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HomeMy WebLinkAbout0066 TERN LANE - Health 66 Tern Lane Centerville A = 192 027 OW471-UtUe NO. 1521/3 ORA 10 k % Commonwealth of Massachusetts Title 5 Official; Inspection Form a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `M 66 Tern Lane Property Address RamsayCrain Owner Owner's Name information is required for every Centerville MA 02632 1/15/2014 page. City/Town State Zip Code Date of Inspection Inspection results must be sjubmitted 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 on the computer, use only the tab ect Inspor: ± key to move your 1. cursor-do not use the return James Ford key. Name of Inspector r j . rea Company Name P.O. Box 49 Company Address rerun Osterville MA Cityrrown 02655 State Zip Code 508-862-9400 S12482 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 try o, 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 'i ❑ Conditionally Passes ❑ Fails 1 ❑ Needs Further E luation�by the Local Approving Authority i 1/22/14 Ins tor's Signature Date Th s stem 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 10,000lgpd 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 describeslp'onditions 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 cone''.ti;ons of use. ; i t5ins•3/13 Title 5 Official Inspeclio F r Subsurface Sewage Disposal System•Page 1 of 17 4' Commonwealth of Massachusetts Title 5 Official; Inspection For a Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments essments _ *M 66 Tern Lane Property Address Ramsay Crain Owner information is Owner's Name required for every Centerville MA 02632 page. City/Town 1/15/2014 State Zip Code Date of Inspection B. Certification (cont.) , Inspection Summary:.Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: l is B) System Conditionally Passes: t ❑ One or more system cdmponents as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, the Board of Health, will pass. p as approved by t '' 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 A 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 s`replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): (L i S; t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 it 9 a 4' Commonwealth of Massachusetts Title 5 OfficiAt Inspection Form a o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r� 66 Tern Lane I! Property Address Ramsay Crain Owner Owner's Name information is required for every Centerville MA 02632 1/15/2014 page. City/Town State Zi Code P Date of Inspection B. Certification (cont) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage,backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s),are:replaced ❑ Y ❑ N ❑ ND (Explain below): I ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box.is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below , ' o p, ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspecf.on if(with approval of the Board of Health): ❑ broken pipe(s) hre replaced ❑ Y ❑ N ❑ ND (Explain below): b, ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i` 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 F. 1 _ El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 ;; Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Officil"' inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Tern Lane f 1y A t' Property Address Ramsay Crain Owner F' information is Owner's Name required for every Centerville MA 02632 1/15/2014 page. City/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. ElThe system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ' ❑ The system has a skeptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septi F c tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private wa)er supply well". Method used to determine distance: I! **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. ' 3. Other: I. r . 1' i k D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" o'r`°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 clog yged SAS or cesspool ❑ ® Liquid:pepth in cesspool is less than 6" below invert or available volume is less than Y2.day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r '• t " i Commonwealth of Massachusetts Title 5 Officialt Inspection Form Subsurface Sewage Disposal .system Form - Not for Voluntary Assessments 66 Tern Lane Property Address k Ramsay Crain Owner k information is Owner's Name required for every Centerville MA 02632 1/15/2014 page. City/I own State Zi Code �� P Date of inspection- B. Certification (cont.) Yes No it ❑ ® Reqdiriid 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 por',tion 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 0ortion of a cesspool or privy is within 50 feet of a private water supply well. i ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system;passes if the well water analysts, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00o'gpd. ® 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. f. E) Large Systems: To be coinsiidered a large system the system must serve a facility with a design flow of 10,000 gpd�io�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. Y ' Yes No i i ❑ ❑ the sysl�tem is within 400 feet of a surface drinking water supply 1 , , ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ,i ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area ri I\VPA)or a mapped Zone II of a public water supply well If you have answered "" es to any y 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 DepartOe'nt. t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1} } d , Commonwealth of Massachusetts Title 5 Official; Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Tern Lane ' Property Address ! Ramsay Crain Owner Owner's Name information is t required for every Centerville MA 02632 page. City/Town 1/15/2014 t State Zip Code Date of Inspection C. Checklist Check if the following havd been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumpip, g!information was provided by the owner, occupant, or Board of Health l ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected,for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? i 4 ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The siie 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 approxi(nation of distance is unacceptable) [310 CMR 15.302(5)] i D. System Information J Residential Flow Conditions,. Number of bedrooms (design): 5- Per as Number of bedrooms (actual): 5 built card ( ) DESIGN flow based on 310.CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 4i q 15ins-3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 e ' 6 r ; . i i Commonwealth of Mas!achusetts W Title 5 Officials: Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `M a 66 Tern Lane Property Address Ramsay Crain Owner Owners Name information is required for every Centerville MA 02632 1/15/2014 page. City/Town I i State Zip Code Date of Inspection D. System Information Description: P' rl ;i Number of,current residents 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes. ® No Laundry system inspected?, ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: ` unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 �MR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): t . 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i I - s s' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` . 66 Tern Lane i Property Address Ramsay Crain Owner Owner's Name information is required for every Centerville MA 02632 1/15/2014 page. City/Town State Zi Code P D. System Information (cont.) Date of Inspection Last date of occupancy/use: Date Other(describe below): } General Information Pumping Records: Source of information: Was system pumped as part of the inspection? El Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,;distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenancb contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 8 of 17 I 1 I Y Commonwealth of Mas4achusetts Title 5 Official Inspection For Subsurface Sewage Disposal .system Form- Not for VoluntaryAssessments essments `M 66 Tern Lane Property Address Ramsay Crain Owner Owner's Name information is required for every Centerville n MA 02632 1/15/2014 page. City/Tow State Zi Code P Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: installed -5/21/2007 per i'fo' Were sewage odors detected:when arriving at the site? s. ❑ Yes ® No Building Sewer(locate on;site plan): t Depth below grade: I I I feet Material of construction: ; ❑ cast iron ® 401PVC ❑ other(explain): Distance from private water,supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): f. P Septic Tank(locate on sitel.;plan): Depth below grade: , 16" fi! feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene 9 l ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gals. Sludge depth: 2" f: i! t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 �i � i Commonwealth of Maslachusetts Title 5 OfficiWl Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 66 Tern Lane M 9 Property Address r ?' Ramsay Crain Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town �' '' 1/15/2014 State Zi Code P Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scltm to bottom of outlet tee or baffle 15 How were dimensions determined? measure i�1 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present. The tank was H-20. The outlet cover was to grade. t K Grease Trap (locate on site,;plan): Depth below grade: ;. feet Material of construction: ❑ concrete ❑ metal' ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: F' Date t5ins•3113 f Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t. ii Commonwealth of Massachusetts W Title 5 Officipl Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `M a 66 Tern Lane t ' Property Address � . Owner Ramsay Crain I kl information is Owner's Name i. required for every Centerville MA 02632 page. City/Town 1/15/2014 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i . Tight or Holding Tank(tah,k must be pumped at time of inspection)(locate on site plan): Depth below grade: F. Material of construction: ' ❑ concrete ❑ metalF ❑fiberglass 1, 9 Elpolyethylene Elother(explain): N/a i Dimensions: Capacity: gallons Design Flow: 1 gallons per day Alarm present: El Yes ❑ No i� Alarm level: Alarm in working order: ❑ Yes ❑ No s� Date of last pumping: ! Date Comments (condition of alarirn and float switches, etc.): i , *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official: Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 66 Tern Lane } Property Address Ramsay Crain Owner Owner's Name information is required for every Centerville MA 02632 1/15/2014 page. City/Town 1 State Zi Code '! P Date of Inspection D. System Informati0h (cont.) Distribution Box(if present:must be opened) (locate on site plan): i '; Depth of liquid level above"outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was normal. The D-box had risers and the cover was 3" below grade. 9 1, t 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.): N/a 3� * If pumps or alarms are notn`working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: L15ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 66 Tern Lane Property Address Ramsay Crain Owner information is Owner's Name required for every Centerville MA 02632 1/15/2014 page. Clty/Town State tip Code Date of Inspection P D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching charrt'bers number: ❑ leaching galleries number: ® leaching trenches number, length: 2'x 13'x 42' per as-built ❑ 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.): ' There was no signs of failure. Used a camera to inspect Cesspools (cesspool must Pe pumped as part of inspection)(locate on site plan): Number and configuration N/a Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool t Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I •, Commonwealth of Masalchusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M ,•'•y 66 Tern Lane Property Address Ramsay Crain Owner Owner's Name information is required for every Centerville MA 02632 page. cltyrrown 1/15/2014 State Zip Code Date of inspection- D. System Information (cont.) Comments (note condition!of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): �i lq u i Privy(locate on site plan): Materials of construction: Dimensions I Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of pondin condition etc.): 9, n of vegetation, N/a i is R i L15,ns 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 66 Tern Lane Property Address Ramsay Crain Owner Owner's Name information is required for every Centerville. MA 02632 1/15/2014 page. City/Town State ZipCode Date of Inspection D. System InformatioI n (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 A- �r0K • Q 2.0 31 .13\ 4 h O 01` L L o � o 3 3 a a� t t i 1' f ` i 'I i t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 u Commonwealth of Massachusetts • W Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M a 66 Tern Lane Property Address !I 4) Ramsay Crain Owner Owner's Name information is required for every Centerville MA 02632 1/15/2014 page. City/Town '' State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells , Estimated depth to high ground water: 15, s 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 Id cal Board of Health-explain: Using topo and!,water contours maps ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: The house is on Weguaquet Lake and took elevations from the lake F Before filing this Inspection Report, please see Report Completeness Checklist on next page. l t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i !I e _ I i Commonwealth of Massachusetts H - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 66 Tern Lane .i 1 Property Address Ramsay Crain Owner Owner's Name information is required for every Centerville MA 02632 page. Clty/Town 1/15/2014 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Itstimated depth to high groundwater d • ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r r I i � n i i. ii •. i o � F ' t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 j Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 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 I on the computer, ( „ use only the tab 1. Inspector: V key to move your cursor-do not Mike DeCosta Jr. use the return Name of Inspector key. Wind River Environmental Company Name 1958 R Broadway Company Address Raynham MA 02767 City/Town State Zip Code 508-822-2003 13230 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 .0 1/9/11 Inspector's Signatur 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. l5ins•11/10 Title 5 Official Inspection Form:Subsurf e S age Disposal S stem•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: No filter installed on outlet tee-recommend installing. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 1119/11 page. City/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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ 'N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. - El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. CityfFown State Zip Code Date of Inspection C. Checklist Check if the following have been done'. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w a'' 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Home has irrigation system used heavily in 2010-5000,700 gallons used(broken irrigation sprinkler head) 2009- 173,000 gallons 2008-187,000 gallons 08-09 aver ae daily used is 500 pd. Sump pump? ❑ Yes ® No Last date of occupancy: 08/2011 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Tern Lane M SV e Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. CitylTown 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: Wind River Environmental Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500gallons How was quantity pumped determined? previous pumping records Reason for pumping: to check structural integrity of septic tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Approximately May 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints sealed, no leaks vent pipe installed on roof. Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: + years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 5' I Sludge depth: 6" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. Cityrrown 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 35" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 20" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert evidence of leakage, etc.q 9 � ) Liquid level is normal, inlet and outlet tees installed. No filter on outlet-recommend installing. No buildup on inlet, minimal solids and sludge. Tank is structurally sound and not leaking. Recommend servicing tank every 18-24 months. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness r Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle I Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? , ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is 36" below grade on a riser to 3" below greade. Two outlets-both accepting equal flow-liquid level normal, minimal carryover into box. Box will be serviced as part of inspection. Box in good overall condition showing no signs of deterioration and is water tight and not leaking PumpChamber locate on site plan): ( p ) 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: Lt5ins1/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 3@ 4' x 4' ❑ 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.): Galley's dry-dry rocky and no ponding. Showing no signs of hydraulic failure. Vegetation is normal 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 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t5ins• 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. CitylTown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Assessing As-Built Cards Page l of 1 M r— TOWN OF BARNSTABLE LOCATION 6 SEWAGE 42007=196 VILLAGE an,.nDelih ASSESSORS MAP&LOTAO a.? INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FAC[LnY: (type) NO.OF BEDROOMS— WELDER OR OWNER PERMTTDATE: I I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5.3 Feet " Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200'feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility Feet Furnished by "11 0� -�-� , a ay•-5 a 6- 1 -3F-c) d 3 H LC 6// j httn //town.barnstable.ma.us/Assessing/HMdisplay.asp?mappar=192027&seq=1 11/11/2011 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 5.3 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: May 2007 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Obtained ground water information from plans online during Perc testing for property. Test hole was dug and groundwater was encountered at 63"and 5.3'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 66 Tern Lane Property Address Ashley Haseotes Owner Owner's Name information is required for every Centerville MA 02632 11/9/11 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 _ TOWN OF BARNSTABLE LOCATION !�6 N WYL 49M SEWAGE 4007- 1 q 6 ILLAGEC;Q,%RAX)ix ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. , SEPTIC TANK CAPACITY I r LEACHING FACILITY: (type) (size) a/� 1 44a/ NO.OF BEDROOMS 5 S�RAA--) BUILDER OR OWNER PERMITDATE: S I f 107 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 3 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 leachin facility Feet Furnished by m IA a' Qo, a 3 o y a9 3- 1 3 1. y 0 X TOWN OF BARNSTABLE 'LOCATION / J SEWAGE# VILLAGE �/4 AS SSOR'S MAP&f PARCEL O;STA T T nn NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS OWNER ou PERMIT DATE: DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY .............. . ....... ... .. . . .......... .... . ... . . ..... .. ... . .. ............ ......... ..... ......... .... .. ......... ....im ........ 20 21 27 7 31 39 a No. 0'�" ` —/ 46 i Fee ^�-• r z THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pphratiou for Ii.5po!5aY *pgtem Con5tructiott permit Application for a Permit to Construct( ) Repair( ) Upgrade(� Abandon( ) ❑ Complete System U Individual Components Location Address or Lot No. 66 I1�� lav2 Owner's Name,Address,and Tel.No. �,yLpt w Assessor's Map/Parcel I �' � 6 6 Installer's Name,Address,and Tel.No. d U Designer's Name,Address and Tel.No. W AA&LQpA4* P. cR �kbAoe y 3�-Szab 13.6.x. y►j '77 S-0 7 3 5 Type of Building: �^ Dwelling No.of Bedrooms 5 Lot Size ��,�g 0( sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 110 gpd Design flow provided 564.2 gpd Plan Date 5116101 Number of sheets , Revision Date Title Size of Septic Tank I Slab Type of S.A.S. Description of Soil A-2e- ,4jb4nt Nature of Repairs or Alterations when applicable) �.QQ� apQg�„� I n 7— SOU �!4 L�Qn w1rPYJ(o j 1 1 . -Sl 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. Signed ` Date S k I0 Application Approved Date 5112167 Application Disapproved by:. Date for the following reasons Permit No. 4,,,,,Date Issued t f� � &.. tom_ f.. -• mow, y1.tom": +o: , �• C Fee `' "� Entered in computer: �. THE,COMMONWEALTH OF,.MASSACHUSETTS �- ;PUBLIC HEALTH DIVISION,,-TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIP � rication forogar �§pgterrY eou5tructionerntit Application for a Permit to Construct(s), Repair( ) Upgrade( �/ Abandon( ) ❑ Complete System LJ Individual Components Location Address or Lot No. 6 6 j�JW\. �yn � Owner's Name,Address,and Tel.No. Y&QQ,".4 Assessor's Map/Parcel 19a a Installer's Name,Address,and Tel.No. Ov Designer's Name,Address and Tel.No. zo-pa. k fla,,U � �.�o LI 3�- S 7cr!J 7�S=0 7 3 S Type of Building: Dwelling No.of Bedrooms Lot Size (JO sq.ft. Garbage Grinder ( ) Other Type of Building _"jrxAjC e. No.of Persons Showers( ) Cafeteria( ) Other Fixtures U Design Flow(min.required) I 10 gpd Design flow provided gpd Plan Date S 1 10 I O Number of sheets Revision Date A..,, Title Size of Septic Tank I SCJC> Type of S.A.S. Description of Soile- ►_ n� Nature of Rep_a/irs,or Alterations(Answer when applicable) ,[J�,i_U., Date last inspected: r 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. Signed Date S 111 ((}-2 Application Approved b Date Jr Z 0 y 77 Application Disapproved by: Date for the following reasons Permit No. C�77172 ")17 Date Issued fl D ---------------------------------------------- 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 % . y (,(� 4�. at 6 6 no_,-A-_v f-y-,- U has been constructed in accordance A�0 with the provisions of Title 5 andthefor Disposal System Construction Permit No,. '� 7^"��� dated _5 7. Installer �J Designer WALQk/t k #bedrooms 5 Approved design flow gpd The issuance of this permit shall not be /o�ns�tr/ued as a guarantee that the system w�il sfultitiioonJ.as/d/esiglnedAl�j4 �yf Date - � � ��/1 ./ Inspector /, /( AW 0 :' !/!4'?l s � -' No. V /� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS =45pogat 6p5tem Cougtruction 30ermit Permission is hereby grantepo-Construct ( ) Repair ( ) Upgrade (L/) Abandon ( ) System located at 6(- , -S?Jt1v�_ ivv &_N&/VU'kb `i' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must e completed within three years of the date of this permit. Date ������ Approvedd r—'� Nutter Patrick M. Butler Direct Line: 508-790-5407 Fax: 508-771-8079 E-mail: pbutler@nutter.com MEMORANDUM May 15, 2007 #107763-1 Via Email TO: Tom Perry CC: Mr. and Mrs. Glenn Tobin (via email) FROM: Patrick M. Butler RE: 66 Tern Lane, Centerville Tom, As you may recall, I prepared a deed restriction for the owner of this property relating to the use of the garage. In the interim, the owner has initiated discussions with the Board of Health, which we believe will lei the issuance of a permit for an increased septic system capacity to 5 bedrooms. ccordingly, the deed restriction will no lon er be necessary, s ou d that s stem be put into place The use of t e garage w1 continue to be an accessory use (i.e., no kitchen act ltles or permanent use). I anticipate having final permits and construction take place in the next thirty days and I will keep you advised. Accordingly, I am holding the deed restriction in my file. Please feel free to contact me should you have any questions. PMB:cam 1630512.1 CCL. Nutter McClennen&Fish LLP ■ Attorneys at LawJ,`��oZ 1513 lyannough Road, P.O. Box 1630 ■ Hyannis,MA 02601-1630 ■ 508-790-5400 ■ Fax:508-771-8079 ■ www.nutter.com From: Cynthia McGrath To: tom.perry@town.barnstable.ma.us Subject: Memorandum from Pat Butler re: 66 Tern Lane Please see the attached memo from Pat regarding the 66 Tern Lane property. Thanks, Cindy MAY-07-2007 MON 09:40 AM FAX NO. P. 02 Patrick M.Butler Direct c Line: 508 790-5407 NuttFax: 508-771-8079 L;-mail: pbutier@nucter.com MEMORANDU May 2, 2007 #107763-1 Via Email TO: Thomas McKean, Health Agent CC: om Perry, Building Commissioner FROM:. atrick M. Butler CO C? E: 6 ern Lane, Centerville ssor's Map 1920, Parcel 27 _ f'om, a his wi serve to confirm our discussions earlie .this week regarding the above e� 91 property. As Vindicated, 1. have previously reached agr ment with the Building P y� Commissioner for the recording of a deed restriction wi i reference to theeed pending building p oh'bits permit application for completion of the garage tmprov ent s. This d the use of any portion of the garage for bedroom use. Duringour meeting on Monday with Anna Brig am, based upon a review of your files, of contribution nor in a Zone we confirmed that the property is not within the 1,993 z ne our clients w have discussed, the ro e As e Accordingly, the 330 Rule does not apply to p P � wish to voluntarily upgrade the septic system from a the a bedroom to a four bedroom to comport with the number of bedrooms in the house. T is voluntary agreement has no relationship, whatsoever, to the garage construction an: renovations. Accordingly, his will or confirm our agreement that you will authorize the issu• ice of the updated building permit the garage only and that we will agree to proceed on ar expeditious basis to upgrade the Title V system to four bedrooms. This will reiterate my req est for an expedited scheduling of update pert test I will explore with the Town Attorney: ' office other possible mechanisms to expedite the septic installation. Please feel free to contact me should you have ny questions concerning the enclosed. PMB:cam 1628152.1 Nutter McClennen &Fish LLP Attorneys at Law 1513 lyannough Road,P.O. Box 1630 ■ Hyannis,MA 02601-1630 ■ 08-790-5400 ■ Fax-.508-771-8079 . www.nutt®r.com MAY-07-2007 MON 09:40 AM FAX NO. P. 01 I�L Nutter FACSIMILE TRANSMITT SKEET `Y,�day's Date: May 7, 2007 Time: 9:37 AM rnployee ID: # of Pages: 2 ^From: Patrick M. Butler Direct Dial: 508-790-540� Fax No: 508-771-8079 I -- FAx No. PHONE NO- RECIPIENT COMPANY Don Desmaris Barnstable Health Departm t 508-790-6304 I ('10MMENTS: r: I i. i III; f' - STATEMENT OF CONFIDED irTALITY The documents included with Atis facsimile transmittal sheet contain information from the la firm of Nutter McClenncn&Fish LLP which is confidential and/or privileged. 'fhe information is intcnJEd to he for the use of the addresscc named on this Iran' nittal sheet. If you are not the addressee,note that any disclosure, photocopying,distribution or use of the contents of this faxed information is prohibited. If y' have received this facsimile in error,Please notify us by telephone (collect)immediately so that we can arrange for the retrieval of the original documents at no )st.to you. IF YOU DID NOT RECEIVE ALL PAGES, 1I THERE IS A PROBLEM WITH CALL 617 439-2676, AS ON AS POSSIBLE FOR NUTTER McCLENNEN &FISH LLP USE ONLY Client-Matter No. 107763-1 Nutter McClennen & Fish LLP i Attorneys at Law Boston,MA 02210-260 ■ 617.439-2000 ■ Fax:617-310-9000 r www.nutter.com World Trade Center West ■ 155 Seaport Blvd. ■ I� MAY-07-;200� MON 09:40 AM NA NU. r UL ILI .7- �. Patrick M.Butler Nutter Direcc Line: 508-790-5407 rax: 508-771-8079 L-mail: pbutler®nuaer.com MEMORANDU May 2, 2007 #107763-1 Via Email TO: Thomas McKean, Health Agent I. CC: -om Perry, Building Commissioner matrick FROM: M. Butler v< a) . l E: 6 _ ern Lane, Centerville ssor's Map 1920, Parcel 27 �om, 0 phis wi serve to confirm our discussions earlie .this week regarding the above property. As 1 indicated, 1 have previously reached agr, ment with the Building Commissioner for the recording of a deed restriction ow 1 refs rence to the deed pending ests ng bup prohibits permit application for completion of the garage lmpr the use of any portion of the garage for bedroom use. Dg urin our meeting on Monday with Anna Brig am, based upon a review of a your lf les, we confirmed that the property is not within the 1,993 z ne of contribution nor in Accordingly, the 330 Rule does not apply to the prope e As Broom to a foure have ssed, our bedroom toients wish to voluntarily upgrade the septic system from a th agreement has no comport with the number of bedrooms in the house. T is voluntary g relationship, whatsoever, to the garage construction an renovations. Accordingly, ermit for confirm our agreement that you will authorize the iss roceed on a ce of expeditious updated building upgrade the Title the garage only and that we will agree to pof V system to four bedrooms. This will reiterate office other possiest for an expedited ble mechangms to update pert test I will explore with the Town Attorney: expedite the septic installation. should you have ny questions concerning the enclosed. Please feel free to contact me PMB:cam 1628152.1 Nutter MoClennen &Fish LLP Attorneys at law 15131yannough Road,P.O.Box 1630 ■ Hyannis,MA 02601.1630 a f 08-790-5400 ■ Fax: 508-771-8079 ■ www.nutter.com F, MAY-07-2007 MON 09:40 AM FAX NO. P. 01 Nutter FACSMLE TRANSMITTI L STET ID: # of Pages: 2 'Y oday's Date: May 7, 2007 Time: 9:37 AM Imployee From: Patrick M. Butler Direc Fax No: 508-771-8079 t Dial: 508-790-540� COMPANY Fax No. PHONE NO. RECIPIENT -- Barnstable Health Departm t 508-790-6304 glon Desmaris coMMENTS: I' I, r I i III I' -- - STATEMENT OF CONVIDEN rIALITY The documents included with this h for the use o(!eet a addressTItAill oc ation mcdton this trap iittal sheet, If y1 uCareton nothe address c,noto that an Fish LLP which is ty disclosure, privileged, 'fhe information have received this facsimile in error,please notify us by telephone photocopying,distribution or use of the contents of this faxed information is Prohibited. If y' (collect)immediately so thnt we can arrange for the retrieval of the original documents at no 3st to you. IF YOU DID NOT RECEIVE ALL PAGES, If THERE IS A PROBLEM WITH CALL 617 439-2676, AS ON AS POSSIBLE FOR NUTTER McCLENNEN & FISH LLP USE ONLY Client-Matter No, 107763=1 Nutter McClennen $ Fish LLP iP Attomeys at Law World Trade Center West ■ 155 Seaport Blvd. ■ Boston,MA 02210-260 . 617.439-2000 ■ Fax-617-310-9000 a www.nutter.com s ` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE;OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION M f t V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION a Property Address: 66 Tern Lane � ''' Centerville MA 02632 `� ��! -Owncr's-Name: William Kern-&Linda Marino Owner's Address: 1 Snowshill Road --► ; Dover MA 02030 c Date of Inspection: September 7,2006 Job#06-234 LA. ' Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. •- Mailing Address: 189 CAMMETT ROAD Cil m MARSTONS MILLS MA 02648 Telephone Number: 508-428-1.779 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: ����°5�"""9rrn►►►��� _X_ Passes y Conditionally Passes =�.° . rtI4K Needs Further Evaluation by the Local Approving Authority _ M. Fails = JUC NN Lt. Inspector's Signature: Date: 9/7/06 The system inspector shall submit a co of this inspection report to the Approving Authority Board of Hea�rl<irorr�,� Y P PY P P PP g tY 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: Leaching chambers have no standing water or sidewall stains and tank is no tin need of pumping at this time.Outlet cover on septic tank was brought to grade as part of inspection. ****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 l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 66 Tern Lane,Centerville Owner: William Kern&Linda Marino Date of Inspection: September 7,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 66 Tern Lane,Centerville Owner: William Kern&Linda Marino Date of Inspection: September 7,2006 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 66 Tern Lane,Centerville Owner: William Kern& Linda Marino Date of Inspection: September 7,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. f Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 66 Tern Lane,Centerville Owner: William Kern&Linda Marino Date of Inspection: September 7,2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ Pumping information was provided by the owner,occupant,or Board of Health _ _X Were any of the system components pumped out in the previous two weeks? _X Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X _ Was the facility or dwelling inspected for signs of sewage back up? _X _ Was the site inspected for signs of break out? _X _ Were all system components,excluding the SAS,located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X _ Existing information.For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 66 Tern Lane,Centerville Owner: William Kern&Linda Marino Date of Inspection: September 7,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents:0 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):Yes Water meter readings,if available(last 2 years usage(gpd)): Two years total:209,000 gal.=286 gpd. Sump pump(yes or no): No Last date of occupancy: unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd- Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _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) _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: Compliance date: 10/2/02 Were sewage odors detected when arriving at the site(yes or no): No i Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 Tern Lane,Centerville Owner: William Kern&Linda Marino Date of Inspection: September 7,2006 BUILDING SEWER:XX (locate on site plan) Depth below grade: 2' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 2' Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5'long x 5.8'wide—1500 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" 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: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank has liquid only,no solids.Liquid level at bottom of outlet invert and tees are intact and clear. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 Tern Lane,Centerville Owner: William Kern& Linda Marino Date of Inspection: September 7,2006 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No solids or hieh stains uresent. PUMP CHAMBER: No (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 l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 Tern Lane,Centerville Owner: William Kern&Linda Marino Date of Inspection: September 7,2006 SOIL ABSORPTION SYSTEM(SAS):XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number: Two 500 gal drywells. 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.): Leaching chambers have no standing water and no sidewall stains CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 Tern Lane,Centerville Owner: William Kern&Linda Marino Date of Inspection: September 7,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 20 21 27 7 31 39 ,WZ�" AN Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 Tern Lane,Centerville Owner: William Kern&Linda Marino Date of Inspection: September 7,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 15 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: _X_Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Lake at rear of property is more than 15 feet lower than bottom of SAS. Town of Barnstable Regulatory Services Thomas F. Geiler,Director sue- Public Health Division 0. . �s ` Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form 2J Date: CID ©� Designer: Installer: jam' Address: Address: rn On was issued a permit to install a (date) (inst• ) septic system at��v based on a design drawn by (address) cv g-- dated designer) i I certify that the septic system referenced above was installed substantially a' cording to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. 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. � �H Of htqsss ` c o� DANIEL E. �Gs • O 0 6RAMAN (Installer's ature) CIVIL 4 No. 32686C (Designer s Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC H]kALTH WaSION. CERTIFICATE OF COMPL ANCE WILL NOT BE ISSUED UNTIL B0T# THIS FORM' AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE IDIMAT IC HEALTH DIVISION. THANK YOU. Q:Health/SepticMesigaer Certification Form r 1` Town of Barnstable P# Department of Regulatory Services a�nxare ' Public Health Division Date Jr � 0 7 srE, 200 Main Street,Hyannis MA 02601 ��f0 AMt h Date Scheduled d--7 Time - Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: ,QL0 /Vv Witnessed By: )� LOCATION& GENERAL INFORMATION Location Address / L>� Owner's Name Glew -S'Nrh4 'M&f-j C P i fiCA--/I f C A Address (�G, '1 e zW I-r'' Assessor's Map/Parcel: , Engineer's Name p."1'eJ�vp l'�[' /10l NEW CONSTRUCTION REPAIR Telephone#3 0L 7 Land Use 0 NQnn11 _ Y i Slopes(%) Surface Stones N A -1-— Distances from: Open Water Body � 0 ft Possible Wet Area ft Drinking Water Well # A ft Drainage Way ft Property Line -t ft Other ft SKETCH:(Street naipe,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) t 40� A Parent material(geologic)�O D J ,,II r1 k Depth to Bedrock Depth to Groundwater. Standing Water in Hole: 7V /f11.. . Weeping from Pit Face '`t Estimated Seasonal High Groundwater O DETERMINATION FOR SEASONAL HIGH WATER TA13LE Method Used: Depth Observed standing in obs.hole: __ in, Depth to soil mottles: Depth to weeping from side of obs.hole: _ in, Groundwater Adjustment Index Well# Reading Date: Index Well level— Adl.factor— Adj.Groundwater Level PERCOLATION TEST ]gate 5.9 07 Ttme Observation Hole# Time at 0" Depth of Perc 54 Time at 6" Start Pre-soak Time @ 1;Z=6 - lime(9"•6") End Pre-soak Rate Min./lneh �— Site Suitability Assessment: Site Passed SiteFailed: 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:\SEPTIC\PERCFORM-DOC DEEP.OBSERVATION HOLE LOG Hole# I Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. e� Con isten % ravel (3w Lao,,, a-4'= 144� G 7✓ Q g16 3a a DEEP OBSERVATION HOLE LOG Hole# 9. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi en % ravel r l p�N Yam✓ �.. .� I rU�•J��li[. t• � 1„ •A:, M'z DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) 'Mottling (Structure,Stones,Boulders. Cnitec e DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consi ten Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes, t=J Within 100 year flood boundary No_ Yes �'Deyth of Naturally Occuffing Pervious Material -Does 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 pe viol' us material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis y was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature UAG aa Date Sh0_1a'7 Q:1$EPTICVERCFORM.DOC l TOWN OF BARNSTABLE iG c LOCATION tP � ���. kAA)� SEWAGE O V1.,LAGE f✓Z A''A—eQ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.;.W11,L/A-n4 VZW ER =2V 16 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) °-02 (2>4L L"C (size) • NO. OF BEDROOMS _ 4i BUILDER OR OWNER o S C �'•��� PERMITDATE: t L COMPLIANCE DATE: l - Separation Distance Betw n 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(g any wetland's exist within 300 feet of leaching facility) Feet Furnished by �OrUI� O XO�J�C, 4 y f3 Air 3y 13AY -1/ � ,5- ,410 ��rn f ane 4 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Digogal *p6tem Congtrurtion Permit Application for a Permit to Construct( )Repair( )Upgrade 04)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4ANd Owner's Name,Address and Tel.No. Assessor's Map/Parcel rJ 11(� Cam^ ' S 5? — ®7 7. — 7</ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. C1aAu�te-N Ce G0�Q, j /Z.✓A,0 t� tT y6 5 s o 1Vj&-a✓ .�.� .9✓_ �� - � /-0 43 /S 39' d - 7 - 13.1, .17Fi- /.3iaCJ 2-T IWA C�Zgx 9 Type of Building: Dwelling No.of Bedrooms 3 Lot Size Z 6 9 sq.ft. Garbage Grinder( ) Other Type of Building 102510eA160 No.of Persons -Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 y gallons per day. Calculated daily flow 330 gallons. Plan Date :I'/- Number of sheets / Revision Date ILIA Title P'eai—, SiTi! )"-Aw of LAwo Iv 13oo2.v_rrw3t.d, 4G 766'e / Size of Septic Tank 15-00 Type of S.A.S. �2a�GH�G/.,��ow1r33� Description of Soil 0 - 7 Q" ,F" Z S 7 4 Z 3 LSO —Jz o" C_ M,FO!,4,.4 .tI'I*V0 Nature of Repairs or Alterations(Answer when applicable) Nib 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 ode and not to place the system in operation until a Certifi- cate of Compliance has been issue b oard of Health. Signed Date Application Approved by Q uL 5 Date Application Disapproved for the following reasons Permit No. Date Issued C� +' _No Fee �� -• -� '' ' s�4. c � Entered in computer! �V THE COMMONWEALTH OF MASSACHUSE•TTS p _ PUBLIC HEALTH DIVISION - TOWN OF�BARINSTABL s MASSACHUSETTS Yes ZIppricatiott for Di.5poga1 *p5tem Conmruction Permit "- Application for a Permit to Construct( )Repair( )Upgrade(X Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / / 7Z-7 e� 4AAI& Owner's Name,Address and Tel.No. C Assessor's Map/Parcel b ci LSD 5' 49- 7 7 77-<1 ,2 Installer's Name,Address;and Tel.No. Designer's Name,Address and Tel.No. t �tona.«rc,. ce��ll, You.vG P 5 5 o kl .w .ate , A- �` � ��Q3 �s 39 "-Type of Building: + Dwelling No.of Bedrooms 3 Lot Size Z 9 6 Z sq.ft. Garbage Grinder( ) Other Type of Building No.46f Persons Showers( ) Cafeteria( ) Other Fixtures ` +: Design Flow / +4 33 A ' gallons per day. Calculated daily flow 330 gallons. Plan Date (:7 /€.:'uZ Number of sheets / Revision Date A.14 Title 1"2u�'. Si7,' Pc,�an✓ a 41—0 /w 13r02it/Sr3r~0 46 Tc �.v ti�Oti�r Size of Septic Tank iSvy Type of S.A.S. 2yt�tic P, y Description of Soil G - Z' D" f i c �. 7 o"- Z S A , Z S"_ -'/Q ` Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: k a 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 ode and not to place the system in operation until a Certifi- Cate of Compliance has been issue b ,- • oard of Health. Signed Date / G Application Approved by C L � 1�!) • Date Application Disapproved for the following reasons r Permit No. -Z C ll>2- 3� Date Issued UZ 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 ✓Lte..�,vim eY.,� 2�.�n.* C .�, at !%4_ ,�,, ..,,. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 11 dated Installer 4 i 1 Designer j The issuance of this permit shall not be construed as a guarantee that the sy .te will fyiction as si ne' . Date 6 ;l b -5, l Inspector tIl/ r' No. V Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTWDIVISION -,BARNSTABLE., MASSACHUSETTS �f Mi5po it.by&em Consstruction Permit Permission is herebygrtanted to,Con"s.truct( aii( Upgrade( )Abandon( ) System located t n( x "1 `t ''Q I I l Q vw + 1 and as described in tH6 ab&e Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions\ • Provided:Construction must be completed within three years of the date of this permit. Date: Approved by J r VV ' i TOWN OF BARNSTABLE C. LOCATION L"A)r� SEWAGE O VILLAGE Cl'r`r/7��2�✓I � ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 'J-®O (2-,4J-, �' (size) NO.OFBEDROOMS BUILDER OR OWNER PERMITDATE: �Il t!l U COMPLIANCE DATE: I-Z 1 0 z 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 r7 k -�- - � l Y T3-3 'Town of Barnstable P# 1) 23 Department of Regulatory Services oF1 ,0' . Public Health Division Date � P� p� 200 Main Street,Hyannis MA 02601 C&../Z. OLK O'L MM& BABNsrA '�` 'b •'$ �/b� Time &ir UU��"� Fee Pd. � v 'O�fD 39. Date Scheduled Soil Suitability Assessment for Sewage Disposal Performed By: 3��7Lr✓p�7j J /a✓t.vG, �GI Witnessed By: 6A LI � 'S7-/1 o✓Tc/1✓ ..:+.::::.::::i::::i' it!:'!!,!;tr.!i�:!i"i::n:::::::!i...:,.,..! ..:..;�._. ......... ......._..:::.��::.....::::::::i,:!::::!'!:i!i5i!ki:;:-,.,,,:...,.,.. r,. v:::n:':n.....I a.r,! t r'!:'!"hii'!'li!5!;i y!,t .... .......,...::.:.._......... '::.!!e:r;:.:::,::,r.,...:,,...r,.,......_.,.:....,,.:r......a......1......:..... .... .. I: .. ..: !;' ' ...r!I!!?!uy!I,._.,,uah: ! .:.:..:............:r:.::::!:r......I:..:n:.rr.!_:.r ni ll.:n.:..:., ..,' va ai ..._,.. ..:.;; ,. .r.......rn ".r.,._..:.............u......._:. .::I, a,...., ...,.L... :r, � ...:. .:.:: .: ..I' :,n. , L: i.g•:!i::fl::l,':.,,!:�!�y:::,!.!,_..ri p!;,:4.!'ti�'y:: ..!L!� .'Iw._.,..r.k..:,l..r.,.. ...1:': ::. ,,:: ... .. ::! :::::.!i ,... ,,. ... ..r..,,....: ...:::,...n. '^!1. ,,:•r,-1.' �.r..r rl:i!1:r.: ::.,;",.,::;!!i :.'.:!4::! :I:! ..... r., �.'... ::�. ...r,:nl....:,.. ... r.:i. shame Owner' gfohC,/Je/1� Location Address 6� terO I wne Address lv 6 72,2y✓ / A1Ata0 r a vt by Assessor's Map/Parcel: '�� (?,�'7 / Engineer's Name /3� NEW CONSTRUCTION REPAIR Telephone# $ `3 9 y —�g 6 U Surface Stones Land Use /2�i�/rr�3n/�r/a(-- Slopes(%) Distances from: Open Water Body f J o ft Possible Wet Area ��v _ft Drinking Water Well Drainage Way lv ft Property Line 45 8 Other NA ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) we v X� s/T / X, -L S cN s A p/ Depth to Bedrock 300 Parent material(geologic) Depth to Groundwater: Standing Water in Hole: A/o Weeping from Pit Face Al-0 Estimated Seasonal High Groundwater G 3�✓ O 5s.,::Y::'a ,I.,.::1 n,i5:,.::::r,.,:::i:.a'lii ii'!��!!,i:: �!M,.!, I.... .,. ..!„ 'y{[may, '.,'1 ......r.... - .. !,::r'!'!9fl,!!4'!i-'!!:!il!!!^I� UIn::,,r:,:- :urF..::!:::-::::in:::l,::u:r,:,:.u�::..::c:rr., ..r. Method Used: 0�/5'26 e� 1. Lle L we4)wA P µ BT �n Depth to soil mottles: 4+�a° in. Depth Observed standing in obs.hole: A-A Groundwater Adjustment tiA ft• Depth to weeping from side of obs.hole: .vA in. Groundwater Ad Groundwater Level Index Well 0 AvA ,✓A Reading Date:-VA Index Well level Adj.factor J• ....r:::.r.,.....r......,:::::!:_..,,r..Ir..,,......,:rll.....r....h....,...'::;.a:_u., ._ ..,!.... ..... .::...1.. ;� A7. .. ......:..:... ..:..�........ ........__.._. !_.,Ir...,..�..... _ am r:,... ._,r....,..,.._I.. ..... ....5....::_............... ......_.-,........,.... .�,.... .: ,....,..h'.... .I:. .. ...i... i�;ti"�riir!irejl�.at .�.,,...,.__ .............Il:::r:=!;:!I!u....u.,.l...r.!......:1!. '' '`r .,...:.r.�..:........... r' L!.';u�!;I:!ux!;,!`,;,I!!,�;!�!!!!!:i!:PI!:::'! cur„rl:;,;:, ,...�,....�,...0 Observation i Time at 9" 3 7- Hole# r �� r(o��� Time at6" 3r �4i Depth of Perc ® Time(9"-6') 0.3 S Start Pre-soak Time® - End Pre-soak 2' L Rate Min.Mch Al Site Suitability Assessment: Site Passed Site Failed: 1 Additional Testing Needed(YRN) Original: Public Health Division Observation Hole Data To Be Completed on Back- n-MEAT.TH/WP/PERCFORM ........... ..... Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consisicitcy ° O'Zo �L N 2 L,aAr-y ^V Irs/-E 4161W ,(,oAri+ MA r'. u6 ve32y /oy'2 �G 2iA �d 410„jZO IoNQ �0Y& ('� L L 0054.? T2aGa C�csA2s� 6.4-A Ile $r— Z1 ::H!ULE.:Lid:G.:::.::;>:.;::.; De %Gravel) pth from Soil Horizon Soil Texture. Soil Color Soil Other Surface (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. 0 :.::...............::: P,:OB.SER�A`I'��N.:H.+C�LE.:�.(�..G.::::::::..:.:........................... 'I;::.:.. Other �•• oi�'Pext re�• �'Soil Color . So Depthfrom soil Horizon �•�� S I u Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. °°Gravel) Flood Insurance Rate Map* Above 500 year flood boundary No_ Yes Within S00 year boundary No Yes Within 100 year flood boundary No Yes Depth of NgturAlly Occuering Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Y, If not,what is the depth of naturally occurring pervious material? Certification I certify that on G a /S °/J� (date)I have passed the soil evaluator examinatio ved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and'experience described in 310 CMR 15.017. ! T 1 c-_ y k ;1 1 I � 1 1 S h g z m o ° 6, z A W ° 6 C o J} �f .................. Ll = . L ratm- � . L. # S A r CS t Y-- -b< � �-----_tea`-�---•- ---��----: �a a a 8 i I�,.esTna..� sntn� 'aQAM— ( R'p 1� EK+57'+wb 3txgt 6e4Ah 't4 na.aow -1 } 1 L r L - --- _ SCALE:I �1 a _qY APPROVED BY: DRAWN BY�, DATE: 11/alV REVISED DRAWING NUMBER A f 1 1 i E�AcfbraNL 8w, fiavdE, v.�Frs.sr<�•[� � 1 ,�'" 1+Y'4 7�M�10taa*Jy �ttKtarfi."y_: 1 �� a�. • �'Yr!,�''' tyt' 1 E � '��h•�1,v 1 �;�x �m ib_ - f$ub4ri KrovlaR?tA+ # o i 1 ,� o'T. IC vKE�tsR�1"�Car9>:e► ..+�p1��¢� �+r ee. �e PLY i.: t� WaniteER�y, � 1 _ `� 1 v4 •Srft*0 Niab tW•`d.e. ..... { _...- ...__.-_____--_.-..-...,-.._.._..._...-_-.�._.-_--.-.._...._._._.__.,r.o- .^., - �$ giu�! El O+°►��_ta�fSktrtfo+?'1� c � I 1 1'J'/'1F1(0 i��ai v✓d9.L. �.= �?-\`t "�u4aaS.�,•tedat.� T`Y�'` i � 1 � 1 I AZD { I �1 SCALE: APPROVED BY: DRAWN BY AT REVISED DRAWING NUMBER NOTE: EXTEND COVERS OF (h NSEPTIC TANK TO WIThIN PiP� �o E3ciio G�vEG N G" OF FINISH GRADELU LLJ 4"5CH 40 PVC FH'E 2~ y � Y9/OE✓3�f7'cat./ �� 'tifi; G7l�E.� 0Y 0- o r�.q sy4c-z�l .STD �( T.O.Q. r✓fl V C� c n EL. ��,Z TOP L 6.. IN7Tll GAI 1111 BOTTOM 190 EL. y 9 / Gw""�'C/� �C..• BASEMENT FLOOR Z �S \) IN 011-1 Tee 52,l J/ 2.5 0 IL Q 1 500 GALLON PRECAST Z SEPTIC TANK _,5>.n;"o,:f77 CL O SEPTIC SYSTEM PROFILE m a' \ -9 ~p �, d GENERAL NOTES V 1 . CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION \ OF ALL UTILITIES, ABOVE * UNDERGROUND, PRIOR TO DESIGN DATA ANY EXCAVATION OR CONSTRUCTION. 2. SEPTIC SYSTEM IS TO BE INSTALLED IN COMPLIANCE y = SSo WITH 3 10 CMR 1 5.00: TITLE V. \ fi DAILY FLOW. ( ) BEDROOMS x I 1 O GPD GPD 3. TH15 PLAN 15 NOT TO BE USED FOR FKOPEKTY LINE SEPTIC TANK: SSo GFD x 200% =//UO GPD DETERMINATION. USE: 1 500 GALLON PRECAST SEPTIC TANK� �sT� 4. ALL D15TUKBED AREA5 ARE TO BE LOAMED * SEEDED. \ DISTRIBUTION BOX: 5. CONTRACTOR TO PROVIDE 48 HOUR NOTICE FOR ANY USE: EXISTING DISTRIBUTION BOX KEQUIKED INSPECTIONS'. SOIL AJ35ORPTION SYSTEM: 7'a .��5.��/�T USE: -L7S7.96 -5"Q-6 G. THIS SYSTEM 15 NOT DESIGNED FOR THE USE OF A e.ol-!i Za oZ-3 J a pp` GARBAGE DISPOSAL. Zip. ,- -- 6ZI s 'x 0 y- t;,)'oycc.)_--c.c.5 CAPACITY: ��xiST. G. Z. �/,i�• '6',o 51DEWALL AKEA: /loch' �? /� 4,7�! /�Z•�3 Tc> �'.�-ra o ._--- �� BOTTOM AREA:- /3' �C yZ'X c�•75/ = �a © °\ TEST HOLE LOG T o DATE: TEST BY. - /• c? L co u r r7= �/"'/ S� �Z \ c ,vc�2 -� '_ �° W TNESS: ram. 1.i c= MA . -� Pe KC RATE: -�- -2;A , '_'�. !�� O.C..�X/��C1.7 UrV.D��Q.�. ,✓'!' � / w, 1 /f'� �✓' / h '�.� r g \ !/ S• a� b•r .- `s`..? `�v�� "� « r � - TF�,T H���I..v .. ._ r PC r ` • �� � < J.3'� zs' S3 S / 2. P L' 2AlJcG 30 0 .°o : , S 01•L �TE S DATE OF SOIL TEST 06-12-02 WITNESSED BY D. SITE �. 5 E WAG � FLAN SOIL EVALUATOR B..J. YOUNG PERCOLATION RATE <2 MIN. IN5H. FOR OBSERVATION HOLEELEv.= 55.9 GG TERN LANE C1=NTfRV(LtE, MA ELEV. DEPTH HORIZ, SOIL TEXTURE COLOR MOTTLING OTHER r PREPARED FOR 54.23 0-20 FILL I - - N - - .�^A�� . GLfNN -5-H_E1LA :TOF31N „ "I yi� 53.81 20-25 A LOA!�Y SAND 1OYR 4/ 0 MASSIVE, VERY FRIABLE � Qs�Rt I _ SCALE: DATE: _ DRAWN BY: j TF ENmf� `� OPBEL E. 52.57 25-40 Bw i LOAMY SAND 10YR 5/ N MASSIVE, VERY FRIABLE 1 " = 20' 05- 1 0-2007 TMW WGW N 35 9 4;?cE'i ��i I t JOB NUMBER: REVISION: SHEET NUMBER: 45.90 40-12 C MED. SAND 1OYR 6/ E SINGLE GRAIN. LOOSE OG-097 5P- I TRACE COARSE GRAVEL r � ��` rn{, & COBBLES AL - WELLED -ASSO-GATES 1,G45 FALMOUTH RD., SUITE 4C P.O. BOX 4 1 7 CENTERVILLE, MA 02G32 PERCOLATION TEST DONE AT A DEPTH OF 56 -68 2 WINDY WAY, #232 NANTUCKET, MA 02554 NO WATER ENCOUNTERED TEL.: (506) 775-0735 --- FAX: (506) 775-0754 PROBABLE HIGH GROL ND WATER EL. 34.0 EMAIL: trlsweller(Scomcast.net PROI✓E5510NAL ENGINEERS LAND SURVEYORS - ------ _ I Cl MANHOLE H-20 SCREENED VENT 1.00' MIN, 3.00' MAX AT GRADE LEVEL 2' MIN tt BENCHMARK: � D DRIP EDGE 0.17 2% SLOPE 0 93 2" PEASTONE OF SHINGLES 9 ' MIN, 36" MAX 564.83 MIN MAX ELEV 57.02 40 MIL VINYL5.001.25 5383 BARRIER BETWEEN �,ELEVATIONS54.50 = 1.17 ;•: :Y ®�®® ®®®® ® ® 50.00 AND 54.00 �_.0 ® � .54.00 53.50 53.33 ®8 ®® �® ®®� °��`�� ��: 3/4 TO 1-1/2 AT LOCATION 0.25 53 75 DOUBLE WASHED STONEt �® ��® ®®� �°`:ww: ON SITE PLAN.0.83 4.00 " 50.90 52.90 LAKE WEQUAQUET `. DISTRIBUTION BOX 16.50' x 4.83' 5.00 . . 1500 GALLON SEPTIC TANK DB-3 OR DB5 H-20 2-500 GAL H-20 LEACHING CHAMBERS ST-1500-H-20 WATER TEST TO BOTTOM OF TEST HOLE 45.90 �� GREAT MARSH PROVE EQUAL FLOW 6" GRAVEL ON NATIVE SOIL OR 24.5' x 12.83' x 2' Z`� LOCATION MAP MECHANICALLY COMPACTED BASE -- ¢(� 72f '9 EL 34: CONTROL ELEVATION OF LAKE WEQUAQUET 8�x\ GENERAL NOTES `Z KIT DR SHORE LINE 1) ALL WORKMANSHIP AND MATERIALS SHALL PUMP AND FILL GIS TOPO CONFORM TO 310CMR15.00 THE STATE CESSPOOL AND EDGE OF WATER ENVIRONMENTAL CODE TITLE V: MINIMUM 10.00 10' EASEMEN ANY OVERFLOW FAM FOUND 05-10-02 REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF 20.00 FOR POWER LI E CONNECTED TO EL 31.8 SANITARY SEWAGE, AVAILABLE FROM STATE HOUSE, 3.00 IT, RESTORE TURF. UNF. BASEMENT BOOKSTORE 1-617-727-2834, AND TOWN OF EL 40.5f BARNSTABLE RULES AND REGULATIONS FOR THE 10.00 / SUBSURFACE DISPOSAL OF SANITARY SEWAGE. PROPOSED WATER SERVICE 60 /y17 / BA --- 2) CONTRACTOR SHALL VERIFY LOCATION OF EXISTING UTILITIES. CONTACT DIG-SAFE AND LOCAL < WATER DEPARTMENT 3 BUSINESS DAYS BEFORE .56� �p s� BR BEGINNING CONSTRUCTION. EXISTING WATER SERVICE < �� 2c BR LR 3) CONTRACTOR RESPONSIBLE FOR OBTAINING ADEQUATE HORIZONTAL AND VERTICAL CONTROL. PATIO 4) CONTRACTOR SHALL VERIFY ALL PLUMBING FLOWS (51' q'\ TO PROPOSED SEPTIC TANK, AND SHALL LOCATE ALL OTHER EXISTING SANITARY FACILITIES ON PREMISES. _ -FLOOR -PLA NTS)- NO LONGER USED AND PUMP, -AND -FILL OR REMOVE SAME IN ACCORDANCE WITH LOCAL REQUIREMENTS. O �JE 5) ALL COVERS OF SANITARY UNITS SHALL BE BROUGHT O IT FINISHED GRADE..12 100' MASONRY UNITS TO BE MORTARED IN PLACE. ALL BUFFER PVC PIPE TO BE SOLVENT WELDED. #1 I 6) UNLESS OTHERWISE SPECIFIED, EXISTING AND / 55 FINAL GRADES SHALL REMAIN ESSENTIALLY 0 W UNCHANGED. V 5 / 4.00 x� LEGEND: 7) NO DETERMINATION HAS BEEN MADE AS TO F` �1 �,� EXISTING SPOT ELEVATION 0x00 COMPLIANCE WITH DEEDED OR ZONING RESTRICTIONS �1. 4.00 EXISTING CONTOUR AND/OR REGULATIONS. OWNER/APPLICANT MUST � FINAL SPOT ELEVATION Ox00 OBTAIN SUCH DETERMINATION FROM APPROPRIATE �64 LIMITS O OF 12.83 20.00 FINAL CONTOUR ELEVATION 00 AUTHORITY. 5' REMOVAL SOIL TEST LOCATION AND ELEVATION s0x00 8) EXCAVATE AND REMOVE UNSUITABLE MATERIAL OF UNSUITABLE UTLILITY POLE -o- BELOW THE LEACHING INVERT ELEVATION FOR 5' MATERIAL UNDERGROUND GAS, WATER, ELECTRIC, AROUND LEACHING SYSTEM AND REPLACE WITH CLEAN 26,962 DOWN TO LIMITS OF 40 TELEPHONE, CABLE -G,W,E,T,C SAND. \ 62 SF f CLEAN SAND VIN L BAR R CATCH BASIN 9) IF ANY DETAIL OF THIS PLAN IS NOT (SE E ATION) UNDERSTOOD, CONTACT DESIGN ENGINEER AT <" 394-1960. \ 56 BOTTOM OF KETTLE 54 � ELEV. 42.1 10) 48 HOUR NOTICE IS REQUIRED FOR ANY 58 52 INSPECTION OR CERTIFICATION REQUIRED. 60 5 Q �� �� 11) SITE LIES WITHIN FLOOD ZONE C AS SHOWN ON fi N . VG dQ SOIL - TEST MAP 2-5QG05--98S8--G DATED 07.-03=8"f. "� APPROVED BY BOARD OF HEAL H �$U��,_00/y G �P P DATE OF SOIL TEST 06-12-02 WITNESSED BY D. STANTON g_, J� (3`� AGENT: � �-- /L SOIL EVALUATOR B.J. YOUNG DATE: / l Q to PERCOLATION RATE <2 MIN./INCH. ASSESSORS MAP. 192 PARCEL: 27 OBSERVATION HOLE PLAN BK 88 PG 13 DESIGN CALCULATIONS ELEV.= 55.9 DEED BK 944 PG 65 ELEV. DEPTH HORIZ SOIL TEXTURE COLOR MOTTLING OTHER , NUMBER OF BEDROOMS 3 54.23 0-20 FILL - - N - GARBAGE DISPOSAL UNIT NOT ALLOWED DESIGN FLOW PROPOSED SITE PLAN OF LAND IN BARNSTABLE ��` 3 BEDROOMS x 110 GAL/(BR-DA)=330 GPD. 53.81 20-25 A LOAMY SAND 10YR 4/4 0 MASSIVE, VERY FRIABLE - �.�'``�"� ,, REQUIRED SEPTIC TANK CAPACITY 1500 GAL 66 TERN LANE, CENTERVILLE �or���s 52.57 25-40 Bw LOAMY SAND 10YR 5/6 N MASSIVE VERY FRIABLE s ACTUAL SEPTIC TANK CAPACITY 1500 GAL eERNARD ��y AS PREPARED FOR: LEACHING AREA REQUIREMENTS o JOHNYUUNG .. SCALE DATE: JULY 1, 2002 45.90 40-12 C MED. SAND 10YR 6/ E SINGLE GRAIN. LOOSE s l� .30Q7& DAVID NAILOR/EST. MADELINE 1t= --BOTTOM 0.74 GAL/(SF-DA) TRACE COARSE GRAVEL p -ARCH- BROADBENT REV.: --SIDE 0.74 GAL/(SF-DA) & COBBLES ' LEACHING CAPACITY BERNARD J. YOUNG, P.E. s ((24.5'x12.83') + 2x(24.5'+12.83')x2') 'SS } BOX 1539, DENNISPORT, MASS 02639 (508) 394-1960 xO.74 GAL/(SF-DAY)- 343 GPD PERCOLATION TEST DONE AT A DEPTH OF 56 -68 � FILE NO. NO WATER ENCOUNTERED 0000-00 SHEET 1 OF 1 PROBABLE HIGH GROUND WATER EL.= 34.0