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0073 TERN LANE - Health
73 Tern Lane ' Centerville A= 192 -031 I *PondafloYr a Esselte Afm mr� In 4210113 ORA 10% P4 I N<: (f �(OV t Fee ®V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' I'es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,`MASSi c_Hjp uT�TS RppliLation for bispo8al *pstrm Construction - P l-it Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.73 T j2a(Y L Fj Owner's Name,Address,and Tel.No. C j q Assessor's Map/Parcel C�� �✓ 19 , O3 t o & �y �t't'lp�®hors /Y/JZ 0 tts Y __ Installer's Name,Address,and Tel.No. $'� 3&,4�D$'3 7 Designer's Name,Address,and Tel.No.5 a� 360 3 3i J I211'S �3PV0�� Cb-�,.sv- wl��.��Sin-► , P o �/ � ..SS,�! Type of Building: Dwelling No.of Bedrooms 3 Lot Size C -F /©� sq.ft. Garbage Grinder Other Type of Building = 42-5 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required)' a 5P_.� gpd Design flow provided Z. . 6 gpd Plan Date (4/aa 6 Number of sheets Revision Date _ Title / /��. '� _ � �.�" -_ c � Size of Septic Tank b Type of S.A.S..�t•,y ;,/f Description of Soil_See Say. Nature of Repairs or Alterations(Answer when applicable) S-Q`e S'eRj, '_ i),o,5N � - 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 sy tern in operation until a Certificate of Compliance has been issued by this Board pf alth. f,, Si 0 Date `� r ' ` Application Approved by Date Application Disapprovedby Date for the following reasons Permit No. Date Issued TOWN OF BARNSTABLE LOCATION 7,3 Te/yt Lh SEWAGE# �Lq,6 160 VILLAGE C�Oyk4-ydl--C ASSESSOR'S MAP&PARCEL 11 a " 03J INSTALLER'S NAME&PHONE NO. fit'hl Gdy1wfX'ff CO-4ii- cScr a (,P of 6?3, SEPTIC TANK CAPACITY So c) LEACHING FACILITY.(type) c`�— S b 0 e (size) NO.OF BEDROOMS OWNER C PERMIT DATE: COMPLIANCE DATE• 3 b 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 l 73 4 +�- .3 A q �3 -s3 6- 4 Fee 0 ` THE CO MONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH,DIVISION - T,,OWN OF BARNSTABLE, MASSACHUSETTS R IOlitation for Disposal *pstrm Construction VPrni t Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(. ) ❑Complete System ❑Individual Components Location Address or Lot No. (I/ 7 3 �(_2 6 AN EJ Owner's Name,Address,and Tel.No. C 19 � ° Assessor'sMap/Parcel C eerie � 1�� r�7 19 oL o3 l6 s cl '�,/.rvi / �yl�Dyoi� /tij G Li5 .2 Installer's Name,Address,and Tel.No. S o$- 3&a (Pa 3 7 Designer's Name,Address,and Tel.No. S o& 3 60 3?,j 14/o s i3 rt, o/ SA '�''Y�..-� 5���-► , hs /'o�� 9�1 �;. S s�c/w Type of Building: Dwelling No.of Bedrooms 3 Lot Size V sq.ft. Garbage Grinder V16/0 Other Type of Building No.of Persons Showers( ) Cafeteria( ) *Other Fixtures Design Flow(min.required) 3C, gpd Design flow provided Z . Z J gpd Plan Date Number of sheets o1 Revision Date. / Title /�!�/ , T /(/ k z4,j 6 Size of Septic Tank D!7 Type of S.A.S Description of Soil � P-e L C fie- C✓f ' SJ�N /J/�A w Nature of Repairs or Alterations(Answer when applicable) Pe S;("o f 'C I v S, 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 H alth. j / Sig - / Date L ( a Application Approved by / Date / Application Disapproved by Date �or the following reasons r Permit No. d Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certlfltate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by IaI I,S C"r hS.,' 1, at t-PJRAI L,nAja ( r��rt I?U 1 . has been constructed in accordance J i l with the provisions of Title 5 and the for Disposal System Construction Permit NoI/k -Ile dated rj �7 �w Installer G I I IS Q raT'1-P f S Cch s/' Designer #bedrooms 12 Approved design flow 3 U gpd The issuance o thi' permit shall not be construed as a guarantee that the system will 1 unct on designed. Date Inspector I f 1-' / -----------------------------------C----------------------------------------------------------------------------------------------i------------ No.,= l tP — �C� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLI.0 HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Vsposal Opstem Construction Permit Permission is hereby granted to Construct( ) Repair(�� Upgrade Abandon( ) System located at 7 3 t i 2/V I.A 1V I. C F/i/1 la I1 v 1 A ' � J and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. i Provided:Construction must be co plete ithin three years of the date of this permit. Date �� � Approved by i v�i � l Town of Barnstable Regulatory Services Richard V. Scali, Interim Director w BAMSfABLE, 9�A MASS. ��� Public Health Division lsc3'�° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form - — - — Dater � 1 - Sewage Permit#-'6Assessor's Map\Parcel , Designer: 4 '�AA nstaller: Address: Address: LZ �J& On ZAe iM/5 A14S ("7_61161 was issued a permit to install a (date) (installer) septic system at A-2-), ��,� N � based on a design drawn by C:ed designer) certify that the septic system referenced above was installed substantially according to Ihe design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10" lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was construct i' e w':th�the terms of the IAA approval letters (if applicable) v� (Installer's Signature) Id ; 91 e ig i afore) (Affix Designer amp Here) PLEASE RETURN TO BARNS LE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT E ISSUED UNTIL BOTH THIS FORM AND AS- BUILT..CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc F` � ,► Town of�3 �-nstable P# ' ' Department of Re ulatory Services �I • Public Health Division Date � Mnsa. � .63y. �e� 200 Main Street,Hyannis MA 02601 Date Scheduled Time j �. --- ret�^Pd• I. s Soil Suita$ility Assessmerztfor- Sewn* Disposal Q�Performed By ! Witnessed By: rn.!`k �'�- ,s- ,/l ^ 1� I LOCATION & GENERAL INFORMATION. Location Address•. 3 '�r I / Owner's Name W 1 tJ AM Address i. b Assessor's Map/Parcel: 1 p1 /6),5 Engineer's Name �\ �"'/!�( NEW CONSIRUtON REPAIR Telephone# Land Use /� y Slopes(4'0) `�J Surface Stones Fe Distances from: Open Water Body } �� ft Possible Wee Areal 0 0 ft Drinking Water Wellft i Drainage Way> ft. Property Lineft Other ft SKETCH:(street name,dimensiods of lot,exact locations of test holes&perc tests,locate wetlands in proxitnity to holes) k2lda 4-- )01 ti WI) I j I I . t L i I Parent material(gecilogie 4� Depth to Beclroek /V/ Depth to Groundwater. Standing Water in Hole: i Weeping from Pit Face /• Estimated Seasonal Ii fth Groundwater /^ D ATION FOR SEASONAL HIGH WATER TABLE Method Used: I in. Depth to soil mottles: In. Depth dbperve standing in obs.hole: in, aroundwater Adjustment Depth wiweeping from side of obs.hole: Adj.Oroundwater l evt'1.,,.,e• Index Weil# — Reading Date: index Well levdl _.. Adj.faetor,,.•.— I PERCOLATION TEST Date Tl` a---. Observation I Time at 9" -- Hole# —J--- /_a Time at G" ..------ Depth of Pere 106 - ��a7 i Time(9"41 Start Pre-soak Time.@ End Pre-soak I22te MinJlnch Additional Testing Needed(YIN) Site Suitability Assessment: Site Passed- Site Failed; Original:.Public i'e$lth Division Observation Hole Data To Be Completed on Back------- ***If percola�ibn test is to be condracted within 100' of wetland,you must first notify the Barnstable C44servation Division at least one (1)week prior to beginning. 11 VS DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel V 1j >M (And d a Sl g b 0-6 �o,-I1SD GZ vM 2•� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) A a n DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, ra I Flood Insurance Rate Map: Above 500 year flood boundary No— Yes X. Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perv' us material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring p rvious material? Certification I certify that on 10 (date)I have passed the soil evaluator examination approved by the Department of Envi onmental Protection and that the I above analysis was performed by me consistent with the require trai i ,expertise and experience described in 3,10 CMR 15.01 . Signature �' Date Jr a /,, Q:\SEPTIC\PERCFORM.DOC Town of Barnstable _ Barnstable Regulatory Services Department B"AFMABM A Public Health Division i639.A P m �fp" 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0001 2273 3296 April 26, 2016 Claire M Wingren TR 1084 Bremen Road Waldoboro, ME 04572 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 73 Tern Lane, Centerville,MA was last inspected on 3/11/2016, by Michael DiBuono, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Septic System invaded with roots You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Ev1\73 Tern Ln Cent Apr2016.doc Town. of Barnstable • + s�rrsrAets, HAS&i659• a Regulatory Services Deparbuent ,gym Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Richard Scab,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6,-2007 - Rev. 7/6/15 DEADLINES TO REPAIR-FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or.cesspool ❑Any portion of the SAS, cesspool, or privy, below high groundwater elevation ❑Aiiy portion of the cesspool within'a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water.quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) Q.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER j�T p�, js�m 1,1,\ VPdRf-ed vv'444 rool-s Repair deadline: \/(ern r Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc c Parcel Detail Page 1 of 3 fill 15 a J - - Cl I F &lllt AS5, ,y AtA55, tit. 1. �. JJ• _"� a r o — & 'le �.� Logged In As: Parcel Detail Tuesday,April 5 2016 Parcel Lookup Parcel Info Parcel ID 192-031 I Developeer LOTS 19&20 I Location 173 TERN LANE f Pri Frontage '250 I Sec Road . ..I Sec Frontage I village ICENTERVILLE I Fire District .C-O-MM I Town sewer exists at this address INO ) Road Index 11698 Asbuilt Septic Scan: r � �t p Interactive �• 192031_1 Mapr�� ' ��r Owner Info Owner IWINGREN, CLAIRE M TR ' Co-owner JCDW REALTY TRUST I Streetl 11084 BREMEN ROAD I Street2 I city IWALDOBORO State FME I Zip 04572 Country - Land Info Acres 0.54 � Use Single Fam MDL-01 I Zoning [RD-1 I Nghbd 0106 Topography Level I Road Paved I Utilities JPUblic Water,Gas,Septic Location I Construction Info Building 1 of 1 Year Roof 1968 I Gable/Hip I Ext Wood Shingle Built Struct wall I Living 1616 '—�'� Roof AS h/�F GIs/Cm AC None Area Cover' p p I Type2. style I Ranch Int Plastered I Bed 3 Bedrooms— Wall Rooms $ 30. RMMT C� � � ; Model Residential Floor rardwood R oms 2 FUII-1 Half g i� zz Grade jAverage Plus Type Hot Water Rooms 7 Rooms Stories 11 Story Heat Fuel Oil —" I Found- Typical �I Gross 3I Area860 Permit Histo Issue Date Purpose Permit# Amount Insp Date Comments http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13579 4/5/2016 Parcel Detail Page 2 of 3 Visit History Date Who Purpose 9/23/2015 12:00:00 AM Tony Podlesney In Office Review 8/9/2011 12:00:00 AM Robin Benjamin In Office Review 3/17/2010 12:00:00 AM Pamela Taylor In Office Review 11/16/2009 12:00:00 AM Denise Radley In Office Review 2/10/2009 12:00:00 AM Paul Talbot Cyclical Inspection 11/28/2000 12:00:00 AM Paul Talbot Meas/Listed-Interior Access Sales Histo Line Sale Date Owner Book/Page Sale Price 1 7/24/2008 WINGREN,CLAIRE M TR 23060/52 $1 2 12/1/1967 WINGREN,DANA W&CLAIRE M 1385/767 $0 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2016 $126,800 $58,000 $0 $141,900 $326,700 2 2015 $124,700 $57,800 $0 $112,600 $295,100 3 2014 $124,700 $57,800 $0 $112,600 $295,100 4 2013 $124,700 $57,800 $0 $112,600 $295,100 5 2012 $124,700 $56,100 $0 $112,600 $293,400 6 2011 $168,900 $8,800 $0 $112,600 $290,300 7 2010 $168,700 $8,800 $0 $112,600 $290,100 8 2009 $159,300 $8,200 $0 $149,200 $316,700 9 2008 $190,800 $8,200 $0 $155,400 $354,400 11 2007 $189,600 $8,200 $0 $155,400 $353,200 12 2006 $178,000 $8,200 $0 $162,700 $348,900 13 2005 $162,400 $8,100 $0 $147,900 $318,400 14 2004 $136,000 . $8,100 $0 $125,700 $269,800 15 2003 $127,300 $8,100 $0 $38,500 $173,900 16 2002 $127,300 $8,100 $0 $38,500 $173,900 17 2001 $127,300 $8,100 $0 $38,500 $173,900 18 2000 $90,900 $7,600 $0 $38,600 $137,100 19 1999 $90,900 $7,600 $0 $38,600 $137,100 20 1998 $90,900 $7,600 $0 $38,600 $137,100 21 1997 $119,800 $0 $0 $34,700 $154,500 22 1996 $119,800 $0 $0 $34,700 $154,500 23 1995 $119,800 $0 $0 $34,700 $154,500 24 1994 $106,500 $0 $0 $27,800 $134,300 25 1993 $106,500 $0 $0 $27,800 $134,300 26 1992 $121,400 $0 $0 $30,900 $152,300 27 1991 $129,400 $0 $0 $61,800 $191,200 28 1990 $129,400 $0 $0 $61,800 $191,200 29 1989 $129,400 $0 $0 $61,800 $191,200 30 1988 $88,600 $0 $0 $29,200 $117,800 31 1987 $88,600 $0 $0 $29,200 $117,800 32 1986 $88,600 $0 $0 $29,2001 $117,800 Photos http://iss ql2/intranet/propdata/ParcelDetail.aspx?ID=13 5 79 4/5/2016 r 8 JOHNS PATH SOUTH YARMOUTH,MA 02664 v MIKE@CAPEC ODTITLEFIVE.COM (508)364-9587 a s t+ � To: David Barnstable Board of health CA David I have made the changes to the following reports 173 Tern In 160 Lincoln rd 2117.Main st I have tried to include more information to better help you understand the reasons for failure. 173 Tern In both the original cesspool and flo diffusers are completely packed with roots and will no longer allow for proper flo. 160 Lincoln rd is straight forward.Two Cesspools that are structurally unsound. 2117 Main st.Both the tank and Dbox are packed with sludge up and over pipes as well as under both covers of the septic tank.The leaching chambers are also holding water up to pipe and are no longer leaching. Thank you for your time and cooperation. Michael DiBuono President DiBuono Sewer&Drain Date: Signature Print ---�_--- Print Name Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 Tern In Property Address Claire Wingren ; Owner Owner's Name Cl information is required for every Centerville Ma 02632 3/11/16 page. City/Town State Zip Code .. Date of Inspection �•+ W 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 P7 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain ,Q Company Name 8 Johns path Company Address S Yarmouth Ma 02664 Citylrown State Zip Code 508-364-9587 S103522 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 3/11/16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 1. . . = Commonwealth of Massachusetts H . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wN 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. Cityrrown 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: The system contains a single cesspool as well as two flow diffusers. Both the cesspool and flow diffuseres are inendated with roots and will no longer allow flow. The area in and around the system is completely covered in trees and Ivy. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13. Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments G1 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. CityrFown 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 I 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 0 ® 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 Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 73 Tern In Property Address Claire Wingren Owner Owners Name information is required for every Centerville Ma 02632 3/11/16 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. Cityrrown State Zip Code Date of Inspection C. Checklist' Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. CitylTown State Zip Code Date of Inspection D. System Information Description: The system contains a single cesspool as well as two flow diffusers. Both the cesspool and flow diffuseres are inendated with roots and will no longer allow flow. The area in and around the system is completely covered in trees and Ivy. Number of current residents: Un occupied Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: none Provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ® Other(describe): Single cesspool and S.A.S. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 30 plus years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence.of leakage, etc.): old orangeburg pipe Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 73 Tern In Property Address Claire Wingren Owner Owners Name information is required for every Centerville Ma 02632 3/11/16 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 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'" 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): 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 15ins•3113 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 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 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 Na Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 2 500 gl Flow Dif ❑ 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.): Flow diffusers are completely packed with roots. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ,1 6x8 Block Depth—top of liquid to inlet invert dry Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): cesspool is completely inendated with roots and will no longer allow flow YI Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. Cityfrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 2V1512016 Assessing As-Built Cards LOAATION SEWAGE PERMIT NO. 'j 3 VILLAGE INSTALLER'S NAME A ADDRESS _ 51,E S,Apo cry G- AY ji , Div R OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED l , f . http://www.townotbarnstable.us/Assessing/HMdisplay.asp?mappar=192031&seq=1 1/2 • Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3/11/16 page. Cityrrown 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: 10+ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: To be determined at time of perk test. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 L O CAT ION SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S NAME i ADDRESS �y a f1 t WER OWNER y Ah-�-.. ID, 14 (Z), -P DATE PERMIT ISSUED DATE COMPLIANCE ISSUED L f � . i t Gil ��ri \ � � ��' � � b �' � y I - y ; , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Tern In Property Address Claire Wingren Owner Owner's Name information is required for every Centerville Ma 02632 3111/16 page. Cityfrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 NohQ.... {l!. FEE... ........00..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -- Town......... OF............Barnstable Appfiratinn for Bhipogal Workfi Tnntrnrtiun rantit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: Tern Ln_ -,Centerville._MA.. 026.32.................... Location-Address or Lot No. Dana Win ren -. _.._______. T.e.rn Ln. e- Centerville t_ M 026 2 .............••--.........---.............. ............•-•-•...... - .....--• •--•• ..--.. ....----------•-•....--- Owne Address A & B Cesspool Service 128 Bishops Terrace, H�rannis, MA 02601 .................••--•- Installer Address Type of Building Size Lot..... ....................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons.....__.__2___.....__._... Showers ( ) — Cafeteria ( ) a F.. � Other fixtures -------------------------------------------------------------------------------------------------•-------••-------------------------------------•---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—,.Liquid capacity............gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.............:......sq. ft. Seepage Pit`No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test.Pit.................... Depth to ground water........................ (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ c� •-•--•••••...................•••••••...............-•••--•-•-•--••--•--••-••-••-••-•-------------•••......................................................... 0 Description of Soil............Sand................................................................................................................................................. x U .................-••••••••----••--••-•-•---•---•--•••••---•-•-•••-•••-•.............•-•._...-•-••••-•-•••----------------••-••--•-•-•-•-•...--•-------•-............................................. ----------- --- -----------------------------------------------------------------------•---------------------------------------------------------------2-.__side..by--sicle..M_awdifusors V Nature of Repairs or Alterations—Answer when applicable---------installation---of..a-.1TMXAMMPre:-cast, son F cked..l���h..ga�t (.-oYerf LOX)-----------•------••----•------------------------------------------------------------------------------•----•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iT:._ p of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the bo r o 1 lth. Signe ... . . • •-•-•----•.............. ...7/1 /BQ....... Date Application Approved By--- . . ......................... -----------7/18//,8Q------••-•--- Date Application Disapproved for the following reasons-............................................................................................................... ...................................................................................................................................................................................................... Date Permit No........80........................................... Issued...................7/18/$0 .................... Date FEs...... ..5.00..... THE COMMONWEALTH OF MASSACHUSETTS �_. .�_. BOARD OF HEALTH A._. . Tom.-...........OF............ stebll=------------------------------------------------- App ira#ion 'for Bigpoaal 3 or Con rnr ion rxuti Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: _Tern Ln., Centerville MA 0262__...,__ 3, .....-•-•-----•--....----•-•--------------------••--------••----------------.........--------••-- Location-Address or Lot No. Dana Wind . .................................-----•-•••--...................• Tern Ln., Centerville,... -----026�2...................... Owner Address a A & B Cesspool Service 128 Bishops Terrace, Hyanniat NIA 02601 Installer Address Type of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms............................................Expansion 2 Attic ( ) Garbage Grinder ( ) p., Other—Type of Building_____________________________ No. of persons___--___-___--_-.._--__----_ Showers ( ) — Cafeteria ( ) QI Other fixtures .... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--_-_-_____----.-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date--------------------------------------- Test Pit No. 1................minutes per inch -Depth of Test Pit.................... Depth to ground water..................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ------------------------------------------------------------------------••---------.....----•-....--..............---.......-----•-•-...-------••--•---••-•. 0 Description of Soil............Sand.---_--------------_--•-----------------------•----------------------------------•---•--------•-------------•-----------•-----........-•-•---- x V W ------•-- -•-------------------------------------------••----•-••---•-•-..:........_....-----------•---•------••---._..__....._...-•----•---•-•--------2-..aide--by...side..Flovdifusors V Nature-of Repairs or Alterations—Answer when applicable--------installation..A $l..lt $76�Xpte--cast, _s ime..packed..10&�0tI.pi......rn!erasgw)........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS p 5 of the State Sanitary Code— The undersigned further agrees Inottolace the system in operation until a Certificate of Compliance has been issued by the b�r '_f�lth. " Signs / !L._ _ :. �.- y18 $0.--••-------- ' to Application Approved By..... ... - . ... j---•---••---------------- ----------mmm------------- Date Application Disapproved for the following reasons-------------------------------------------------------------................................................... .....................................................---•----------------•-----•-------------....................................... •-----•-•--•.....----------------••------....--•-•-•----.......-- r Date x Permit No........$0- = _.................. Issued..................7`18/80 Date t t` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........T.ow? ..........oF...........Barnet ,ble............................................... Cnrdifirtt#r.of Tontpliattre THIS IS TO CERTIFY, That the izndividual Sewage Disposal System constructeg > or Re aired ( X) by A & B Cesspool Service, 1243 Bishops_ Terrace, Hyannis, MA 02 0 ...............................•-•--•••......---- Tern Ln., 'Centerville, MA 026Q2 InstaV&na Wingren at. -•------- --............... ------- ----- ---------- • ------••------ •-•----------- . has been installed in accordance with the provisions of TITLE 5 of T e State Sanitary Code as esyr' e in the application for Disposal Works Construction Permit No.___$��-._?i_ _..s__--___. da.ted.........................l _0 .................. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. /f 7/18/$0 nnG yy��,, .. ../'3/ � ' Inspector...DATE.-•-•................•--•-••-•-•-••----•....V ...1..::!I'f —.. THE. COMMONWEALTH ,OF MASSACHUSETTS BOARD OF HEALTH 80 / ................Town..........O F Barnstable 5 00 No........ FEE......... ..... �i��iao�tl or�� �.�tt��nr�ion .ertni# Permission is hereby granted.........A & B Cesspool Service • •---------------•-•-•-------------•-•-----........-•--•---.............._...... to Construct (_ ) or Repair (X ) an Individual Sew e Disposal System at No..................•ern Ln., Centerville, _MA_. 02��2 -- Dana Wingren-_.___._.___._--.. -- ---- Stre t. as shown on the application for Disposal Works Construction Per > No._8._-. .._ :..'Dated.__.__._711 DATE.. 7/18/80 Board of Health ................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS LEGEND CENTERVILLE o 62 PROPOSED CONTOUR 1 _ 98 PROPOSED SPOT GRADE 6z 6l _� _ —— gg —— EXISTING CONTOUR pips LOC S WEQUAQET - LAKE + 96.52 EXISTING SPOT GRADE •`\ oR\ E,N pY 9G1� z W— EXISTING WATER SERVICE uNeP�Eo Pp � u- TEST PIT I o SCALE: 1"=30' ---- ------------ ,-------- eo 0 _ f N ' "54-- \ m 7 ROUTE 28 eA 52 - 58 LOCUS MAP i r 50 ` LOCUS INFORMATION z PLAN REF: 088/013 TITLE REF: 23060/052 i i I PARCEL ID: MAP 192 PAR. 031 *PROPERTY IS IN ESTUARIES PROTECTION DISTRICT* 5P 52 56 I•\ \ f I 1 54 I 98 BENCH MARK - % _ SEPTIC .SYSTEM TOP OF FOUNDATION 60.58 " ----- A. REPAIR PLAN VPA`"co - � LOCATED AT: BARNSTABLE CIS DATU I ORr� -------� - I eGyq Y 1 73 TERN LANE CEN TER VI LLE, MA. W PREPARED FOR -60 CLAIRE WINGREN 60 APRIL 22, 2016 58 GG s, OF M / 7' �2 EXIST. LEACHING 52 \ 0 1 40, see note 10REG/STER�� l LOTS 19 & 20 SgNITAR ���� moo` 50�„ `� ! \ , -YrR-€e — 23900 sf+— PROP: 1,500G.1 PLAN Boor.88 PACE 13 �e" SEPTIC TANK „>SR MAP 1'92 PCL 31 as_ / 0 0 i MEYER & SONS, INC. I {! \ ! 160.5 58 P.O. BOX 981 52 56 ! 48 .i! EAST SANDWICH, MA. 02537 PH: (508)360-3311 FAX: (774)413-9468 meyerandsonstitle5©gmail.com SHEET 1 OF 2 J#1808 ELEV. TOP FOUNDATION NOTE: PLACE MAGNETIC MARKING TAPE, OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (50.70) 60.58 F.G.EL: 55.0 F.G.EL: 54.80 F.G. EL: 50.70 VENT MAINTAIN 2°10 MIN SLOPE OVER: LEACHING AREA - A zf - 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1 F.G.EL: 54.0 /2" . . .T1 STONE OR FILTER FABRIC DOUBLE WASHED STONE 4 SCH 40 PVC " .a 110"t 6 ®ai®®®®®®®®® 14" IINV.46.80 1% (MIN. ®I3!®®®®�a®®®® TEE'S ARE TO BE: @ INV.47.0 2 E F. DEPTH ®®!®®®®�®®®® EEO ,, ..` 4' SCH 40 PVC INV..52.70 4' 2 X 8.5' 4' GAS PROPOSED DB-3 EXISTING OUTLET BAFFLE EFFECTIVE LENGTH = 25' INV. 54.58 INV. 52.95 DIISTRI(H2 ON BOX INV. ELEV.= 43.70 PROPOSED 1 ,500 GALLON SEPTIC TANK: OF GAS BAFFLE TO BE INSTALLED ON �P��� MVS BREAKOUT OUTLET TEE AS MANUFACTURED BY y o DA REN M. ELEV.= 44.70 s TUF-TITE, ZABEL, OR EQUAL t ER TOP CONC. ELEV.= 44.70 a No. o INV. ELEV.= 43.70 �E3Q 0 ®® NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING ®®®®®®® PIPE INVERTS PRIOR TO CONSTRUCTION �'EGISTE ®®31 E3 Ea Ea 2) TANK AND D-BOYS SHALL BE SET LEVEL AND SANITAR��`� DOTTOM EL.= 41 .70 TRUE TO GRADE ON A MECHANICALLY COMPACTED , 3.75' 5 FT. 3.75' SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN �' U� 310 CMR 15.221(2) SEPARATION 6.00 FT. EFFECTIVE WIDTH = 12.5' 3) INSTALL INLET & OUTLET TEES W/ SEPTIC SYSTEM PROFILE GAS BAFFLE AS REQUIRED If BOTTOM OF TESTHOLE EL: 35.70 SOIL ABSORPTION SYSTEM (SECTION) 4) PLACE SANITARY TEE IN D-BOX. (500 GALLON H2O LEACH CHAMBER) GENERAL NOTES: SOIL LOGS P#:15004 DESIGN CRITERIA 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL NUMBER OF BEDROOMS: 3 BEDROOMM BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: APRIL 8, 2016 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPWCABLE DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS, EXCEPT AS NOTED BELOW. f SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 - 310 CMR 15.405 (1) (B): WITNESS: DAVE STANTON, BARNSTABLE HEALTH DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. 1) A 3.00 Fr. VARIANCE FROM 310CMR15.221(7) TO-ALLOW LEACHING GARBAGE GRINDER: NO (not designed for garbage grinder) TO BE 6.00 Fr (MAX) BELOW GRADE VS REO'D 3!Fr. (H20/VENT PROVIDED) LOAMY SAND LEACHING AREA REQUIRED: 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR Elev. SEPTIC TANK: TO INSPECTION AND APPROVAL. BY THE BOARD OF HEALTH AND THE TP- 1 Depth Elev. TP-2 Depth 330 gpd x 200'� = 660 gpd, USE PROPOSED 1,500 GAL. SEPTIC TANK DESIGN ENGINEER. 48.70 A LOAMY SAND 0" 51.50 A 0" ei (330) = 445.94 S.F. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 1OYR 3/2 10YR 3/2 •74 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 47.52 14" 51.42 13" ENGINEER BEFORE CONSTRUCTION CONTINUES; F� B B USE TWO (2) 500 GALLON H2O PRECAST LEACH CHAMBERS W 4 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. LOAMY SAND LOAMY SAND 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 10YR 5/8 10YR 5/8 STONE ON ENDS & 3.75 STONE ON SIDES: 25 L X 12.5 W x 2'D THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 45.70 36" 48.32 38" BOTTOM AREA: 25 x 12.5= 312.5 SF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. C C 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. SANDY LOAM SANDY LOAM SIDE AREA.. (25 + 12.5) X 2 X 2 = 150 SF 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 10YR 6/6 10YR 6/6 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. + 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE 43.70 60" 46.32 62" DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING C2 MEDIUM- I C2 MEDIUM- SAND10. EXISTING CONSTRUCTION.LEACHPIT TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 2.5 /4 2.5Y 6/4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN TION 12. THIS NOTICE TO BERUSEDIFORRSEPTIC SYSTEM PURPOSES ONLY <2MI 35.70 156" 38. 156" 73 TERN LANE, CENTERVILLE, MA W AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY NO GROUNDWATER UNDWATT O SOILSS ER OBSERVED Prepared for: in ren 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 4STSA 14. NO WETLANDS WITHIN 100' OF" PROPOSED LEACHING. Engineering and Survey by: SCALE DRAWN 15. ALL PIPING TO BE 4" SCH 40 0 1/8" 81 9 1/8/FT (UNLESS SPECIFIED) • 1, Darren M. Meyer. R.S., CSE, hereby certify that I am(currently approved by MADEP pursuant to 310 CMR 15.017 M BOXYER SONS,INC. N.T.S. DMM to conduct soil evaluations and that the above onalysis,lhos been performed by me consistent with the: E SHEET NO. requirements of 310 CMR-15.017. I further certify that I have passed the Soil Evol. Exam in October, 1999. LAST SANDWlCPI,MA 02537 DATE CHECKED 50"62-2922 04/22/16 DMM 2 of 2