8)]
H-20 Where appropriate? [310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.211]
Required when gther than single-family dwelling or flow>1000
d 310 CMR 15223 1 b )
First compartment 200% daily flow; Second compartment 100%
daily flow 310 CMR.15..224 2 .and .3 ]
"U" pipe through or over baffle, outlet of each compartment with
as baffle or approved filter 310 CMR 15.224(4)]
Address Sheet 3 of 9
N/A OK NO
Located at least ten feet from any water line? [310 CMR
15.222(2)]
Disposal piping at least 18" below water line(when water and
sewer cross, see 310 CMR 15.211 1 [1
Cleanouts required/provided ? [310 CMR 15.222(8)]
Thrust blocks s ocified in force mains? 310 CMR 15.221 6 c ) ✓
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
310 CMR 15.222(6)] .
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) [310 CMR 15.251 9 and 310 CMR 15.252(2)(c)]
Siphonproblem/ ieachfield below pump chamber
Endca s or vent manifoldspecified?
Size and orientation of discharge holes specified? (not smaller than
3/8 not larger than 5/8 ) [310 CMR 15.251(8) and 310 CMR
15.252(2)(h)]
Materials specified (310 CMR 15.251(5) specifies various pipe
types allowed
s MEMO
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.232(2)(a)]
Splash plate or baffle tee required on inlet/provided? (when /
pressure sewer to d-box or steep pitch of gravity sewer) [310
CMR 15.323(3)(a)]
Riser if deeper than 9 f 310 CMR 15.232(3)(f)]
Inside minimum,dimension 12" [310 CMR 15.23 2 2 b
Minimum sum ¢" 310 CMR15.232 3 e ] l
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
310 CMR 15.232(3)(d)]
Capacity(emergency storage above working--design flow)? [310
CMR 231 2 ]
Proper setbacks [310 CMR 15.211 same as se tic tanks)]
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE [310 CMR 15.231 5
Service components accessible(not too deep with piping,
disconnects accessible
Alarm floats - alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.23 1 6 and 8 ]
Stable Com acted Base[310 CMR.15.221(2)] .
Address Sheet 4 of 9
Buo anc calculations needed ?Provided? [310 CMR 15.221 8 ]
Address Sheet 5 of 9
N/A OK NO
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(l)]
Required separation togroundwater? 310 CMR 15.212
Aggregate specified as double washed [310 CMR 15.247(2)]
System Venting mquired/provided? (system under driveway or '
>36 deep) [310 CMR 15.241
Inspection ports specified and within 3"final grade? [310 CMR
15.240(13)]
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document]
y
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253 6 ]
Each structure With one inspection manhole(if>2000 gpd must be
tograde) [310 CMR 15.253(2)] �J
Aggregate 1 minimum-4' maximum: 310 CMR 15.253 l b ]
2' sidewall credit maximum 310 CMR 15.253 1 a
In bed configuration, inlet eve 40 s . ft. [310 CMR 15.253 6 ]
., ` .
Width 2'minimum 3'maximum [310 CMR 15.251 1 b ]
100 feet - maximum length [310 CMR 15.251 1 a]
Minimum separation 2x effective depth or width whichever greater
3x if reserve between trenches _[310 CMR 251 1 d ]
Situated along contours 310 CMR 15.251 2 ✓
Breakout OK? [ 10 CMR 15.211 1 [4] and Guidance Document]
minimum 2 distribution lines [310 CMR 15.252(2)(a)]
Maximum separation between lines 6' [310 CM RI 5.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CUR 15.252(2)(e)]
Aggregate depth below discharge pipes 6" minimum, 12"
maximum. 310 CMR 15.252 2
Separation between beds 10'minimum.. 310 CMR 15.252 2 ]
Bottom area used in calculations only [310 CMR 15.252(2)(i)]
Address Sheet 6 of 9
N/A OK NO
Pressure Dosed System ? Provided pump and piping calculations
as required 310 CMR 15.220(4)(r)]
Pressure dosing required on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals]
If used in gravelless system -make sure jet is directed as not to
scour soil interface Guidance Document
Inspections once per year(systems<2000 gpd) or quarterly
>2000 dgood to note on plan [310 CMR 15.254(2)(d)] IT
Construction in fill -Did the plan specify that the fill shall meet
the specification of 310'CMR 15.255 3 ?
Impervious barrieer and/or retaining wall ? [Guidance Document]
Impervious barrier installation must be supervised by designer
310 CMR 15.2552 b ]
Retaining wall must be designed by Registered Professional
Engineer 310 CNIR 15.211(2)(a),
Side slope not exceed 3:1 ? [310 CMR 15.255(2)]
Breakout requirements met? [310 CMR 15.252(2)and
Guidance Document]
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended [ 10 CMR 15.255 2 e)]
Check DEP`A roval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface
/
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a gote on the plan regarding the requirement for
perpetual maintenanceagreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Hasa licant submitted a coRX of a maintenance a eement?
Are the variances listed on the plan? [310 CMR 15.220
4 ]
RLS Stamp.-necessary on plan if a component is within five
feet of property dine 310 CMR 15.412(4)]
Address Sheet 7 of
New construction or increased flow proposed - [Refer to 310
CMR 15.414]
Address Sheet 8 of 9
0
N/A OK NO
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply Well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216 - also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well ?
310 CMR 15.214 2
Are the nitrogen loads proposed in compliance? [310 CMR
15.216 1
7}9 fis. x . 9h
r �i h � d of E�.��:u�,'� -a�,
Pumping to septic tank? 310 CNM 15.229
Shared System 1-0 CMR 15,290]
Address Sheet 9 of 9
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 73 Tellegen Trail
Property Address
Carrington Mortgage Services LLC.
Owner Owners Name
information is required for every Santa Ana CA 97205 6-1-09
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
(1
on the computer, J
use only the tab 1. Inspector:
key to move your
cursor-do not Joseph R. Smith
use the return Name of Inspector
key.
Stevens Construction, Inc.
Company Name
P.O. Box 71
Company Address
Marstons Mills MA 02648
Cityrrown State Zip Code
508-776-9054 S14994
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
-111 6-1-09
spect ignature 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.
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner
ame
information is Sav-er's N
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Surnmary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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. f`
❑ Y ❑ N ❑ ND (Explain below):
t5ins•05/03 Title 5 Official Inspection Fcm.Subsurface sewage Disposal System-Page 2 of 17
y Commonwealth of Massachusetts
� : - Title 5 Official Inspection Form
isI Subsurface Sewage Disposal System Form - Not for Voluntary^,ssessments
F operty A dress
Owner
O nerIs Name
information is {
required for —
�� ���� �. � �•��� _ �, 1 v�
Town State Zip Code Date of Inspection,
every page. (f
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pace 3 of 17
S r
Commonwealth of Massachusetts
E� Official nspection Foi
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Properly dress —T
V 1-5
Owner D, er's Name
information is
required for
every page. Ci y/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*'This system passes if the well water analysis, performed at a DEP certified laboratory, for 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
❑ A 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
dot or clogged SAS or cesspool
( ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
V- than 'Y2 day flow
,5in5 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pace?of i7
1 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
=1. rj Subsurface Sewage Disposal System Form Not for Voluntary Assessments
P J operty� ress G
�S
Owner O er's Name
information is required for � d ��� � 1 ` 03
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
-of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ I The system is a cesspool serving a facility with a design flow of 2000gpd-
U� 10,000gpd.
❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure----- - - - -
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For,large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ n the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— iWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304, The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
5, Commonwealth of Massachusetts
rlc 4. I itle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
9 P Y y
- �— —
Pr perty Address
�Jr�
Owner ner's Name
information is
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
l �
❑ 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
�l 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 es 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:
C
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins•09/08 Title 5 Official Inspection Forms Subsurface Sewage Disposal System•Pace 6 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
h Subsurface Sewage Disposal System Form Not for Voluntary Assessments
P operty Ad ess v
VZ
Owner ler s Name
information is
required for �=c+--F
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes04 No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes a,\ No
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ .Yes No
Last date of occupancy: U
Dat
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 or 17
f
r
Commonwealth of Massachusetts
ai Title 5 Official Inspection Form
M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner er's Name
information is
required for
every page. City/Town State Zip Code Date of Inspection
D. System information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
XSeptic tank, distribution box, soil absorption system( t..J
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
i5ms•09/08 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
47`' Commonwealth of Massachusetts
,Z Title 5 Official Inspection Form
=l _ i, Subsurface Sewage Disposal System Form Not for Voluntary Assessments
dress
Owner er's Name
information is
required for , -�� I1�,
every page. City/Town State Zip^-
de Date of Inspection.
Co
D. System Information (Cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ YesN 1 No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron �l 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 1 1
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: —
feet
Material of construction:
Xconcrete ❑ 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: ocDO '��
Sludge depth:
f'
t5m 09/08 Title 5 Official nspection Form:Subsaiiace Sewage Disposal System•Paoe 9 of 17
i
Commonwealth of Massachusetts
a;= - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
� �❑ �1CLt
Pr perty Ad4ress /
Owner Owners Name
information is
required for ?JSaa_ Ca
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
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 —
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.).:
04
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: --
Scurn thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffle --
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
ai = Title 5 Official Inspection For.
1; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L,
r perty A4.,dress ;
Owner Owner's Name
information is I—)
required for L -�-� C)� �
every page. City/I own State Zip Code Date of nspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pace 11 of 17
=` Commonwealth of Massachusetts
Title 5 Official Inspection Form
=! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property . dress
Owner wn ne
required for
information is �1-
� a
every page. City/I own 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
P 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(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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disoosal System•Paoe 12 of 17
Commonwealth of Massachusetts
I i Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Pperty ress o J
to Add
y
Owner wners Name
information is y
required for �� ( � � Q
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
leaching pits �oQ-C" number:
❑ 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.): t
Vey 1.,����� ,�/Z:1� ��L'-��.�`� 6,�`C2..`� � 3 l �,•���-�2:� \C,�s•� �c�����
-sCa,1 r 5 1 L_ Wes)N'e, ';U'.\ e k)k)f
� \
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 13 of 17
f
a �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
hi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
PrPr perty ACjdress
Owner Owner's Name
information is
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
s" ry Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
s
. , Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property dress
`��;
Owner ner's Name
information is (117
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
drawing attached separately
t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
ICI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property dress
��
Owner �wner's Name
information is
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Check Slope ® � 76
Surface water �'�^x C
�Checkcellar C>Y
AShallow wells )N3e',k_ I 4
Estimated depth to high ground water: ee
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers- (attach documentation)
Acces ed USG�database- explain:
You must describe how you,established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09108 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
—� �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property A01ress
Owner �nels,
Name
information is required for Y—
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
XInspection Summary: A, B, C, D, or E checked
(X Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
([� System Information— Estimated depth to high groundwater
(�(J Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
(Sins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION -7 J 7 �/ g�rxl fi�';c 'L SEWAGE#
VILLAGE � yj/ ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
I
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) /,�o L
NO. OF BEDROOMS
OWNER lC�N.�/ T% ��o r SiV "V
PERMIT DATE: 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 leach-ifig facility Feet
..;
FURNISHED BY
I
i
?
r / i
r-ApvT C 0i+11 F
o 'Por C 11 i
FF,Gt, T-
i
i
i
i
iZ 6—oq
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
BARMAINA Public Health Division
MAM
59. Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: _-/Z7 Sewage Permit# Assessor's Map/Parcel
Installer&Designer Certification Form
t.�.e T
Designer: riy n-e e rn��c.�3 dYw , 1,1 C . Installer: �� d''`
1 Query ��
Address: _ -
> MA
On ( L F &C2L VIIX�'N" was issued a permit to install a
(date) I (installer)
septic system at `� —T;L�� ��� (SQAA'k based on a design drawn by
(address)
dated 7 116 4
(designer)
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. Stripout (if required) was inspected and the soils
were found satisfactory.
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. Stripout(if required) was inspected and the soils
were found satisfactory.
oTAo 00
�O PETER T. GN
(Installer's Signatu o WEN TEE 4,
CZ CIVIL
.o No.35109 Q
90 FO/ S�ti
(Designer's Signature) (Affix De re)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTII. BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice fonnAdesip mertification form.doc
Town of Barnstable P#
Department of Regulatory Services
/ on s v
Public Health Division DXAS& ate
�3
200 Main Street,Hyannis MA 02601
rEn r�txt"
Date Scheduled U Time , n Fee Pd. Up
oil Suitability Disposal
Assessment for Sewage osa l
- g p
Performed By: C f "� �� t
Witnessed By: h
Location Address LOCATION & GENERAL INFORMATION
Owner's Name
9 3 Te I le-9 en-TrQ 1 L. \10n6•er-bul t_T M t9
Address urns+cab lsz I M�
Assessor's Map/Parcel: a 3D I SU / Engineer's Nam, ie ✓4l- �n+e
NEW CONSTRUCTION REPAIR ✓ Telephone# 9 ll,e of t 61
(� 1
Land Use f�S i C�t?v� ,1`r Slopes(%) Surface Stones AJ112,
Distances from:. Open Water Body ft Possible Wet•AreaeLL�t _ft Drinking Water Well ft
Drainage Way ft Property Line `��{'/,_ ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes)
01 sv�
1.
zo
Ii,LC— °v
4 C r) i
Parent material(geologic) GAC C_z.J �.,�-. 5�, Depth to Bedrock NI 4
Depth to Ground wat r StandIng Water in Hole: 7 (3 Weeping from Pit Face /A
Estimated Seasonal High Groundwater "� l . O
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles:
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index Well# Reading Date:_ Index Well level W, Adj,factor- Adj.Groundwater l evel„
Observation
PERCOLATION TEST . butp 7i'lntt,.
*�
Hole#
Time at 9"
Depth of Perc
Time at 6"
Start Pre-soak me @ (� I
- Ti �,l�G� Time(9"-6") _.
End Pre-soak tQ 2
` Rate Min./Inch L2'
Site Suitability Assessment: Site Passed. Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the,
Barnstable Conservation Division at least one (1) week prior to beginning.
Q:4S EPTICIPERCFORKDOC
DEEP-OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency,%(ravel
10 (LS/
t a.v,,- 5,a o (emu
DEEP OBSERVATION HOLE LOG Hole#_ 1
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
(rJ � /�
SS
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,
Consistency. I
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes .
Within 500 year boundary No / Yes
Within 100 year flood boundary No Yes --
Depth of Naturally Occurrine 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?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on l( (�t�t (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 g,expertise and experience described in 310 CMR 15.017.
Signature Date
QASEPTIOPERCFORM.DOC
i COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
V
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
r-.3
Pro Address• 7 3 T//� s
perry;. �.�.e/ 7"!.f'/3i
CcrYTE�zv/l/1r f i'n1�3 � .y
Owner's Name: zLff& --7-A P41Ch C-S'yEy
Owner's Address: -7 3 22 i y&riY 7rf:012
CFw/T ce✓i%/Y Af#
Date of Inspection: ?//G/0 6 �-
Name of Inspector:(please print)�,Ps�,rrs3.on✓� d�M�s
y t
Company Name: 1w1v1sss�.yv✓dsc.��,o� ca+'4r
Mailing Address: LSZ V Ott eW
�fXr��✓.;//tom ,h11.�
Telephone Number: 15-y6-7-7 8-+ 5�9
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: - Date: 3 ./ 6
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address.how the system will perform in the future under the same or different
conditions of use.
Page 2 of 1.1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
- CERTIFICATION(continued)
Property Address: '7!; 7560-�L
Owner:
Date of Inspection: =f111 o�
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
�Ihave not found any information which indicates that any of the failure criteria described in 310 CUR
15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
No 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 rot)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:
q D 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:
N 0_ 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:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7.3 /&rl/.6 ALw TX�
Owner. �YF_.✓Nf Tt} D uc/f-=spy
Date of Inspection: 3/id/a G
C. Further Evaluation is Required by the Board of Health:
1 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:
UU Cesspool or privy is within 50 feet of a surface water
Lo 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: .
00 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
I�Lv 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.
j 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:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: -79 72Fi Ew %7'A/-/
Owner: k;g-1YMc7% bvchEs- nv
Date of Inspection:
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
_ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than May flow
�(p Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
Of times pumped
IVO 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:
_ No Any portion of a cesspool or privy is within a Zone 1 of a public well:
_ LYv_ Any portion of a cesspool or privy is within 50 feet of a private water supply well
_ 4&2 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.]
N b (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;ste
ply to large systems in addition to the criteria above)
yes no
the sywi 400 feet of a surface drinking water supply.
the sy ithin 00 feet of a tributary to a surface drinking water supplythe cy located in nitrogen sensitive area(Interim Wellhead Protection AreaIWPA)or a mapped
Zonepublic 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 CNIR
15304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9i/ -Afly/L
C�y�E ✓�%/w .4 .
Owner: kr I✓N,---7-4 D L*—<h a:sAIZ y
Date of Inspection: 3/i(g/o G
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
_Yes No I
L_ 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?
ve 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?
v----_ _ 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 unac_ceptable) [310 CMR 15.302(3)(b)l
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Ei,- c / 7-R41 C
CLEM2 411r., a .
Owner:
Date of Inspection:
y FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): A40
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): ,tip
Seasonal use:(ves or no):�0
Water meter readings,if available(last 2 years usage(gpd)): 06 7B 000 oSi 73 00o
Sump Pump(yes or no): /1/0
Last date of occupancy: Iy o w
COMMERCIAL INDUSTRIAL
Type of establishment:.
Design flow(based on 10 .203): gpd
Basis of design flow(s ns/sgft,etc.):
Grease trap present(yes no):
Industrial waste hol ' present(yes or no):
Non-sanitary w scharg 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: a Y 2 =�►rc;��.i s s PC9 OW411er.
Was system pumped as part of the inspection(yes or no):_A0
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
TE OF SYSTEM
Septic tank,disif ib ofien bM soil absorption system No. 1).90)e
_Single cesspool
Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information
19. -1 ; A�5 PF r�.�u H<r�r g c R o r� K�c occ ds
Were sewage odors detected when arriving at the site(yes or no):�1l0
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7e v,2
Owner. k,�.a/�t/.�r/i ,�Gii6s.r/E v
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _Z40 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:
Material of construction:�rete_metal_fiberglass_polyethylene
other(explain)
If tank is metal list age: Is age conffimed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: k/ X 5-7"�l
Sludge depth:
Distance from top of sludge to bottom of outlet tee or bale:
Scum thickness: 2, 'O
Distance from top of scum to top of outlet tee or baffle: 19''
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: rmc.v 5VR
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_co to_metal_fiberglass_,polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from t o scum to top of outlet tee or baffle:
Distance fro otto of scum to bottom of outlet tee or baffle:
Date of pumping:'
Comme (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relate to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73 r,_c>i,r raA;A1
—�yr�.o✓ii/Tryac�
Owner: /w�'/ sv�v
Date of Inspection: 3//(L/6 6
(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: gallonstday ,
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.): .
DISTRIBUTION BOX: if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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: (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.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: '?3 T �/Eg�,�/ T�e'•�,L
Iylri;z.
Owner: D crhPsrreY
Date of Inspection: jZ/A.A 4
SOIL ABSORPTION SYSTEM(SAS): r/ (locate on site plan,excavation not required)
If SAS not located explain why:
T"eac
pits,number:
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part.of inspection)(locate on site plan)
Number and configuratiod
Depth—top of liquid torinlet invert:
Depth of lids 1 r.
Depth of er.
Dimensions esspool:
Materials o co on:
Indicatio of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY. (locate on site Ian) .
Materials of co n
Dimensions:
Depth of solids:
Comments(no cou lion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
y
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SERiAGE DISPOSAL SYSTEM INSPECTION FORM
PART C i
SYSTEM INFORMATION(continued)
PmpertyAddress ?3 T.��/��FN T�t'/�i�
_ _,_CE�l�r2d� / �•
Date of Inspection= �//�,/0.6 .
SSETCH OF SEWAGE DISPOSAL SYSTEM
Pnde a sketch of the sewage disposal system including ties to_at least:two peirrt referee landmass or
bend Locate all wells wrtbin 104 feet.Locate where.public water.supply:enteis tlbe bumn.
-777
31
. Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73
GENr'=R d,i/,-, /l+,.4
Owner. kfn�,v�rh u�/%�s.�E�'
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
i,-' Checked with local Board of Health-explain: 07a p s f CAOU y's
Checked with local excavators,installers (attach documentation)
_Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
To Po yj.3
Aiit/ 36 u/G
o2,2 -o
/4 DST. �2 y
V
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
odo
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632 3U SU
Name of Owner ROBERT SHIELDS
Address of Owner: 1 GROUND COVER LANE SANDWICH MA.02563
Date of Inspection: 10/31/00
Name of Inspector: JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) 1_
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX.2119 TEATICKET,MA.02536 (�'1�r p
Telephone Number: 608-564-6813 FAX 508-564-7270 C j
NOV
CERTIFICATION STATEMENT a� 9 n� i
1 certify that I have personally inspected the`sewage disposal system at this address and that the'information:rep�orted be2lOUtrue,accurate
and complete as of the time of inspection.The'inspection was performed based on my training and.experience;in heejproopper function and
maintenance of on-site sewage disposal systems.The system:
X Passes _`
_ Conditionally Passes / L
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 11/2/00
The System Inspector shall s bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defiried in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,
inspection does not imply any warranty or'guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
revised 9/2/98 Paae 1 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner ROBERT SHIELDS
Date of Inspection: 10/31/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
n& The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the
septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure
is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved
by the Board of Health.
Na Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction is removed
_distribution box is levelled or replaced
I]& The system required pumping more than four 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
E-.
� y
revised 9/2/98 Paoe 2 of 11
�: i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner ROBERT SHIELDS
Date of Inspection: 10/31/00
4
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 the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I:
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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,Method used to determine distance n1a (approximation not valid).
3) OTHER
n/a
;t'l
I .
revised 9/2/98 Paoe 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner ROBERT SHIELDS.
Date of Inspection: 10/31/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an 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 1/2 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 n/a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health
and safety and the environment because one or more of the following conditions exist:
sty ri,
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of
the Department for further information.
revised 9/2/98 Paoe 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner: ROBERT SHIELDS
Date of Inspection: 10/31/00
Check if the following have been done:You must indicate either"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 - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that
period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X - The system does not receive non-sanitary or industrial waste flow.
X - The site was inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X - The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material
of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site
has been determined based on:
X - Existing information,For example,Plan at B4O,H,
Xa„
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 1 5.302(3)(b)J
u`t.
X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
8fl1
it
revised 9/2/98 Paqe 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner ROBERT SHIELDS
Date of Inspection: 10/31/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom ,J
Number of bedrooms(design): 4 Number of bedrooms(actual): FM �l
Total DESIGN flow: 440 gpd
Number of current residents:0
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: 614/00
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow: n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to'date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM IS 21 YEARS OLD
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Paoe 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner ROBERT SHIELDS
Date of Inspection: 10/31/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 14"
Material of construction: _ cast iron _ 40 Pvc X other(explain)
Distance from private water supply well or suction line: n/a
Diameter: nla
Comments: (condition of joints,venting,evidence of leakage,etc.)
TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 8"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: nla
Dimensions: 1000G L 8'6"H 5'7"W 4'10""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.) n
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SEPTIC SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.THERE ARE SOME ROOTS COMING IN ON INLET SIDE OF TANK.
GREASE TRAP: _
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: nla
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: nla
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
nla
revised 9/2/98 Paoe 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner ROBERT SHIELDS
Date of Inspection: 10131/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence-of solids carryover,evidence of leakage into or out of box,etc.)
n/a
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nla
j,.
revised 9/2/98 Paae 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner ROBERT SHIELDS
Date of Inspection: 10/31/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by nun-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number: (1)1000 GAL 6'X 6'
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE
INSPECTION.THE PIT HAS NOT HAD MORE THAN 1'OF WATER IN IT.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments: i.
(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2/98 Paoe 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner ROBERT SHIELDS
Date of Inspection: 10/31/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
El
A I
A
G f:_
� Fria
AA
3`74
II$
� ayb
revised 912/98 Paae 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73 TELLEGEN TRAIL CENTERVILLE, MA 02632
Name of Owner ROBERT SHIELDS
Date of Inspection: 10/31/00
NRCS Report name: n/a
Soil Type: nla
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
Checked local excavators,installers
X Used USGS Data
9i!
y p,ip
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
revised 9/2/98 Paoe 11 of 11
-No..-.1_2- .......... s Fnx._,Z:...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
---....OF........ ...... t j --_ .�'-----------.................
Appliration for Utspoii tl Works Tonstrurtion Vantit
Application is hereby made for a Permit to Construct or Repair ( / an Individual Sewage Disposal
Y
S stern t• �` l
` ......- :G- ..... � .......-- fir ' ---------------------------------•---.--
a Loca o -Addres or Lot No.
......... ....Z2-• ........ . ..... . . ..................•....... ---••---------------------..__........._..-------------••••-------..............................
ner Address
Installer Address
UTy e of Build Size Lot_________________________-Sq. feet
,-� Dwellin�gjj—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
1:14 Other—Type of Building ---------------------------- No. of persons_-_--__.-_----..______----__ Showers ( ) — Cafeteria ( )
Q' Other fi u ------------------------------------------------------------------------
Design Flow__.._..__._... .... .......-gallons per person per day. Total daily flow__---------- ... __....... ........_gallons.
WSeptic Tank�Liquid capacity.__. gallons Length................ Width---------------- Diameter---------------- Depth--------------
Disposal Trench—N . .................... Width------_-__ _ Total 1 ............ Total leachingarea.....................s ft.
Seepage Pit No... -------- Diameter/-_ %... e�ow inlet.................... Total leaching area__j-f _ q. 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-----_-_-_.--.__--__-...
w Test Pit No. 2................minutes per inch Depth of '.rest Pit.................... Depth to ground•water..._............_.......
9 ----------- ---- -----------------
-
O Description of Soil........ _
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
UNature 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 bee • sued by the bo rd of h lth.
Signed. - -------------------- --------------------------------
Application Approved BY G .�- --r----• <#/PC ae
Application Disapproved for the following reasons---------------------------------•----------------------------------------------------------•------------------.
---------------•---•----------------•----------•------------------------•-- --------------•---....•--•----------•-----•------•--•--•------------•---•------------------------------••-------••-•----
Z ,3---.Date
---
Permit No......................................................... Issued........-� 1----- --- ------
Da e
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HEAL
Appliratio t for Uhipoiia1 Norkil C onri#rurtion Prrmit
Application is.hereby made for a Permit to Construct (f'. ) or Repair ( an Individual Sewage Disposal
Syst of: .
re ;
--
re or Lot No.
Loc ierd- -- ------------•--- ••••-••-••----••-••----- Address
Installer Address
TPwNo.
Size L'ot___________________________Sq. feet
U.
Dwellin of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`.4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
`4 P4 Other fixtuTA
W Design Flow..........._ _gallons per person per day. Total daily flow-_____---- .._ . .........---------------- ---- --- - -- ------
WSeptic Tank-Liquid capacity _.gallons Length___.. . ._____ Width________________ Diameter__---- _______ eptli-_ -_. . --- .
x Disposal Trench-N__.................... Width__ _ Tot�a 'engtl �______:____ Total leaching area---------...........sq. ft.
Seepage Pit No _________ Diameter ep del in e __---------_------- Total leaching area _ °_ sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by______________________________________________________
a •------------------- Date---------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit----._.________.__. Depth to ground water---__--__-__-_-_____---.
LL, Test Pit No. 2................minutes per inch Depth.of Test Pit.................... Depth to ground water.-----__----__-_-_------
ODescription of Soil----- •--- ----•--••-------------------------------------------------------------------------------------------------------
x
W
--------------------------------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------
UNature 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 bee tied by the b rd of h lth.
f % ,
Sign ed.....- =-2` % ram ` --------------------------------
Dam,
Application Approved B
PP PP Y--------- �•�- � --- --- -- - --- - - -------a------- --- --•---•-
Lj ate
Application Disapproved for the following reasons:-----------------------------------------------------•---•-------------------------•--------------------------
...-•---•----•••---------------.........................................................•-------------•--------•----------..-•-------•-----------_.._..•---------------------------------•-•--------•-
Date
PermitNo........................................................ Issued.-----...------........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ........OF....
"WTrrttf irativ of Toutpliazlirr ,,
T IS IS TO CE FY iI t the Individual Sewage Disposal System constructed ( ) or Repaired ( )
` Inatalle
at ( .. a' '• •----- --•----•------------•--------•-------------------
has been installed in accordance wit H the provisions of Article XI of`The State Sanitary Code de cr4ed in the
application for Disposal Works Construction Permit No____________________________ __________ dated.___ ._ _ ____.___.__________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN E THAT THE
SYSTEM WILk FUN TIONN SATISFACTORY. 11
DATE.------�// 'Z 7v...................................... Inspector• :•---------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF .HE
No....... -••----•-- FEE ...................
lVorks T , Mr tort anift
Permission is hereby granted==. --- �� " =-" " ------------------------------------••-
to Const uc •( o epair, y Individual Sewap ispp a Syste
at Noy _. _ _._.... -- r '
f Yt Street f
as shown on the application for D�spos�al Works ConstructVP
e mit No ._ _ Datedr __
:r ,
-- -t
oar of Health
DATE. .....................
FORM 1255 HOBBS & WARREN INc 4:,PUBLISHERS `
Wequaquet
Lake
N
5P PB 254 PG 52 (LOT 6)
Q�� ® /
°
HERRING RUN
d o A Dr
Scour Line of ditch _•�•
• �
Great Marsh Rd 0 ^ R0 2a 9 I — _ --------96-770.08' _------- 96 �l
�e9 6� 8--- -9- --
Route 28 ? We LOCUS 8 -\ _ _ — -1-GO— ——— — ——_— --\10,
st Main St 10 — p
LOCUS MAP - _
NOT TO SCALE 106
8 ��\ 106
-- EXISTING CONTOUR __ - - —� / -70
x 100.98 EXISTING SPOT GRADE
W EXISTING WATER SVC. LOT 6
G EXISTING GAS SERVICE C� 20,080E S.F. \ / a
—O.H. W-- OVERHEAD WIRES map 230
TEST PIT
'� Ponce/ 150
BENCHMARK _ _- --- a `
LEGEND
106,61 \�
O �
AV
O C
. Benchmark Set
OUTSIDE CORNER/CONC. STEP \ O to
(orange paint mark) i DECK \
EL.=108.16 (Assumed) BUFFER ZONE _
.®. .— — ...... .......
EXISTING SEP11C TANK
TOP OF TANK, EL.106.24 0 Q EXISTING
INV.(OUT)=104.91E
a PORCH HOUSE (#73)
TO.F.=109.13t
1 p6�1
EXIS77NG LEACH PIT �- N
TO BE PUMPED, FILLED W/ c^� PAVED
SAND AND ABANDONED 'A DRI VEWA Y
gyp. � ��?k3 43 D S � •1
� ,, l�'q•S, 0 10�
68 t
TP-2
�2.12 / �\ 43'
VENT n i
GENERAL NOTES: o`P�P�r �.00. _ L5O. 0 1
z
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 07'01Y00" E
BOARD OF HEALTH AND THE DESIGN ENGINEER. ✓� '
2_ ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS S
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE .0
LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: `
310 CMR 15.405(1)(b): ,
1) A 2' variance to the 3' maximum cover requirement, for no greater 'l edge of pavement I
than 5' of cover. S.A.S. shall be vented and H-20 Rated. �9s ^ O99
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR D
INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
D TELLEGEN TRAIL
DESIGN ENGINEER. rci
4ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGNENGINEER BEFORE CONSTRUCTION CONTINUES. ER T.
5. ALL ELEVATIONS BASED ON ASSUMED DATUM. NTEE
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF OWNER OF RECORD CIVIL
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF LOUD, JOSEPH M No. 35109
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. % VANDERBILT MTG & FINANCE INC A9 '£PSI
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. P.O. BOX 9800 E
8. THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S. 500 ALCOA TRAIL
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS MARTVILLE, TN 37804 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE PLAN REFERENCES: PLAN BOOK 254, PAGE 52 LOT 6 11
DIRECTED BY THE APPROVING AUTHORITIES.
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY PROPOSED SEPTIC SYSTEM UPGRADE PLAN
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 73 TELLEGEN TRAIL, CENTERVILLE, MA
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS Prepared for: B & B Excavation, 14 Teaber Lane, Forestdale, MA 02644 y
IN THE -AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND P rY
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). Engineering by: SCALE DRAWN JOB. NO.
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE "Inc.
INSPECTED.BY HEALTH DEPARTMENT PRIOR TO BACKFILL. Engineering Works, 1 =20> P.T.M. 176-09
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. (508) 477-5313 7/16/09 P.T.M. 1 Of 2
lL
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL:104.69
FOR A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S.
SEPTIC TANK PROPOSED D—BOX PROPOSED S.A.S.
INSTALL RISERS & COVERS OVER INLET & INSTALL WATERTIGHT RISER & INSTALL INSPECTION PORT SET TO 3" OF FINISH
T.O.F. OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE GRADE & PLACE REBAR AGAINST CAP FOR LOCATING
EXISTING F.G. FL.=107.0+ F.G. EL: 108.5t F.G. EL: 109.69 (MAX.) VENT
\
MAINTAIN 27. GR REBAR
ADE MIN. OVER S.A.S. i
L = 48' 7INV.=104.25
6' TWO 2'x3'x43' LEACHING TRENCHES WITH
MW
® S=17 (MIN.) % (MIN.) SCH 40 PERF. PVC DISTRIBUTION LINES
3.
4'SCH40 PVC 40 PVC
s'
ia•I CONN /
rT
i a• s
2' EFF. LINES VE
EXISTING as' LIQUID DEPTH
LEVEL
AM SLOPE OF PERF. PIPE = 0.5%
GAS BAFFLE INV.=104.42 PROPOSED
INV.=104.91 f D—BOX INV.=104.19 43' EFFECTIVE LENGTH
EXISTING 2 OUTLETS (MIN.) INV. EL.=103.97(END)
EXISTING SEPTIC TANK
SOIL ABSORPTION SYSTEM (PROFILE)
IITS
MAINTAIN 2% GRADE (MIN.) OVER SA.S.
NOTES: 2" LAYER OF1/8"-1/2" DOUBLE WASHED
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE STONE (OR APPROVED FILTER FABRIC)
INVERTS, PRIOR TO INSTALLATION. BREAKOUT ELEV.=104.69
2) D—BOX SHALL BE SET LEVEL AND TRUE TO GRADE 2'
ON A MECHANICALLY COMPACTED SIX INCH CRUSHED
STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). BOTTOM ELEV.=101.97 TWICE EFFICTIVE WIDTH
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 3' 6' 3'
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 5' MIN. ABOVE BOTTOM OF 12'
AS MANUFACTURED BY TUF—TITE, ZABEL OR EQUAL. T.P. EXCAVATION OR G.W.
NO G.W. EL: 96.5 TWO 2'x3'x43' LEACHING TRENCHES
SOIL ABSORPTION SYSTEM (SECTION)
N.TS
3/4"-1 1/2" DOUBLE
WASHED STONE
SEPTIC SYSTEM PROFILE
N.T.S.
SOIL LOG (3) 5" DWOUTLETS
DATE: JULY 16, 2009 (REF#12,632) 15.5" 2".
SOIL EVALUATOR: PETER McENTEE PE(SE#1542)
WITNESS: DAVID STANTON 7 ,
HEALTH AGENT
' . ELEV. TP--l-—DEPTH —- ELEV:-- TP—`2 DE 1
DEPTH ._ �--1 a "
2
11
109.5 A 0 108.0 A 0" 15.5 $"
6" is
SANDY LOAM SANDY LOAM
108.5 1OYR 412 107.3 1OYR 4/2
12" 8" I
B SANDY LOAM B SANDY LOAM H—1 0 LOADING 2"
107.0/104.7 10YR 5/8 30/58" 105.3 10YR 5/8 32
C C 42„ D—BOX
N.T.S.
PERC
54"
M—C SAND M—C SAND
2.5Y 6/4 2.5Y 6/4
EXIS7/NG
98.0 138" 96.5 1 138" PORCH HOUSE (#73)
TO.F.=109.13t
PERC RATE <2 MIN/IN. ("C" HORIZON)
NO GROUNDWATER OBSERVED
DESIGN CRITERIA N s,
NUMBER OF BEDROOMS: 4 BEDROOMS M
SOIL TEXTURAL CLASS: CLASS I
DESIGN PERCOLATION RATE: <2 MIN./INCH
DAILY FLOW: 440 G.P.D.
DESIGN FLOW: 440 G.P.D. C•�CNE
GARBAGE GRINDER: NOco
43•�`��
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY �•
LEACHING AREA REQUIRED: (440) = 594.5 S.F.
.74 S.A.S. LAYOUT
INSTALL TWO 2' x 3' x 43' LEACHING TREHCHES WITH STONE PROPOSED SEPTIC SYSTEM UPGRADE PLAN
. AND SCHEDULE 40 PERFORATED PVC DISTRIBUTION LINES 73 TELLEGEN TRAIL, CENTERVILLE, MA
SIDEWALL: 2 TRENCHES x 2 SIDES/TRENCH x 2' x 43' = 344 SF
BOTTOM AREA: 2 TRENCHES x 3' x 43........................... = 258 SF Prepared for: B & B Excavation, 14 Teaberry Lane, Forestdale, •MA' 02644
TOTAL AREA:.................... SF Engineering by: SCALE DRAWN JOB. NO.
Engineering Works, Inc. NTS P.T.M. 176-09
DESIGN FLOW PROVIDED: 0.74 GPD/SF(602 SF) = 445.5 G.P.D. 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 7/16/09 P.T.M.'• 2 Of 2
f