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HomeMy WebLinkAbout0143 TERN LANE - Health 143 Tern Lane Centerville A= 212-019 5 M E A D No.2•153LOR UPC 12534 smud.com • VW*In USA .roAl I'Va- IrI�Y1s1�R1i1� SFI �ncw ■aa O I allo. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippliLation for bisposal 6p tPm Cane-'t`T-UCtion 3permit . G93 33aS-��� Application for a Permit to Construct( ) Repair( - Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location aA/Address Lot No. 3 '�-.e�,-.n�,/`Ltj Owner's Name,Address, Tel.No.�'J0131 3-7�� C+ Ass sso is Map/ Cq�' k ". �/ �✓►°iND CCh�1 Cy.� Installer's Name,Address,and Tel.No. Sc*- 36ta(&3-*Y)7 Designer's Name,Address,and Tel.No. ?,SS 3 G,/ Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 11 G 13 = 3 3C gpd Design flow provided u"�G S• gpd Plan Date ��7 Number of sheets Revision Date Title Size of Septic Tank i So a Type of S.A.S. iX 4 CkV4 11 f /1' S ' �� Description of Soil 5'�-e S�r� 1 4>° ' Nature of Repairs or Alterations(Answer when applicable) �'�.p 'Y246jLv EyP�N 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 Hea th. �7 i `'1� Date Application Approved by Date �l Application Disapproved by Date for the following reasons Permit No. �t` Date Issued /I ---�— --_ ---------__-__---------------------------------------------------------------------------------------—_---------- ----- TOWN OF BARNSTABLE LOCATION 143 a k Aj L d ti s SEWAGE# QLC?1) �� 3 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO.J91 i /by-els ce',S d- SEPTIC TANK CAPACITY �a Q LEACHING FACILITY:(type) u�,4 ert�� ,57W404 4mi "3' (size) NO.OF BEDROOMS OWNER- 00tAiQ Cav,hr r PERMIT DATE: 11 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY • i ' i i A^1 11-36, A-3 13 -4 19 - 725Zr) // y Li k... , . Fee # - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 5 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pprita ion for Misposal 6pstetn ConsArtittton jhrmit6a3 33a S Application for a Permit to Construct( ) Repair(jUpgrade( Abandon( ) ❑Complete System El Individual Components Location Address o�Lot No. *err,(� t—h Owner's Name,Address,and Tel.No.PQ � '37 '7�/t Assessor's Map/Parcel C4 n kro. j� t� i C� �C �ti 7 f�'i`�/�Q 5�;'t 63 Installer's Name,Address,and Tel.No. Sc�r 36a Ga Designer's Name,Address,and Tel.No. 3015 Y Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons /` Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 11 G 3 33C gpd Design flow provided y 4G S. gpd Plan Date D p L Number of sheets ,,`` Revision Date Title % Size of Septic Tank 1 S G �J Type of S.A.S. a P Ch 5"./Sf-Jr Description of Soil S-r P S�) i Nature of Repairs or Alterations(Answer when applicable) S-e P • I ^+� 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 He th. Stgne Date Application Approved by Date Z Application Disapproved by Date for the following reasons L' Permit NO. �l' 7 Date Issued ` - = - - - - ----------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired 41) Upgraded(L�,/ Abandoned( )by I_(t,c (3 CC-n S) at I q 3 -P rn I-.i n/ C•p 91a r i,-i has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.)-6 f/ `'N_3dated /Q- Installer 1` f ,S ('r T `S C° S Designer C S 4 S-a/'vim;/k C. #bedrooms Approved design flow 73 r_j gpd The issuance of this permit shall not be construed as a guarantee that the system will/ nfit ccti n as' esigned. Date t Inspector tom..;__ -J --------------------------------------------------------------------------------------------------------------------------------------- No..l� / r 7 L� Fee / THE COMMONWEALTH OF MASSACHUSETTS Y - PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal ,pstem Construction 3permit Permission is hereby granted to Construct( ) Repair Upgrade(7,,)7 Abandon( ) System located at Lf-3 f-P I'n La n / r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be compl ted within three years of the date of this permit. �! Date /cam / � ) Approved bye,. X 01/12/2012 06:41 5083621590 FES PAGE 01 Town of Barnstable •� Regulatory Services Thomas F.i"eiler,birector ° KAM r Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,N" 02601 Ofte: 508-8624644 Fax: 508-790-6304 Date: / // /Z- Sewage Permit# `a 0 l r- 443 Assessor's Mapmareel au a. c)t 9 Installer&Desi=n Certification;form Designer: U /Z L) ���/:/'h( installer: _Cq1i j fits- Cvwt Address: L-�I rL+ CP U G 134 (7-Vddress• f.3 13h LoWrdJ-? /9"tcJ 6PaP—le"x S� On 4,a 20fI as I h S �'j6a�f--S (" x S ; was issued a permit to install a date instal septic system at Jq3 TEO/ I!41VI _ based on a design drawn by (address) dated 130/// (designer) . I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank- Stripout (if required) was inspected and the soils were found satisfactory. 1 I certify that the septic system, referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if requir inspected and the soils were found satisfactory. %Ati OF/.rgUVr� for DAvi FLAHER tY JR. v (Installer's Signature) No. 1zt1 s9t/ 7..�1P (Deli er's Signa ) (Affix Designers Stamp Here) PLEASE RETLMN TQ BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WLLL NQT BE ISSUED UNIM BOTH THIS FORM MM M- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YQU. g1oflSce fenmWcsiracmifieation form.doc . A- Town of Barnstable P# J 3 Do Department of Regulatory Services X&MSTABM j Public Health Division Date �) E NA9S 4/_ rEA�A�� y'I 200 Main Street,Hyannis MA 02601 149 Date Scheduled Time ' Fee Pd. Soil Suitability Assessment fog- age Disposal Performed By: e &, — '" l�"'C Witnessed By: LOCATION& GENERAL INFORMATION Location Address /43 —22—;�—P ot / r+ nr Owner's NameT-W., ,.t No t& ✓ r VV Address �C 9 z tG3 Assessor's Map/Parcel: Z.( 2 (� Engineer's Name C V, � NEW CONSTRUCTION REPAIR Telephone# =,rr1�— .577--9--c-3 e.0 • Land Use —a2St \ p ( ) Surface Stones MIA Distances from: 0 Wal od a ft possible Wet Area N�.4 ft Drinking Water Well VoV A4 Drainage Way 75'-"- ft Property Line !L' ft Other y-j 13 r�) / ft /n/ pert! 1-440 . `VY, \ SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetland ro5Fim%%' �J J ` - �- �- 1 J I Parent material\(geI,\g Depth to Bedrock Depth`to Groundwater. Standing Water in Hole: y Weeping from Pit Ftloe 13 Estimated Seasonal High Groundwater �i tit) Gj 7� DETERMINATION FOR SEASONAL GHJA' ER TABLE Method Used: 2 Depth Observed standing in obs.hole: n, Depth mottles: ,(/ In, De I th to weeping from side of obs.hole: �I.Vel , Groundwater Adjpst nt f. /vim Index Well# e m�Date _ j0 Index WeAdj,factor,, RcQ.droundwater Level PERCOLATION TEST Data Yme� b3�6 /j1i9� Observation Y4}l70� Hole# Time at 4" _� L � Depth of Perc �'p✓!� Time At 6" Start Pre-soak Time m �0•• 7z /rf' Time(V-0) End Pre-soak : /7 2� Rate Mini Anch .G 740�^ Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP•OBSERVATION HOLE LOG Hole# �2.9 Depth from Soil Horizon Soil Texture .Sdil Color Soil Ot er Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,,Bon dens. o i ten;y,96 Gravell 112 4 6 DEEP OBSERVATION HOLE LOG Hole# "�7 Z.9 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) \ Mottling (Structure,Stones,Boulders. Consistency,%Grave Iva ! 4 a �s 0 s6 v 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, Consi t n e Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No= Yes ' Within 100 year flood boundary No._ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi r,It terial exist in all areas observed throughout the area proposed for the soil absorption system? v� If not,what is theAepth of naturally occurring pe ious matorial? Certification I certify that on 1 9 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that a above analysis was performed by me consistent with . the required traini se and a 'en cribed in I10 CMR 15.017. Signature Date ��'✓J Q:1S.EPT1C\PERCF0RM.D0C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 P Y rY M 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O. Box 33724, San Diego, CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 � 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 aoS on the computer, use only the tab 1. Inspector: key to move your cursor-do not REID C. ELLIS use the return Name of Inspector key. ELLIS BROTHERS CONSTRUCTION ,y Company Name 23 ENTERPRISE ROAD Company Address YARMOUTH PORT MA 02675 Cityrrown State Zip Code 508-362-6237 S121891 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: asses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 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 . . Commonwealth of Massachusetts th . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Tern Lane, Centerville, MA Property Address Donald J Connor P. O Box 33724, San Diego CA 92163 Owner Owner's Name information is MA 02632 12/09/2016 required for every Centerville 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: ,iIAJ I have not foun ny 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 deE cribed in the"Conditional Pass"section need to be replaced or repaired.The system, upon ompletion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes', "no"or"not determi ed" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years o d* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or afiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced witt 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 th an 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Tern Lane, Centerville, MA Property Address Donald J Connor P. O Box 33724 San Diego CA 92163 Owner Owners Name information is MA 02632 12/09/2016 required for every Centerville page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ElPump Chamber pumps/alarms not operational)/System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): N1W ❑ 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 bro en, 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): i ❑ The system required pumping more than 4 tim s 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): /v C) Further Evaluation is Required by the Boa d of Health: ❑ Conditions exist which require further evaluat on by the Board of Health in order to determine if the system is failing to protect public health, fety 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 functior ling in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of surface water ❑ Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh 1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O_ Box 33724, San Diego, CA 92163 Owner Owner's Name information is Centerville MA 02632 12/09/2016 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) �� 2. System will fail unless the Board o Health (and Public Water Supplier, if any) determines that the system is functioi iing in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and so il absorption system (SAS)and the SAS is within 100 feet of a surface water supply or trib itary 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 a nd 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 analy is, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the pr sence 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 D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑ or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O. Box 33724, San Diego, CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 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 ❑ ytributary to a surface water supply. j 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- 1 0,000g pd. ElThe 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 fee of a surface drinking water supply ❑ ❑ the system is within 200 feel of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nil ogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped one II of a public water supply well If you have answered"yes"to any question in Sec ion E the system is considered a significant threat, or answered"yes" in Section D above the large sy tem has failed.The owner or operator of any large system considered a significant threat under Secti n 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 Form: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 143 Tern Lane, Centerville, MA Property Address Donald J Connor P. O. Box 33724, San Diego CA 92163 Owner Owner's Name information is Centerville MA 02632 12/09/2016 required for every page. City/Town state Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as 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,�wluding 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: ? 3 Number of bedrooms(design): J Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): �3® t5ins•3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O. Box 33724, San Diego, CA 92163 Owner Owners Name information is required for every Centerville MA 02632 12/09/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: / z,4/ 6� 6� Number of current residents: Does residence have a garbage grinder? ❑ Yes ;7N Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes i<o Water meter readings, if available(last 2 years usage(gpd)): Detail: -e������ Sump pump? El Yes. No Last date of occupancy: 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 " .,. 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O_ Box 33724, San Diego, CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) A Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Wass 'stem pumped as art of the inspection?Y P P P P Yes ❑ No If yes, volume pumped: gallons 'i How was quantity pumped determined? Reason for pumping: Type of System: M/ 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-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 y 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O. Box 33724, San Diego, CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 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: Were sewage odors detected when arriving at the site? ❑ Yes /No Building Sewer(locate on site plan): Depth below grade: feet Mat ial of construction: cast iron El40 PVC ❑ other(explain): 0 j Distance from private water supply well or suction line:�9. feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: ,Y feet ,,Material of construction: CJ concrete metal ❑fiberglass ❑ polyethylene ❑ other(e lain) h414�;p avo#n( A917W IAI&4�- 9L PV If tank is tal, list e: ye K Is ag onfirme by a Certificate of Compl ance? (attach a copy of certificate) Yes ❑ No Dimensions: J� �I�2fyj2. `��.5rlof� Sludge depth. 3 � t5ins-3FI3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �., 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O. Box 33724, San Diego, CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) o� 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 y v Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? `n Comments (on pumping recommendations, inlet and outlet tee or baffl condition, structural integrity, liquid levels as r lated to outlet' vert, evidence of leakage, etg.): �/ lU�S,/�p/A 4� N ati All— Grease Trap(locate on site plan): Depth below grade: d , feet Material of construction: ❑concrete ❑ metal ❑ fi erglass' ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee o baffle Distance from bottom of scum to bottom of outl t 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 ,M 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O. Box 33724, San Diego, CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendatlolnsrinPetan liquid levels as related to outlet invert, eviden of leakage, etc.)r baffle condition, structural integrity, Tight or Holding Tank(tank must be pu m ed a time of inspection Locate on( site plan): Depth below grade: Material of construction.- concrete ❑ metal ❑fiberglass 9 El polyethylene El 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 switc ies, etc.): Attach copy of current pumping contract(re wired). 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 143 Tern Lane, Centerville, MA Property Address Donald J Connor P. O. Box 33724 San Diego, CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened,) (locate on i e plan): Depth of liquid level above outlet invert !V v 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): AP Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, c ndition 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: WS t5ins-3/13 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 u 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O. Box 33724, San Diego CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc. : U dz .1 v 41`;V 5I A/A .�/ Cesspools (cesspool must be pumped as pa4 of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 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 M 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. 0. Box 33724, San Diego, CA 92163 Owner Owners Name information is required for every Centerville MA 02632 12/09/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydrauli 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 hydrauli( 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 F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O. Box 33724, San Diego, CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to _q at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate W whe public water supply enters the building. Check one of.the boxes below: ` hand-sketch in the area below ❑ drawing attached separately 20 10 t5ins•3113 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ^.w 143 Tem Lane, Centerville, MA Property Address Donald J Connor, P. 0. Box 33724, San Diego, CA 92163 Owner Owner's Name information is required for every Centerville MA 02632 12/09/2016 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope -G�f��� `_ Qi �eaGG,�yv ! �✓3 ��� ❑ Surface water ❑ Check cellar ' G ❑ Shallow wells MIA- 6 "z�i/ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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-exp a:n: You must describe how you established the high ground water elevation:` 31 6.7 8v. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.•'• 143 Tern Lane, Centerville, MA Property Address Donald J Connor, P. O. Box 33724, San Diego, CA 92163 Owner Owner's Name information is Centerville required for every MA 02632 12/09/2016 page. Clty/Town State Zip Code Date of Inspection E. Report Completeness Checklist ('Inspection Summary:A, B, C, D, or E checked [Inspection SummaryD S (System Failure Criteria Applicable to All Systems)completed VVS g ystem Information—Estimated depthg to high gr oundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LOCUS DAjTA N E J NOTE: PLAN REFERENCE 8.8-13 = UNDERGROUND ELECTRIC LINE Z TO BE RELOCATED BETWEEN ^' TERN LN THE HOUSE AND THE GARAGE. DEED REFERENCE 21 1 1 6/1 51 5:: A o LOCUS WEQUAQUET ZONING DISTRICT RD-1 0 ko = LAKE z N OVERLAY DIST. NOT A STATE i0 ZONE II N 0$ � J FLOOD ZONE 250001 a ARSH RpAp 66 ASSESSORS MAP 212 LOCUS MAP NOT TO SCALE: PARCEL 019 f \ \ \ \ TTAGBENC ML RK / LOT AREA 40,049f S.F. /cp. // /�/ \ \ �� \ \ EL=3 49 w / / \ \ unur ( / /i \ \POLE�9 \\ rc N86'39'50"E 109.10' , \� w q� po/ /b~ /b / % iA,' \\ \ ' a SITE 8c SEWAGE '� •' ` ' ' w 3 1 Q REPAIR PLAN ABUTTERS LAWN / GARDEN `\\ \1\ \\ \\ \ /��. GARAGE W PORTION OF RESERVE DRAINAGE..AREA / / // � / / / „\ �,�: •::`\ //�,��v� � i � ,� Z TERN L A NE / ,/ �,, / , ,�LOT 35 �N INTERIOR PROPERTY LINES —// ' / / �' LOT 37 \\#210'� �- LOT 36 L / / / / / / / \�•. \ MIN \ \\ \ CENTERVILLE I I DATE: DECEMBER 2 2011 '36�-''%'��' li'i i /' ir PATIO \ �' \` �H\#� \\ 189'}\\ OWNER/APPLICANT: � , '''3� � \ � 2'� \ \ \ \\ XISTJNG \\ ,1O LAKE • DONALD J. CONNOR Z P. 0. BOX 33724 / i�2 j L\ \\ BED BH KITCHEN \ \ \ \\ \\ \\\ j w z I c / / 1 \ #3 \ \ \ \ \ACE SAN DIEGO 40,049f s.f. ; ; \ \\ #143 C A 92163 BED#2 LIVING (6 2 3) 3 3 2- 5 3 9 3 r BED#1 ABANDON EXISTING SEPTIC y I o I SHEET 1 OF 2 D \ SYSTEM PER TITLE 5 I I I 9 FILL AND CRUSH r' Z PREPARED BY: BENCHMARK. EXISTING LEACHING PIT I w TOP OF MASONRY WALL ELEV 47.89 rS86'39�50"W 131.91' I I o EAS SURVEY, INC. 9'50"W 120.00' °F� 141 R T. 6 A DA ID � q ss9 GNP �o� EDWARD q, 0 30 45 60 1729 n. A. P. O. BOX N 11 ST N cn SANDWICH MA 02563 y ' `�01sTE� �- - `. �; GRAPHIC SCALE: uTlurY PH. (508) 888-3619 S'4NITAR\ ' L o5 / 1 INCH = 30 FEET POLE #10 CELL (508) 527-3600 11 -0126 REMOVE CONCRETE PATIO SYSTEM DESIGN OVER SEPTIC TANK RAISE COVERS TO WITHIN G" OF FINISH GRADE OBSERVATION DESIGN FLOW SILL 47.19 FINISH GRADE PORT TO GRADE 3 t`•,..: F.G. ELEV,-46.10a` ELEV, .45.b�' FINISH GRADE BEDROOMS AT110 GPB/D 5Q GPD ,.. //&� - �� / � ELEV. 43.5 REQUIRED SEPTIC TANK .in10,0S= 0.10 TOP ELEV 42.0 1.5' OF COVER TOP=43.0 330 x_2__ _ __ 660 GAL. 15'OS= 0.07 ` SEPTIC TANK PROVIDED = 1500 _GAL. r� 4" P 4" PVC SCH 40 6'OS= 0.01 5' STRIPOUT SCH 40 INV.= 2 MIN-3 MAX INV.= 44.19 43.19 10"TEE 14"TEE INV.= AROUND SAS SIZE OF LEACHING FACILITY REQUIRED 310CMR 15.255 5,_7" 42.99 6" 00 TO MIN Cl HOR. DESIGN PERC RATE __ <2 ____MIN./INCH .+ 4 BAND 1 GAS BAFFLE 3 OUTLET ,. 40 MIL LONG TERM APPL. RATE_0•_74_GPD S.F. f: STAINLESS STEEL 4-6 /" ROWS OF 8 QUIK2"x I"X75"ATORS / 2 4'-1" LIQUID LEVEL D-BOX POLY LINER 4'-4" \IINV.=341.6724 UNITS 12 x34"x75' > CONNECTOR INV.=41.90 a ci BOT.=39.0 SIZE OF LEACHING SYSTEM PROVIDED: 41.73 L38. 5 32•0' I N o 41.0 330 = 0.74 SF/GPD = _446 S.F. MIN. REQ. BOT. ° 0. ° 0. 8 ® 48 EACH ui ui PROPOSED 1,500 GALLON SEPTIC TANK STRIPOUT (18.5 X 42.0) 35.8 USING 24 CHAMBERS WITH NO STONE AROUND CONSTRUCTION NOTES: ADJ. MAX. G,WATER "QUIK-4" INFILTRATORS 4.73 SF / LF X (96) = 454 S.F CONTRACTORS. I CERTIFY THAT I AM CURRENTLY APPROVED BY THE 1 / INSTALLERS SHALL VERIFY GRADES AND 454 x 0.74 G/SF = 336 GPD DEPARTMENT OF ENVIRONMENTAL PROTECTION TO CONDUCT ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING 11 -012.6 WORK ON THE SITE. SOIL EVALUATIONS AND THAT THE RESULTS OF MY SOIL 2, NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE EVALUATION RE ACCURATE AND IN ACCORDANCE WITH 310 WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 336 GPD PROV > 330 GPD REQ. = 6 GPD RES. CMR 1 HROUGH 1 , 0 IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY, SITE �c SEWAGE �� NO (GARBAGE DISPOSAL / GRINDER ALLOWED) `. _ A. 1 ii-C ___ 3, VEHICULAR TRAFFIC, PARKING OF VEHICLES AND PLACING REPAIR PLAN EDWARD A STONE, CERTIFI D S ALUATOR MATERIALS OVER THE SEPTIC TANK, DISTRIBUTION BOX AND R S,A,S, AREA IS PROHIBITED #143 GENERAL NOTES: TERN L A NE 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. DATUM: D.T.H. #1 ib D.T.H. #2- ib TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS DATE: 11-15-2001 DATE: 11-15-2001 IN FOR SUBSURFACE DISPOSAL OF SEWERAGE. VERTICAL DATUM: BARN. GIS MSL± GROUND ELEV. 42.90 GROUND ELEV. 42.90 F 2, AT LEAST ONE ACCESS POINT OVER TANK TEES SHALL BE ADJ. G.W. 35.80 ADJ. G.W. 35.80 C E N TE R VI L L E ACCESSIBLE WITHIN 6" OF FINISH GRADE, WITH ANY REMAINING ACCESS PORTS BROUGHT TO WITHIN 6" OF FINISH GRADE. BENCH MARK USED: CORNER OF BULKHEAD DATE: DECEMBER 2, 2011 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE ELEVATION 29.00 A A r CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE �HOF�s LOAMY SAND LOAMY SAND OWNER/APPLICANT: UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEY ya`� �, 10YR 4/3 " 10YR 4/3 MUST WITHSTAND H-20 LOADING. o� V �� 8 10' D 0 N A L D J. C 0 N N 0 R 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION o� DTH #1 ib TEST DEEP B B OF ALL UTILITIES PRIOR TO ANY EXCAVATION. � in RTY TEST HOLE LOAMY SAND LOAMY SAND P. O. B 0 X 33724 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE 7.5YR 5/6- 1211 7.5YR 5/6OR WI „ SAN DIEGO 6. FFINISHTGRADE SHALL HAVEHALMINIMUM OF OE02BE MORTARD1FEETAPER PLCE. ELEV = 41.1 22 ELEV =40.9 24 INDICATES C-1 C-1 CA 92163 7. SEPTIC TANK SANITARY TEFOOT OVER THE S.A.S. DE'S ISHALLL BEN NCONSTRUCTED OF BOX. SA"I rA P-1 54" PERC TEST COARSE SAND COARSE SAND SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE �, 10 R 6/6 50'� 1 10YR 6/VEL �a (623) 332- 53 1 93 THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND ( INDICATES ADJ. G.WATER 85" 85" LOCATED DIRECTLY UNDER THE CLEAN OUT MANHOLES. INDICATES OBV. G.WATER ELEV =31.4 ELEV =31.4 „ SHEET 2 OF 2 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN C-2 138" C-2 138 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT ELEVATION OF THE OUTLET PIPE. MEDIUM SAND MEDIUM SAND PREPARED BY: 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES VARIANCE REQUESTED 2.5Y 7/4 2.5Y 7/4 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS �p�jNOFSSq 144"NONE ELEV = 30.90 ELEV = 30.90EAS SURVEY, INC. 144" BAFFLE, 4 INCHES IN DIAMETER AND CONSTRUCTED OF 4- PVCo�'� EDWARD cti� 141 R T. 6 A 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND �� A GROUNDWATER ADJUSTMENT B.O.H. SHALL BE SLOPED 1/4 INCH PER FOOT MIN. EXCEPT FOR THE o -+ DON DESMARAIS FIRST TWO FEET OUT OF THE DISTRIBUTION BOX WHICH SHALL " STON cn SOIL EVALUATOR P. O. B 0 X 1729 BE LEVEL � No. 89 o INDEX DATE OF WELL: AIW2471 ED. STONE 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION °� p� E A WELL ZONE: C SOIL EV. LIC. APRIL, 1995 SANDWICH MA 02563 7 BACBRUCKHOE OPERATOR. TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW �o WELL DEPTH: 24.03 " ' AND APPROVAL. BRUCE ELLIS BROS' 13. MAGNETIC TAPE OVER ALL COMPONENTS. N L ANO �� DEPTH OF WATER: 138" SOIL TYPE: �_ PH. (508) 888-3619 WELL ADJUSTMENT: 52" PERC RATE: ! 2 MIN. PER INCH CELL (508) 527-3600 DEPTH OF ADJ.: 85" LOADING RATE: 074 GAL/SF/MIN i`