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0017 THREAD NEEDLE LANE - Health
17 Thread Needle Lane Centerville A= 210- 076 /111 � o fill UPC 12534 N e514 No. .2�153LOR HASTINGS.YN 1 TOWN OF BARNSTABLE LOCATION i ��}r�,�s, Q�.t L*,i- L q SEWAGE# `'VILLAGE �i , � LUQ f_L ASSESSOR'S MAP&.PARCEL 440 a INSTALLER'S NAME&PHONE NO. C_ ( • 5� • ']-T 1—W SEPTIC TANK CAPACITY EkjC ON6 i00 4,44— 11/4, LEACHING FACILITY:(type) ZV;g`,�_ (size) `';�_I I NO.OF BEDROOMS a'4— OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) 4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 04 r Lk 2 r' 4f (-7 i F No. Fee l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4pliYation for 33ispoSal *pBtem ConstCUttioii permit Application for a Permit to Construct( ) Repair(.4 Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.17 i ert,4 f0a.,.4(e_L n• Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �%�*p✓j(p e Ilse P i�o�—y 1�2/iS1e nS p d Installer's Name Address,and Tel.No.C_08-q;g- Designer's Name,Address,and Tel.No. 67,$>q0* -5313 & ►joloZt& ;s��k�rl,_Z7& /00.rj'ex boy �q i r�ee���,g s s. I to A ox W Type of Building: p 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) y q() gpd Design flow provided IV 912, 3 gpd Plan Date Tj I a, Number of psheets � �, -� Revision Date I n A Title��mSRG� §ien rJ.�n� ( ) cnl��a ' 1 �L1►n 1 7 r hre2<0 l(�n�le Size of Septic Tank i Y 3 Type of S.A.S. ;19-Att.34o 46 AO UA'ldS 1)16 ,k :�L Description of Soil fir'+=�55 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental an of to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2 b 6 v 336 Date Issued w i{ e No. O` F� J �*. Fee THE COMMONWEALTH'OF�MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for MispoSal Lipstein (Construction Permit Application for a Permit to Construct( ) Repair(4 Upgrade( ) Abandon( ) ❑Complete System Z'Individual Components Location Address or Lot No.17 7h rer c( j(,,E Ln• Owner's Name,Address,and Tel.No. a eehl-edv�It� i���af;�y +`te /i5� ff � Assessor's Map/Pazcel /p ^07(o f.a• r !�S try b e, e�l Installer's Name Address,and Tel.No.,308•qX&-8 I a(r, Designer's Name,Address,and Tel.No. 5-z;8 q,9/j •5313 tvl�tGc Maras/��C�iGr7, 1./x P.6.C3c,x '70V Eng I nee6Vn Wq.f e-/S ns A11,85 bVA Oo1o' VJ Cres s N. )::70-fes AoxYV Type of Building: Dwelling No.of Bedrooms Lot Size a4,5 l sq.ft. Garbage Grinder( ) t Other Type of Building No.of Persons Showers( ) Cafeteria( ) �f Other Fixtures ti Design Flow(min.required) � y 0 gpd Design flow provided (/9 7, 3 gpd i Plan Date__ %�)/1 Co Number of sheets a;.` Revision Date Title?1y)M. SP_, � `e, �C Sun ,� l 1G,K,(C I �k V) rECI[T ltlp r�/e -' l C'i A-c(0 t I+E i'`'f Size of Septic Tank 2X irS R nc /L1�X��r. Type of S.A.S.aS- I��36 ITC. f4L7' j4,4kis/1,S�tox �<'L .. , d L . Description of Soil 7L�G� ��J/ �rr�F/ ��ei 5t�neleSS i a Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system l accordance with the provisions of Title 5 of the Environmental Cod an of to place the system in-operation until a Certificate of Compliance has been issued'by this Board of Health. Signed Date Application Approved by %AAADate -r — v Application Disapproved by Date for the following reasons Permit No. ;? 01 G— 330 r Date Issued 6` --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the /On-site Sewage Disposal system Constructed( ) Repaired(4,,j Upgraded( ) Abandoned( )byJyi � I tt � at 17 I h Lrg n A 1ye,d(e jClN1G ~ &,j k, l 11 has been constructed in accordance with the provisions off Title 5 and the for Disposal System Construction Permit No,.70/6-3?y dated Installer r Io(�•tL� Designer E� ; ��o r; trr. /8 )n f k4_), Tr-jc #bedrooms -7 / Approved design flow J i / 3 Al g d The issuance of this e t sha n•'t be construed as a guarantee that the syste 1 , cti�onj de gn�. / Date Inspector ---------------------- - - --,- -------------- No. RA Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby grantedd too Construct,( ) Repair( ) Upgrade( ) Abandon( ) System located at 1 1 (�r�Ect A 1 ygai!/LE La cen`l er -(le 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:ConstWctio to lmust be completed within three years of the date of this permit. Date f ( Approved b PP Y SEP-29-2016 02:14 From: To:150e7906304 Paee:1,11 Torn of Bar stable Regulatory Silt-vices RichArd V.Seatl,Inte rim Director NAM sic ' a Public Health Division Thomas McKean, irector 200 plain Street,Hyani is,MA 02601 Office: 509-862-4644 Fax: 509-79"304 Installer&Designer Certifi lation Form Date: °(�2 Ll Sewage]Permit# Za 1& -830 Assessor's Map\Parcel —7— 1 0 —d 7 G Designer. r` ;v�►+au.�. iay�rd is 1.. � InstHer: o rL-.e� � —a �ah s �r v��•ti Address: i Z i Add ess: �S ve On 91141NG B CSt-w issued a permit to install a (date) (installer) septic system at 1�7 r4oA N LA-1 based on a desigo drawn by (address) L iz'n dated i (v ( esigner k I certify that the septic system referenced above as installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution'box and/or septic tank_ Strip out (il 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 w iy 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 I if required)was inspected and the soils were found satisfactory. _ L i comity that the etn referenced above was co structed in co fiance with the terms of the fietters(if applicable) PETER T. M&-WEE - I (Instane s Signature} CIVIL No- 35109 2. Sim (Designers Signature) esit ere PLEASE RETURN TO BARNSTABLE PUBLIC HE TH DIVISION.. CERTIFICATE OF.COMPLIANCE WML NOT BE ISSUED UNT BQTH THIS FZR1Wi R1D .AS- $UlL'1'CA1tD ARE RECEI IA 1 Y THE BARK LE PUBL,LC IILEAL.TH DIVISION. TRAM XML QASepticw)*igncrCeWficadoa Fom R@v$-l4-i3.doc i HEAVY DUTY CHAMBERS IN 310 CMR 15.405 APPLICATIONS Arc 36 Heavy Duty (HD) Chamber and 310 CMR 15.405 Contents of Local Upgrade Approval states in Arc 36 High Capacity Heavy Duty (HD) Chamber part' (1)In granting local upgrade approvals where full compliance 310 CMR 15.405 Cross Section as defined in 310 CMR 15.404(1)is not feasible the options set Typical Trench Detail(not to scale) forth below should be considered. Rating size per 310 CMR 15.242 (b)an increase in the maximum allowable depth of system components required by 310 CMR 15.221(7),from 36"to 72" below finish grade,provided that H-20 loading is provided for all ESTABLISH system components." VEGETATIVE COVER GRADE TO DRAIN NATIVE BACKFILL ADS makes available chambers for use in"deep cover" f applications,including those detailed in 310 CMR 15.405(1)(b) (above).These chambers are known as"Heavy Duty"model chambers,and carry a"Heavy Duty"or"HD"label.When 11I installed in accordance with the instructions in this manual and a minimum of 36 inches of cover material,HD chambers can sustain an H-20 load.ADS specifically recommends the use 36-72" p Y of these"Heavy Duty"model chamber products in deep burial applications,including those specified in 310 CMR 15.405(1)(b). The following"Heavy Duty"chamber products are required by ADS for use in 310 CMR 15.405(1)(b)applications: ARC 36 HD Chamber 13°OR 1s" ARC 36 High Capacity HD Chamber BioDiffuser-16"High Capacity H-20 Chamber ARC 36 HD or I "Heavy Duty"or"HD"chambers may be installed with up to a ARC 36 HIGH CAPACITY HD 36" maximum of five-feet(5')of cover in bed and eight-feet(8)of cover in trench installations respectively.These chambers are not designed for use in commercial traffic loading applications. Length and number of trenches determined by design. Arc 36 Heavy Duty(HD) Chamber and Arc 36 High Capacity Heavy Duty (HD) Chamber Chamber 310 CMR 15.405 Cross Section Typical(not to scale) Rating size per 310 CMR 15.242 ESTABLISH VEGETATIVE COVER GRADE TO DRAIN NATIVE BACKFILL Ali,% 1� ,V ,i V i � li U �r li�Iii,V I I. �II�,Inlli,V •� h Flu,I�lv,t V I�i, 31 i0" ARC 36 HIGH CAPACITY HD OR ARC 36 HD `\ 13"OR 16" 36" ►{ LENGTH AND WIDTH PER DESIGN Contact Infiltrator Systems,Inc.1-800-221-4436 for additional technical and product information. h - Commonwealth of MassachuSsetts Exec.hive Office of Energy &Environmental Affairs e er ment of Environmental Protection One Winter Street Boston, MA 02108 m 617.292-5500 Charles D. Baker Matthew A. Beaton Governor Secretary Karyn E. Polito Martin Suuberg Lieutenant Governor Commissioner CERTIFICATION FOR GENERAL USE Pursuant to Title 5, 310 CMR 15.000 Name and Address of Applicant: Infiltrator Water Technologies, LLC. P.O. Box 768 4 Business Park Road Old Saybrook, CT 06475 Trade name of technology and models: BioDiffuser I I" Standard, BioDiffuser 14" High Capacity, BioDiffuser 16" High Capacity, BioDiffuser 16" High Capacity H-20', BioDiffuser 15"Narrow (Bio 2), BioDiffuser 22 Narrow (Bio 3), ARC 36, ARC 36HD, ARC 36HC, ARC 36HC HD, ARC 50, ARC 18, ARC 24, ARC 36 LP (3.8 inch-invert), and ARC 36 LP (8 inch-invert) (hereinafter the "System"). Schematic drawings of the System and a design and installation manual are a part of this Certification. This approval allows the installation of the above identified chambers without aggregate. Transmittal Number: X264258 Date of Revision: February 19, 2015, modified June 12, 2015 Authority for Issuance Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000, the Department of Environmental Protection hereby issues this Certification to: Infiltrator Water Technologies, LLC., P.O. Box 768, 6 Business Park Road, Old Saybrook, CT 06475 (hereinafter "the Company"), for General Use of the System described herein. The sale, design, installation, and use of the System are conditioned on compliance by the Company, the Designer, the Installer and the System Owner with the terms and conditions set forth below. Any noncompliance with the terms or conditions of this Approval constitutes a violation of 310 CMR 15.000. OJ44", June 12, 2015 David Ferris, Director Date Wastewater Management Program Bureau of Water Resources This information is available in alternate format.Call Michelle Waters-Ekanem,Diversity Director,at 617-292-5751.TTY#MassRelay Service 1-800-439-2370 MassDEP Website:www.mass.gov/dep Printed on Recycled Paper - 1 BioDiffuser and ARC Chambers by Infiltrator Water Technologies, LLC. } Page 2 of 6 Revised Approval for General Use—June 12,2015 1 I. Design Standards 1. The models listed in Table 1 are covered under this Certification. Table 1: Chamber Dimensions Dimensions Invert Model W x L x H Height Inches Inches BioDiffuser I I" Standard 34 x 76 x 11 6.5 BioDiffuser 14" High Capacity 34 x 76 x 14 9 BioDiffuser 16" High Capacity 34 x 75 x 16 11.3 BioDiffuser 16" High Capacity H-20' 34 x 75 x 16 11.3 BioDiffuser 15"Narrow (Bio 2) 15 x 87 x 12 6.87 BioDiffuser 22"Narrow (Bio 3) 22 x 87 x 12 6.87 ARC 36 34.5 x 60 x 13 7.13 ARC 36 HD 34.5 x 60 x 13 7.13 ARC 36HC 34.5 x 60 x 16 10.75 ARC 36HC HD 34.5 x 60 x 16 10.75 ARC 50 51.5 x 42.75 x 30 22.25' ARC 18 16 x 60 x 12 6.24 ARC 24 22.5 x 60 x 12 6.25 ARC 36LP (3.8-inch invert) 34x60x8 3.8 ARC 36LP (8-inch invert) 34x60x8 83 This approval allows the use of the high capacity H-20 chambers but makes no determination as to the chambers meeting the H-20 loading requirements. 2. Only Systems installed with this invert height shall be allowed to use the effective leaching area associated with this model in Table 2. 3. Only System installed with the inlet pipe entering through the roof of the chamber. 2. The System is an open-bottom leaching unit molded from high density, high molecular weight polyethylene (HDPE) Type III, Class A or B, Category 1 or 3 or Polypropylene Group 03, Class 3, Grade 0. It can be installed without aggregate or distribution pipe as an absorption trench or as a bed or field. If the System is installed with stone aggregate then the " Effective Leaching Area" in Tables 2 and 3 is not applicable, and must be designed in accordance with the provisions of 310 CMR 15.000. 3. The total effective leaching area for any Chamber Model shall be calculated by multiplying the Effective Leaching Area per square foot of chamber times the total length of chamber from Side Port Coupler to Side Port Coupler including Side Port Coupler. n BioDiffuser and ARC Chambers by Infiltrator Water T8chnologies,LLC. Page 3 of 6 Revised Approval for General Use—June 12,2015 Table 2: Effective Leaching Area in Trench Configuration for New Construction and Remedial Sites Effective Effective Model Leaching4 Leaching Area Area (SF/LF) SF/LF BioDiffuser 11" Standard 6.53 N/A BioDiffuser 14" High Capacity 7.18 N/A BioDiffuser 16" High Capacity 7.88 N/A BioDiffuser 16" High Capacity H-20' 7.88 N/A BioDiffuser 15"Narrow (Bio 2) 4.00 N/A BioDiffuser 22"Narrow (Bio 3) 4.97 N/A ARC 36 6.78 N/A ARC 36 HD 6.78 N/A ARC 36HC 7.79 N/A ARC 36HC HD 7.79 N/A ARC 50 NA 6.71 ARC 18 3.96 N/A ARC 24 4.87 N/A ARC 36LP (3.8-inch invert) 5.79 N/A ARC 36LP (8-inch invert) 6.96 N/A 4. Effective Leaching area is equal to 1.67(bottom width+(2x invert height)) 5 Effective Leaching area is equal to 1.0(bottom width+(2x invert height)) 6. The maximum trench width allowed for calculation of Effective Leaching area is 3 feet. 4. For new construction or upgrades, the applicant can size the System in a trench configuration, using the Effective Leaching areas presented in Table 2. 5. Systems installed on remedial sites shall be allowed to utilize the Effective Leaching areas presented in Tables 2 or 3, or additional reductions in soil absorption system may be allowed. In no instance shall the reduction in the soil absorption system required in 310 CMR 15.242 exceed the maximum reduction allowed for alternative systems approved in accordance with 310 CMR 15.284. 6. For new construction or upgrade, the applicant can size the System in bed or field configuration, using the Effective Leaching areas presented in Table 3. 7. When the System is used with a secondary treatment unit approved in accordance with 310 CMR 15.284 or 15.288, additional reductions in soil absorption system may be allowed. In these situations the reduction in the SAS cannot exceed the maximum allowed under the secondary treatment units approval. In no instance shall the reduction in the soil absorption system area required in 310 CMR 15.242 exceed the maximum reduction allowed for alternative systems approved in accordance with 310 CMR 15.284. - 1 BioDiffuser and ARC Chambers by Infiltrator Water Technologies,LLC.' Page 4 of 6 Revised Approval for General Use—.tune 12,2015 Table 3: Effective Leaching Area for Bed or Field Configuration for New Construction & Remedial Sites Effective Model Leaching' Area SF/LF BioDiffuser I V Standard 4.73 BioDiffuser 14" High Capacity 4.73 BioDiffuser 16" High Capacity 4.73 BioDiffuser 16" High Capacity H-20' 4.73 BioDiffuser 15"Narrow (Bio 2) 2.09 BioDiffuser 22"Narrow (Bio 3) 3.06 ARC 36 4.80 ARC 36 HD 4.80 ARC 36HC 4.80 ARC 36HC HD 4.80 ARC 50 7.16 ARC 18 2.22 ARC 24 3.13 ARC 36LP (3.8-inch invert) 4.73 ARC 36LP (8-inch invert) 4.73 Effective Leaching area is equal to 1.67 times bottom width only. q II Special Conditions I. The System is an approved Alternative Chamber for use as an Alternative Soil Absorption System. In addition to the Special Conditions contained in this Approval, the System shall comply with the Standard Conditions for Alternative SAS with General Use Certification and/or Approved for Remedial Use (the 'Standard Conditions'), except where stated otherwise in these Special Conditions. 2. New Construction This Certification is for the installation of a System to serve new construction or an existing facility with a proposed increase in flow, for which a site evaluation in compliance with 310 CMR 15.000 has been approved by the Approving Authority and the site meets the siting requirements for new construction, as provided in Paragraph 6 in section II Design and Installation Requirements of the Standard Conditions. 3. Remedial Site This General Use Certification also applies to the installation of a System for the upgrade or replacement of an existing failed or nonconforming system, provided that the facility meets the siting requirements for upgrades, as provided in Paragraph 7 in section II Design and Installation Requirements of the Standard Conditions. 4. The System shall be exempt from the minimum inlet spacing requirements of 310 15.253. BioDiffuser and ARC Chambers by Infiltrator Water Technologies,LLC. Page 5 of 6 Revised Approval for General Use—June 12,2015 5. The System shall have a minimum of one inspection port through the top of one of the chambers. The inspection port shall be capped with a screw type cap and accessible to within three inches of finish grade. 6. When the System is installed in trench configuration, then the System shall comply with these requirements: a) Length (each trench) 100 feet maximum (310 CMR 15.251(1)(a)); b) Width (each trench) 2 feet minimum to 3 feet maximum (310 CMR 15.251(1)(b)) - Chambers greater than 3 feet wide, when specifically approved, are subject to other Special Conditions and limitations; c) The minimum separation distance between any two trenches shall be two times the effective width or depth of each trench, whichever is greater, or where the area between trenches is designated as reserve area, three times the effective width or depth of each trench, whichever is greater (310 CMR 15.251(1)(d)); d) The effective leaching area shall be calculated using the bottom area and a maximum of two feet (per side) of side wall area for each trench (310 CMR 15.251(1)(e)); e) Trenches shall be situated, where possible, with their long dimension perpendicular to the slope of the natural soil. Where possible they shall follow the contour lines (310 CMR 15.251(2)); f) Trenches constructed at different elevations shall be designed to prevent effluent from the higher trench(es) flowing into the lower trench(es) (310 CMR 15.251(3)); g) The area between trenches may be designated as system reserve area only where the separation distance between the excavation sidewalls of the primary trenches is at least three times the effective width or depth of each trench, whichever is greater (310 CMR 15.251(4)) - Chambers greater than 3 feet wide, when specifically approved, shall be separated by three times the actual width and are subject to other Special Conditions and limitations; and h) Effluent distribution lines exceeding 50 feet in length shall be connected and venting provided in accordance with 310 CMR 15.241 (310 CMR 15.25 1(11)). 7. When installed in trench configuration, approved Alternative Chambers greater than 3 feet wide: a) Shall be installed with a minimum separation distance between any two trenches of two times the actual width of the chamber, or where the area between trenches is designated as reserve area, three times the actual width of the chamber; and b) Shall only be entitled to a maximum effective width of 3 feet for the purposes of calculating total effective leaching area. 8. When installed in a bed or field configuration, the System may be installed without distribution piping, but must comply with the following requirements in 310 CMR 15.252: a) The use of leaching beds or fields is restricted to systems with a calculated design flow of less than 5,000 gpd per leaching bed or field (310 CMR 15.252(1)); I BioDiffuser and ARC Chambers by Infiltrator Water Technologies, LLC. '' Page 6 of 6 Revised Approval for General Use—June 12,2015 b) The maximum length of chambers in series shall be 100 feet (310 CMR 15.252(2)(b)); c) Separation distance between adjacent beds/fields shall be ten feet (310 CMR 15.252(2)(f)); and d) The effective leaching area shall include only the bottom area, not the sidewalls (310 CMR 15.2 5 2(2)(i)). 9. For Systems constructed in fill and installed, the System shall be installed as specified in 310 CMR 15.255 - Construction in Fill, except the minimum 15 foot horizontal separation distance to be provided between the soil absorption area and the adjacent side slope shall be measured horizontally from the top of the chamber. 10. The System is exempt from 310 CMR 15.287, specifically items: (5) requiring written notification of alternative system prior to property transfer, (6) need for a certified operator, (9) need for an operation and maintenance contract with an operator and (10) deed notice requirement. i Commonwealth of Massachusetts Executive Office of Energy & Environmental .Affairs g Department of Environmental protection One Winter Street Boston, MA 02108.617-292-5500 Charles D. Baker Matthew A. Beaton Governor Secretary Karyn E. Polito Martin Suuberg Lieutenant Governor Commissioner Standard Conditions for Alternative Soil Absorption Systems with General Use Certification and/or Approved for Remedial Use Revised: February 3, 2016 These Standard Conditions apply to Alternative Soil Absorption System (Alt. SAS) technologies for disposal-only as well as for technologies providing both treatment and disposal. Currently these approved alternative technologies include the following, Alt. SAS Disposal-Only, • Contactor,Field Drain Contactor, and Recharger Chambers, by Cultec, Inc. • Biodiffuser &ARC Chambers,by Infiltrator Systems, Inc. • Infiltrator Chambers, by Infiltrator Systems, Inc. • Eljen Mantis M5, by Eljen Corp. Alt. SAS Treatment with Disposal - Patented Sand Filters, • Eljen GSF Geotextile Sand Filter System, by Eljen Corp. • Enviro-Septic Wastewater Treatment System, by Presby Environmental, Inc. • Advanced Enviro-Septic System, by Presby Environmental, Inc. • Simple-Septic Wastewater Treatment System, by Presby Environmental, Inc. An alternative SAS may be appropriate for new construction, increases in flow, or for the upgrade of an existing failing, failed, or nonconforming system where reducing the disturbance of the site is desired. Alternative Disposal-Only technologies approved by the Department may be substituted for conventional SAS's allowed under Title 5. The alternative Chamber technologies, when compared to conventional Title 5 chambers,provide options from some of the Title 5 requirements such as offering plastic instead of concrete chambers and eliminating the need for stone aggregate around the chamber while allowing higher loading rates and reduced effective leaching area. Other options include Chambers installed with aggregate meeting the requirements of Title 5, however Alternative Chambers used with aggregate are not allowed higher loading rates which must remain the same as required by Title 5 for conventional chambers with aggregate. In addition to alternative Chambers, disposal-only approved Alt. SAS technologies also include the Mantis M5 pipe and sand System design. This information is available in alternate format.Call Michelle Waters-Ekanem,Diversity Director,at 617-292-5751.TTY#MassRelay Service 1-800439-2370 MassDEP Website:www.mass.gov/dep Printed on Recycled Paper Standard Conditions for Alternative Soil Absorption Systems '' Page 2 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 Alternative Treatment with Disposal technologies approved by the Department refer to alternative leaching systems that have demonstrated higher removal of organics and suspended matter prior to the percolation of wastewater into underlying unsaturated pervious soils when compared to conventional leaching systems. Higher loading rates are allowed than would be permissible with a conventional design and additional relief from other design standards is permissible for upgrades. A System approved under these Standard Conditions consists of a septic tank conforming to the requirements of Title 5, either conventional or I/A approved, followed by the Alt. SAS which may provide for a reduced effective leaching area. The use of an approved Alt. SAS, subject to these Standard Conditions, requires among other things: • A Disclosure Notice in the Deed to the property for installed Systems according to the following: • when installing an Alt. SAS Disposal-Only System (chambers or Eljen Mantis M5) a Disclosure Notice in the Deed to the property is not required; • when installing an Alt. SAS Treatment with Disposal-Patented Sand Filters System under the General Use Certificate a Disclosure Notice in the Deed to the property is not required; • when installing an Alt. SAS Treatment with Disposal-Patented Sand Filters System under the Approval for Remedial Use a Disclosure Notice in the Deed to the property is required in accordance with 310 CMR 287(10); • Certifications by the Designer and the Installer(310 CMR 15.021(3)); • Notification within 24 hours by the System Owner to the Local Approving Authority (LAA) of any System failure; • When System requires pumping prior to the SAS, 24-hour emergency wastewater storage capacity above the elevation of the high level alarm; • System Owner Acknowledgement of Responsibilities, in accordance with these standard conditions and the Technology Approval's Special Conditions. This Approval does not address the use of the following alternative SAS's,which are covered under separate Title 5 I/A Program Approvals: a) Drip Dispersal Systems b) Bottomless Sand Filters Definitions and References The term "System" refers to the approved technology in combination with the other components of an on-site treatment and disposal system that may be required to serve a facility in accordance with 310 CMR 15.000. The term"Approval" or "Certification" refers to these Standard Conditions; the Special Conditions contained in the Technology Approval, the General Conditions of 310 CMR 15.287, and any Attachments. Standard Conditions for Alternative Soil Absorptlon Systems Page 3 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 The phrase "new construction" always refers to construction of a new facility or any increase in actual or design flow to any existing system above the approved capacity. The phrase "upgrade of a system" or the term "upgrade" or the term "remedial site" refers to any repair, modification, or replacement of a whole system or a component of an existing failing, failed or nonconforming system where there is no increase in the actual or design flow to the system. The Conditions contained herein MUST be read in conjunction with any Special Conditions that are technology-specific. I. Purpose 1. These Standard Conditions shall apply to all Alt. SAS technologies identified in a General Use Certification or a Remedial Use Approval as either a Disposal-Only technology or a Treatment with Disposal technology as listed above. In addition to the Special Conditions contained in the technology-specific Approvals, the System shall comply with all these "Standard Conditions for Alternative Soil Absorption Systems", except where stated otherwise in the Special Conditions. 2. The sale, design, installation, and use of the System shall be subject to these requirements for all systems that submit a complete Disposal System Construction Permit (DSCP) application after the effective date of these Standard Conditions. Existing systems and systems for which a complete DSCP application was submitted prior to the effective date of these requirements shall not be subject to the design and installation requirements, however, the System Owner, the Service Contractor, and the Company shall be subject to all other requirements contained herein. 3. With the other applicable permits or approvals that may be required by Title 5, the Approval authorizes the installation and use of the System in Massachusetts. All the provisions of Title 5, including the General Conditions for Alternative Systems (310 CMR 15.287), apply to the sale, design, installation, and use of the System, except those provisions that specifically have been varied by this Approval. 4. Provided that the Local Approving Authority (LAA) approves the System in conformance with the Department's Approval for the System, Department review and approval of the site-specific System design and installation is not required unless the Department determines on a case-by-case basis, pursuant to its authority at 310 CMR 15.003(2)(e), that the proposed System requires Department review and approval. II. Design and Installation Requirements 1. Where any contradiction may exist in design standards between the Company guidance and the requirements of Title 5 or this Approval, the design shall meet the standards of Title 5 and this Approval unless the Company guidance is more stringent. Standard Conditions for Alternative Soil Absorption Systems ' Page 4 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 2. In accordance with 310 CMR 15.240(6), absorption trenches should be used whenever possible. Accordingly, approved Disposal-Only and Treatment with Disposal Alt. SAS Systems shall be used in trench configuration whenever possible, unless a different configuration is allowed by the Approval(s) Special Conditions. 3. The Alternative System shall include a properly sized and constructed septic tank, designed in accordance with 310 CMR 15.223-15.229 or approved as an Alternative technology per 15.280-15.288, connected to the building sewer and followed in series by the approved Alternative Soil Absorption System. A 1,000 gallon septic tank may be allowed in accordance with the provisions of 310 CMR 15.404(3)(a). 4. The Alternative System shall be installed in a manner which does not intrude on, replace, or adversely affect the operation of any other component of the subsurface sewage disposal system. 5. The Designer shall be a Massachusetts Registered Professional Engineer or a Massachusetts Registered Sanitarian, including when designing systems for repair, provided that such Sanitarian shall not design a system with a discharge greater than 2,000 gallons per day. 6. For new construction or increases in flow, the System shall be subject to the following: a) The System may only be installed in soils with a percolation rate of up,to 60 minutes per inch (MPI); b) A site evaluation, in compliance with 310 CMR 15.100 through 15.107, must be approved by the Approving Authority and the site must meet the siting requirements for new construction; c) The record drawings, approved by the LAA, must clearly indicate an area for a full- sized conventional primary SAS and a full-sized conventional reserve area that are for the sole purpose of on-site sewage disposal; d) Where the System has reduced the effective leaching area, as allowed by the Standard Conditions, the installation shall not disturb the site in any manner that would preclude the future installation of the conventional full-sized primary SAS without encroaching on the reserve area; and e) Except for the installed SAS, the System Owner shall not construct any permanent buildings or structures or disturb the site in any manner that would encroach on the area approved for a full-sized conventional primary SAS or the area approved for a full-sized conventional reserve SAS. 7. For the upgrade of a system, the installation of the proposed System shall be subject to the following: a) The System may only be installed in soils with a percolation rate of up to 90 minutes per inch (MPI); b Prior to approving the installation of the System, the LAA must determine there is no Pp g increase in the actual or proposed design flow; Standard Conditions for Alternative Soil Absorption Systems Page 5 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 c) Prior to Local Approval of the System, the Designer shall show on the plans the maximum available area for a conventional system (without reserve) designed in accordance with the standards of 310 CMR 15.100 through 15.255. d) The proposed System must include the approval by the LAA for the upgrade or replacement of all other existing components, as necessary, to comply with the standards of Maximum Feasible Compliance (MFC) of 310 CMR 15.404; e) The record drawings, approved by the LAA, must clearly indicate an area for the best feasible replacement system that could be installed in the event that the proposed Alternative Soil Absorption System fails or it is determined that it is not capable of providing equivalent environmental protection; f) When evaluating the best feasible replacement system that could be installed in the event that the proposed Alternative Soil Absorption System fails or it is determined that it is not capable of providing equivalent environmental protection, the Designer shall consider these options in the following order: i. a conventional system designed in accordance with the standards of 310 CMR 15.100 through 15.255 that can be built feasibly, with the exception of providing a reserve area(15.248); ii. a conventional system that can only be built feasibly under a Local Upgrade Approval (LUA); iii. where a conventional system cannot be built feasibly under a LUA, a Bottomless Sand Filter, in conjunction with a Secondary Treatment Unit; iv. where a System can only be built feasibly with variances, a System that has been demonstrated to vary the design requirements of 310 CMR 15.000 to the least degree necessary and have the least effect on public health, safety, welfare and the environment (the System may be an Alternative System with variances); or v. a tight tank. f) The installation of the proposed System shall not disturb the site in any manner that would preclude the future installation of the best feasible replacement system that could be installed to replace the proposed System. Components of the proposed System may be sited in an area for the future installation of the best feasible replacement system, provided that it does not render the area unusable for a potential future replacement system; and g) Except for the installed SAS, the System Owner shall not construct any permanent buildings or structures in the area for the best feasible replacement system that could be installed to replace the proposed System and the System Owner shall not disturb the site in any other manner that would preclude the future installation of the best feasible replacement system. 8. Alternative Design Standard to 310 CMR 15.242(1)(a) Effluent Loading For new construction or increases in flow, the required effective leaching area may be reduced up to 40 percent when using the loading rates for gravity systems of 310 CMR 15.242(1)(a), provided: - I Standard Conditions for Alternative Soil Absorption Systems `' Page 6 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 a) no variance is granted for a reduction in depth to groundwater; b) no variance is granted for a reduced depth of pervious material; and c) a minimum of 400 square feet of effective leaching area shall be installed if any reduction in the leaching area would result in less than 400 square feet proposed g q of effective leaching area; (Facilities with small flows that would not require 400 sq.ft. of effective leaching area, when designed in accordance with Title 5, may be with le than 400 s . ft. provided that no reduction in effective leaching area built t less q p g is taken). 9. Alternative Design Standard to 310 CMR 15.242(1)(a) and 15.245(4), Effluent Loading Rates For the upgrade of a system, the System shall be subject to the following: a) For soils with a percolation rate of 60 minutes or less per inch, the size of the SAS may be sized with 40 percent less effective leaching area than required when using the loading rates for gravity systems of 310 CMR 15.242(1)(a); b) For soils with a percolation rate of between 60 and 90 minutes per inch, the size of the SAS may be sized with 40 percent less effective leaching area than required when using the loading rate of 0.15 gpd/square foot as specified by 310 CMR 15.245(4); c) Unless allowed under the Special Conditions for the Technology, no additional reduction in the effective leaching area is allowed under an LUA or a variance that would result in a reduction greater than 40% of that which would be required under 310 CMR 15.242(1)(a) and 15.245(4), respectively. Any other deviations to design standards, except the effective leaching area, may be granted under LUA or a variance; and d) A minimum of 400 square feet of effective leaching area shall be provided if any proposed reduction in the leaching area would result in less than 400 square feet of effective leaching area. Where 400 square feet of effective leaching is not feasible, the greatest effective leaching area shall be installed provided that no more than a 40 percent reduction is taken. 10. Specific Conditions for Treatment with Disposal Alt. SAS Technologies a) The use of aggregate as specified in 310 CMR 15.247 is not allowed with Patented Sand Filters. b) Unless determined necessary by the Designer or Company, the System shall not be used with pressure distribution for any design flow. When installed for a facility with a design flow of 2,000 gpd or greater, approved Patented Sand Filter Systems are exempt from the requirement for pressure distribution under 310 CMR 15.231. c) Patented Sand Filters shall not be installed in a Nitrogen Sensitive Area (NSA) to serve facilities with actual or design flows of 2,000 GPD or greater since those facilities require installation of a Recirculating Sand Filter (RSF) or equivalent technology. Patented Sand Filters may be installed as a disposal-only alternative Standard Conditions for Alternative Soil Absorptlon Systems Page 7 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 technology when used in addition to an approved Secondary Treatment Unit (reduction of BOD/TSS). When a Patented Sand Filter is used in this type of septic system design, only the reductions permitted in the Secondary Treatment Unit's (STU) alternative technology approval, such as a reduction in SAS size, depth of naturally occurring pervious material or depth to groundwater, are allowed. d) For upgrades only, a reduction in the depth to groundwater and/or a reduction in the pervious material may be taken in accordance with Section II, paragraph 5 of the Standard Conditions for Secondary Treatment Units Approved for Remedial Use. In no case, shall the reductions allowed under the Standard Conditions for Secondary Treatment Units be combined with any reduction provided by this Approval, the alternative technology's Remedial Use Approval Special Conditions or with any reduction that may be allowed under the procedures of Local Upgrade Approval or variance procedures of 310 CMR 15.401-415. 11. Specific Conditions for Disposal-Only Alt. SAS Technologies a) In a NSA, as defined in 310 CMR 15.215, Alternative Systems serving facilities with actual or design flows of 2,000 GPD or greater must include treatment with a RSF or equivalent technology, as required by 310 CMR 15.202(1). Under this Approval, Disposal-Only Alt. SAS technologies shall not be installed in an NSA to serve facilities with actual or design flows of 2,000 GPD or greater unless installed in conjunction with a RSF or equivalent technology. b) For new construction or upgrades, a reduction in the effective leaching area may be taken in accordance with the conditions and limitations imposed by the approval of the Secondary Treatment Unit employed. (approved Alternative Chambers may be installed with or without aggregate for the disposal of effluent from an approved Secondary Treatment Unit, see paragraph I I(e) below.) For upgrades only, a reduction in the depth to groundwater and/or a reduction in the pervious material may be taken in accordance with the conditions and limitations imposed by the Remedial Use Approval of the Secondary Treatment Unit employed. In no case, shall the reductions allowed under the Secondary Treatment Unit approval be made less stringent. In no case, shall the reductions allowed under the Secondary Treatment Unit approval be combined with any reduction provided by this Approval or combined with any reduction that may be allowed under the procedures of Local Upgrade Approval or the variance procedures of 310 CMR 15.401-415. c) For the upgrade of a system, installations without secondary treatment are entitled to reductions in depth to groundwater or depth of naturally occurring pervious material only to the limits that may be allowed by the LAA under the procedures of Local Upgrade Approval or the variance procedures of 310 CMR 15.401-415. d) The use of aggregate as specified in Title 5, 310 CMR 15.247 is not required. Standard Conditions for Alternative Soil Absorption Systems '' Page 8 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 Chambers Specific Standard Conditions, e) The installation of approved Alternative Chambers with aggregate is allowed provided that it complies with the aggregate requirements of 310 CMR 15.247. However, when approved Alternative Chambers are installed with aggregate the reduction in effective leaching area provided by Standard Conditions II (8) and (9) is not allowed. Only when upgrading a system, approved Alternative Chambers installed with aggregate may be allowed a reduction in effective leaching area (up to 25%) under the limitations and procedures of a Local Upgrade Approval (310 CMR 15.401-405). f) Effluent pressure distribution shall be provided for actual or design flows of 2,000 gpd or greater and shall be designed in accordance with Department guidance. The effluent loading rates provided in 310 CMR 15.242(1)(b) for pressure distribution may be utilized, but no reduction in the effective leaching area as may be provided under this Approval may be taken when using the loading rates for pressure distribution, as stated in the regulation. 12. All System control units, valve boxes, distribution piping, conveyance lines and other System appurtenances shall be designed and installed to prevent freezing. 13. When pumping is required to a distribution box or to a SAS pressure distribution tank, the System pump chambers/tanks shall be equipped with sensors and high-level alarms to protect against high water due to pump failure, pump control failure, loss of power, system freeze ups, backups, etc. Emergency storage shall be provided when pumping to discharge is employed, including but not limited to, pressure distribution. Emergency storage capacity for wastewater above the high level alarm shall be provided equal to the daily design flow of the System including an additional allowance for the volume of all drainage which may flow back into the System when pumping has ceased. 14. System control panel(s) including alarms and controls shall be mounted in a location always accessible to the operator (Service Contractor). Any System malfunction and high water alarms shall be readily visible and audible for the facility occupants and the Service Contractor and shall be connected to circuits separate from the circuits serving the operating equipment and pumps. 15. The System shall not include any relief valve or outlet for the discharge of wastewater to prevent flooding of the system, back up or break out. 16. Any System structures with exterior piping connections located within 12 inches of or lower than the Estimated Seasonal High Groundwater elevation shall have the connections made watertight with neoprene seals or equivalent. 17. In compliance with 310 CMR 15.240(13), a minimum of one (1) inspection port shall be provided within the SAS consisting of a perforated four inch pipe placed vertically down to the elevation of the SAS interface with the underlying unsaturated pervious soils to enable monitoring for ponding. The pipe shall be capped with a screw type f Standard Conditions for Alternative Soil Absorption Systems Page 9 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 cap and accessible to within three inches of finish grade. (A locking cap at-grade is preferred) Facilities with multiple SAS's shall have an inspection port in each. 18. Upon submission of an application for a Disposal System Construction Permit (DSCP), the Designer shall provide to the Local Approving Authority: a) proof that the Designer has satisfactorily completed any required training by the Company for the design and installation of the Technology; b) certification of the design by the Company for any residential system with a design of 2,000 gpd or more or for any proposed non-residential system or if required by the Special Conditions for an approved Technology; c) certification by the Designer that the design conforms to the Approval, any Company Design Guidance, and 310 CMR 15.000; and d) a certification, signed by the Owner of record for the property to be served by the Technology, stating that the property Owner: i. has been provided a copy of the Title 5 I/A technology Approval, the Owner's Manual, and the Operation and Maintenance Manual, and the Owner agrees to comply with all terms and conditions; ii. for Systems installed under a Remedial Use Approval, the owner agrees to fulfill his responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5); iii. if the design does not provide for the use of garbage grinders, the restriction is understood and accepted; and iv. whether or not covered b a warranty, the System Owner understands the Y h' Y requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303. 19. The System Owner and the Designer shall not submit to the LAA a DSCP application Y g pP for the use of a Technology under this Approval if the Approval has been revised, reissued, suspended, or revoked by the Department prior to the date of application. The Approval continues in effect until the Department revises, reissues, suspends, or revokes the Approval. 20. The System Owner shall not authorize or allow the installation of the System other than by a locally approved Installer and, if required by the Company, a person certified or trained by the Company to install the System. 21. Prior to the commencement of construction, the System Installer must certify in writing to the Designer, the LAA, and the System Owner that (s)he is a locally approved System Installer and, if required by the Company, is certified by or has received appropriate training by the Company. 22, The Installer shall maintain on-site, at all times during construction, a copy of the approved plans, the Owner's manual, the O&M manual, and a copy of the Approval. Standard Conditions for Alternative Soil Absorption Systems Page 10 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 23. Prior to the issuance of a Certificate of Compliance the following shall be provided: a) the System Installer and Designer must provide certification in writing to the LAA that the System has been constructed in compliance with the terms of the Approval; and b) For System upgrades installed under a Remedial Use Approval the System Owner shall provide a copy of record and/or register the Deed Notice required by 310 CMR 15.287(10), to the LAA. The Deed Notice shall be completed as follows: i. a certified Registry copy of the Deed Notice bearing the book and page/or document number; and ii. if the property is unregistered land, a copy of the System Owner's deed to the property as recorded at the Registry, bearing a marginal reference on the System Owner's deed to the property. The Notice to be recorded shall be in the form of the Notice provided by the Department. 24. The Department has not determined that the performance of the System will provide a level of protection to public health and safety and the environment that is at least equivalent to that of a sanitary sewer system. a) If it is feasible to connect a new or existing facility to the sewer, the Designer shall not propose an Alternative System to serve the facility and the facility Owner shall not install or use an Alternative System; and b) When a sanitary sewer connection becomes feasible after an Alternative System has been installed, the System Owner shall connect the facility served by the System to the sewer within 60 days of such feasibility and the System shall be abandoned in compliance with current Code requirements, unless a later time is allowed in writing by the Department or the LAA. III. Operation and Maintenance 1. For Systems with design flows of 2,000 gpd or greater where the effective leaching area installed is less than 75% of that required by Title 5 (310 CMR 15.240(4)), measurement of the depth of ponding within the SAS above the interface with the underlying unsaturated pervious soils shall be performed once per year by means of the inspection port(s) and any other available access to the distribution system. Inspector must be an Approved System Inspector. 2. Whenever an Alt. SAS system's inspection port ponding depth is measured and indicates the ponding level within the SAS is above the invert of the distribution system, an additional measurement shall be made 30 days later. If the subsequent reading indicates the elevation of ponding within the SAS is above the invert of the distribution system, the System Owner shall be responsible for the submittal to the LAA within 60 days of the follow-up inspection, a written evaluation of the System with recommendations for changes in the design, operation, and/or maintenance. The Standard Conditions for Alternative Soil Absorption Systems Page 11 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 written evaluation with recommendations shall be prepared by a Designer and the submission shall include all monitoring data and inspection reports for the previous 3 years. Recommendations shall be implemented, as approved by the LAA, in accordance with an approved schedule, provided that all corrective measures are implemented consistent with the limitations described in Paragraph IVA. 3. For Systems less than 2,000 gpd or facilities where the effective leaching area installed meets the requirements of Title 5, the System shall not be required to be inspected at any greater frequency than would be required if the facility was served by a conventional system, unless the LAA, Company, or Designer requires more frequent inspection. 4. If at any time a septic system with an Alt. SAS is inspected by a System Inspector, the following shall be recorded, at a minimum: a) date, time, air temperature, and weather conditions; b) observations for objectionable odors; c) observations for signs of breakout of sanitary sewage in the vicinity of the Alternative System; d) depth of ponding within the SAS; e) identification of any apparent violations of the Approval; f) since the last inspection, whether the system had been pumped with date(s) and volume(s) pumped; g) sludge depth and scum layer thickness, if measured; h) when responding to alarm events, the cause of the alarm and any steps taken to address the alarm and to prevent or reduce the likelihood of future similar alarm events; i) field testing results when performed as part of the site visit; j) samples taken for laboratory analysis and results of previous samples, if any k) any cleaning and lubrication performed; 1) any adjustments of control settings, as recommended or deemed necessary; m) any testing of pumps, switches, alarms, as recommended or deemed necessary; n) identification of any equipment failure or components not functioning as designed; o) parts replacements and reason for replacement, whether routine or for repair; and p) further corrective actions recommended, if any. 5. The System Owner shall maintain copies of any service records or inspection reports and all reports and notifications to the LAA for a minimum of three years. 6. Unless directed by the LAA to take other action, the System Owner shall immediately cease discharges or have wastewater hauled off-site, if at any time during the 1 Standard Conditions for Alternative Soil Absorption Systems Page 12 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 operation of the Alternative System the system is in failure as described in 310 CMR 15.303(1)(a), items 1 or 2 (sewage backing up into facilities or breaking out to the surface). IV. Additional System Owner Requirements 1. For System upgrades installed under Remedial Use Approval, prior to signing any agreement to transfer any or all interest in the property served by the System, or any portion of the property, including any possessory interest, the System Owner shall provide written notice, as required by 310 CMR 15.287(5), of all conditions contained in the Approval to the transferee(s). Any and all instruments of transfer and any leases or rental agreements shall include as an exhibit attached thereto and made a part of thereof a copy of the Approval for the System. The System Owner shall send a copy of such written notification(s) to the LAA within 10 days of giving such notice to the transferee(s). 2. The System Owner shall not install, modify, upgrade, or replace the System except in accordance with a valid DSCP issued by the LAA which covers the proposed work. 3. Upon determining that the System is failing to protect public health and safety and the environment, as defined in 310 CMR 15.303, the System Owner shall be responsible for the notification of the LAA within 24 hours of such determination. 4. In the case of a System that has been determined to be failing to protect public health and safety and the environment, an equipment failure, alarm event, components not functioning as designed, components not functioning in accordance with manufacturers specifications, or violations of the Approval, the System Owner shall provide written notification within five days, describing corrective measures to the local board of health and the Company and may only propose or take corrective measures provided that: a) all emergency repairs, including pumping, shall be in accordance with the limitations and permitting requirements of 310 CMR 15.353; b) the design of any repairs or upgrades are consistent with the System Approval; c) the design of any repairs or upgrades requiring a DSCP shall be performed by a Designer who is a Massachusetts Registered Professional Engineer or a Massachusetts Registered Sanitarian, provided that such Sanitarian shall not design a system with a discharge greater than 2,000 gallons per day. d) the installation of any repairs or upgrades requiring a DSCP shall be done by an Installer with a currently valid Disposal System Installers Permit and, if training is required, the Installer shall be certified by the Company as qualified to install the System. 5. To determine whether cause exists for modifying, revoking, or suspending the Approval or to determine whether the conditions of the Approval have been met, the System Owner shall furnish the Department any information that the Department requests regarding the System, within 21 days of the date of receipt of that request. Standard Conditions for Alternative Soil Absorption Systems Page 13 of 15 General Use and Remedial Use Approvals Last revised February 3,2016. 6. The Approval shall be binding on the System Owner and on its agents, contractors, successors, and assigns, including but not limited to the Designer, Installer, and Service Contractor. Violation of the terms and conditions of the Approval by any of the foregoing persons or entities, respectively, shall constitute violation of the Approval by the System Owner unless the Department determines otherwise. V. Company Requirements 1. The Approval shall only apply to the model unit(s) with the same model designation(s) specified in the System Approval and meet the same specifications, operating requirements, and plans, as provided by the Company or its authorized agent at the time of the application. Any proposed modifications of the unit(s), installation requirements, or operating requirements shall be subject to the review of the Department for inclusion under a modification of the Approval. The Designer shall be responsible for the selection of the appropriate model unit(s) as applicable. The Company shall be responsible for verification of the appropriate model unit(s) as part of any review of proposed installations that may be required by Paragraph V.3 of these Standard Conditions or the Special Conditions in the Approval. 2. Prior to submission of an application for a DSCP, the Company or its authorized agent shall provide to the Designer and the System Owner: a) All design and installation specifications and requirements; b) An owner's manual and, if alarms are provided, including response procedures; c) A copy of the Company's warranty; and d) If training or certification is required by the Company, lists of qualified Designers, Installers, and Service Contractors. 3. Prior to the submission of an application for a DSCP, for all nonresidential Systems and any System with a design flow of 2,000 gpd or greater, the Company shall submit to the Designer and the System Owner, a certification by the Company or its authorized agent that the design conforms to the Approval and all Company requirements and that the proposed use of the System is consistent with the Technology's capabilities. The authorized agent of the Company responsible for the design review shall have received technical training in the Company's products. 4. If the Company requires trained or certified Designers, Installers, or Service Contractors, the Company or its authorized agent shall make available programs of training and continuing education, as necessary. The Company or its authorized agent shall maintain, annually update, and make available by February 151" of each year, lists of trained or certified Designers, Installers, and Service Contractors. If training or certification is required, the Company shall not sell the Technology to an Installer unless the Installer is trained or certified to install the System by the Company. Similarly, if training is required, the Company shall ensure distributors and resellers of the Technology shall not sell the Technology to an Installer unless the Installer is trained or certified to install the System by the Company. Standard Conditions for Alternative Soil Absorption Systems Page 14 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 ' 5. As part of any training programs for Designers, Installers, or Service Contractors, the Company or its authorized agent shall provide each trainee with a copy of this Approval with the design, installation, O&M, and owner's manuals that were submitted as part of the Approval. 6. The Company shall provide, in printed or electronic format, the System design, installation, O&M, and Owner's manuals, and any updates associated with this System Approval, to the System Owners, Designers, Installers, Service Contractors, vendors, resellers, and distributors of the System. Prior to publication or distribution in Massachusetts, the Company shall submit to the Department for review a copy of any proposed changes to the manual(s) with reasons for each change, at least 30 days prior to issuance. The Company shall request Department approval for any substantive changes which may require a modification of the Approval. 7. Prior to its sale of any System that may be used in Massachusetts, the Company shall provide the purchaser with a copy of this Approval with the System design, installation, O&M, and Owner's manuals. In any contract for distribution or sale of the System, the Company shall require the distributor or seller to provide the purchaser of a System for use in Massachusetts with copies of these documents, prior to any sale of the System. 8. To determine whether cause exists for modifying, revoking, or suspending the Approval or to determine whether the conditions of the Approval have been met, the Company shall furnish the Department any information that the Department requests regarding the Technology within 21 days of the date of receipt of that request. 9. Within 60 days of issuance by the Department of these Conditions and any other. revisions to the Approval, the Company shall provide written notification of changes to the Approval to all distributors and resellers of the System. 10. The Company shall provide written notification to the Department's Director of the Wastewater Management Program at least 30 days in advance of the proposed transfer of ownership of the technology for which this Approval is issued. Said notification shall include the name and address of the proposed owner containing a specific date of transfer of ownership, responsibility, coverage and liability between them. All pp provisions of this Approval applicable to the Company shall be applicable p to successors and assigns of the Company, unless the Department determines otherwise. 11. The Company shall maintain copies of. a) the Approval; b) the installation manual specifically detailing procedures for installation of its System; c) an owner's manual and, if alarms are required, including alarm response procedures; d) a copy of the Company's warranty; and Standard Conditions for Alternative Soil Absorption Systems Page 15 of 15 General Use and Remedial Use Approvals Last revised February 3,2016 e) if training or certification is required, lists of qualified Designers and Installers. 12, The Company shall maintain the following additional information for `Treatment with Disposal' Systems installed in Massachusetts, and make it available to the Department within 30 days of a request by the Department: a) the address of each facility where the System was installed, the Owner's name and mailing address (if different), the type of use (e.g. residential, commercial, institutional, etc.), the design flow, the model installed; and b) the installation date, start-up date, current operational status. 13. The Approval shall be binding on the Company and its officers, employees, agents, contractors, successors, and assigns, including but not limited to dealers, distributors, and resellers. Violation of the terms and conditions of the Approval by any of the foregoing persons or entities, respectively, shall constitute violation of the Approval by the Company unless the Department determines otherwise. VI. General Requirements 1. Any System for which a complete Disposal System Construction Permit ("DSCP") Application is submitted while the Approval is in effect, may be permitted, installed, and used in accordance with the Approval, unless and until: a) the Department issues modifications or amendments to the Approval which specifically affect the installation or use of a System installed under the Approval for the System; or b) the Department, the local approval authority, or a court requires the System to be modified or removed or requires discharges to the System to cease. 2. All notices and documents required to be submitted to the Department by the Approval shall be submitted to: Director Wastewater Management Program Department of Environmental Protection One Winter Street - 5th floor Boston, Massachusetts 02108 3. The Department may suspend, modify or revoke the Approval for cause, including, but not limited to, non-compliance with the terms of the Approval, for obtaining the Approval by misrepresentation or failure to disclose fully all relevant facts or any change in or discovery of conditions that would constitute grounds for discontinuance of the Approval, or as necessary for the protection of public health, safety, welfare or the environment, and as authorized by applicable'law. The Department reserves its rights to take any enforcement action authorized by law with respect to the Approval and/or the System against the Company, a System Owner, a Designer, an Installer, and/or Service Contractor. r t Town of Barnstable E Regulatory Services Richard V. Scah,Interim Director 8"MABLE ' Public Health Division MAS& %'0r 639� Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Offi e: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Systems Property Address: 1 r14MVA D A)EIPCE L,dv Assessor's Map\Parcel: Z:r o --p to Property Owners Name: '77 M a 11-4 i In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an 'x°' in the applicable box next to each.he certifying the information. Yes N\A ❑ I have beenprovided a copy of the Title 5 I/A technology Approval letters. (15 page Standard Conditions letter and ltbe specific technology letter) El 0 I have been provided with the Owner's Manual 4 -I have been provided with the Operation and Maintenance Manual ? For Systems installed under a Remedial Use Approval; I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10). and the Approval For Systems installed under a.Remedial Use Approval,I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) 91 El If the design does not provide for the use of garbage grinders, the restriction is understood and accepted 1 Whether or not covered by a warranty, I understand the requirement to repair, replace,;modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303 I , -7t r"16 7-A-1 y GCSE agree to comply with.all terms and conditions above. Property Owners printed name 1 Propert Owners.Signature Date Note: This form ;must be submitted along with the. septic system disposal works permit application for all RA systems including new construction, repairs\upgrades with and without ap-ereuate (stone) and with conventional design criteria or credited design. criteria: QAaf eptic\[A homeowner certification.doc l H Bk 24782 Pa 339 43042 08--27-2010 a 02 = 27P �s Deed Restriction Whereas, Kathryn G. Green, Trustee of the Green Realty Trust udt dated August 7, 2001 being recorded in Book 14460, Page 261, is the owner of property located at 17 Thread Needle Lane, Barnstable (Centerville), Barnstable County, Massachusetts,by Deed recorded in Book 16855,Page 39, said land being shown on Barnstable Assessor's Map 210 Parcel 76 and being shown as Lot 12 on Plan recorded in Book Ici I Page l�+rj Whereas,Kathryn G. Green, Trustee, as the owner of said Lot, has agreed to a . restriction as to the number of bedrooms which can be included in any home existing or to be built in the future on said lot as a pre condition to obtaining a building permit for this lot; Whereas, The Town of Barnstable, as a pre-condition to granting the building permit for the conversion of a garage into a library/piano room existing on this lot is requiring that the agreement for the restriction of the number of bedrooms in any house existing or to be constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document. Now Therefore, Kathryn G. Green,Trustee does hereby place the following restriction on the above referenced land in accordance with this agreement with the Town of Barnstable, which restriction shall run with the land and be binding upon all successors in title: 1. Lot 12, Plan Book 191, Page 47,house# 17 Thread Needle Lane, Barnstable (Centerville), Massachusetts, may have a house containing no more than four (4) bedrooms. Kathryn G. Green, Trustee hereby agrees that this shall be a permanent deed restriction affecting the above described premises. r . r• For title see deed recorded in the Barnstable County Registry of Deeds Book 16855, Page 39 and Book 16778, Page 261. Executed as a sealed instrument this C, day of , 2010 Kathryn d Gr en, Trustee COMMONWEALTH OF MASSACHUSETTS Barnstable, ss On this 1 day of , 2010, before me, the undersigned notary public, personally appeared Kath n G. Green, Trustee, proved to me through satisfactory evidence of identification, which was a Massachusetts Driver's License, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purpose, Notary Public: Com Exp: 7 /01 P /� DONNA k ROBERMON NoftyPublic musadwaft t M'Cammiselon Expires ' July 8,2016 TRUSTEE CERTIFICATE 1,Kathryn G.Green,Trustee of the Green Realty Trust u/d/t dated 8/7/01 and recorded in the Barnstable County Registry of Deeds in Book 14460, Page 261, of 17 Thread Needle Lane, Centerville, Massachusetts 02632 hereby certify in accordance with the terms of said Trust: 1. That I am the incumbent Trustee of the Trust; 2. That said Trust has never been amended or modified to date. 3. That said Trust remains in effect and has never been terminated; and 4. That the Trustee has been duly directed by the beneficiaries, who are of full and legal age, owning 100% of the beneficial interest in and to the aforesaid Trust to place a deed restriction on the property located at 17 Thread Needle Lane, Centerville for nominal consideraton and that the Trustee has the authority to execute such documents as the Trustee deems necessary in order to effectuate the above-described transaction. EXECUTED as a sealed instrument this 6' day of , 2010. Kathryn G. ee , Trustee COMMONWEALTH OF MASSACHUSETTS Barnstable, ss On this day of 2010, before me, the undersigned notary public, personally appeared Kathryn G. Green, Trustee as aforesaid proved to me through satisfactory evidence of identification,which was a Massachusetts driver's license, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purpose as an authorized person for said Trust, 4�owlv/� Notary Public: Commission Expiration: DONNA K ROBERTSON '-D r-7 '`--,)0/5 WWy Public commwwsa of YeaeaiClu"M t my cammiwwon Exp m July 9,201 a BARNSTABLE REGISTRY OF DEEDS EXIST. 7� RCMOO. R-MOD, — REMOD. 'DECK MASTER - MASTER I ROOM LY m BEDROOM "" "" BATH I Fx. =i I , — — Sa. _ t REMOD. j rr _I_.I � RF_MOD DINING BEDROOM t I KITCHEN—_' o i [ l`---- T »�-_ -- o.�NEW J t -- i ` -- T- -_'--- --_ - "BATH. CLOS. �� HALL --i0_i .y yJ� 'NEW I I UDRY. I EXIST. —I pro, i IoLos. EXIST. EXIST. I--`— GARAGE NEW BEDROOFA BEDROOM W NEW I HALL N NEW FIRST FLOOR_PLAN LEGEND: EXISTING WALLS -7 CONSTRUCTION TO BE REMOVED 17MNEW CONSTRUCTION PRELIMINFlRY DRAWING 9 SENDER: COMPLETE • K COMPLETE THIS SECTIONON DELIVERY ■ Cou�plefe items 1,2,and 3.Also complete A Signature �`ST O FF� Rem 4 if Restricted Delivery is desl.�. ';; �— Agent ■ Print your name and address on theeverse X y,` � �4ddressee so that we can return the card to you. B.Received by(Print t e) r C. Da N Delivery ■ Attach this card to the back of the mailpiece, t a .or on the front if space permits. D. Is delivery address dill from item 1 as 1. Article,,Addressed to: If YES,enter delivery a dle lro3 No 3. S rviceType TCertified Mail® 0 Priority Mail ExpresC 13 Registered A Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) I]Yes 2. Arl---.— (r„ 7012 1010 0000 2847 8759 X PS Form 3811,July 2013 Domestic Return Receipt AA JE" UNITED STATES ; ERVICE First-Class Mail -. ;)' I. Postage&Fees Paid USPS `"16 Permit No.G-10 Sender: Please print your name, address, and ZIP+4®in this box* a vise � N/A 5 � a o.a main o6Dl ann�5, Town of Barnstable Barnstable Regulatory Services Department 'AHni allca0v BARNBTABLE, I ' , '39. ,� Public Health Division ff°t"p�A 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# 7012 1010 0000 2847 8759 August 29, 2016 Timothy Calise & Ashley J PO Box 1290 Barnstable, MA 02630 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 17 Thread Needle Lane, Centerville,MA was inspected on 06/24/2016 by Mark Polselli, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level, <12" below inlet (per Town Code 360-9.1). You are ordered to repair or replace the septic system within two (2)years 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 ThorriaV- edri,._ R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\I7 Thread Needle Lane Centerville.doc Town of Barnstable Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA*02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 I Thomas A.McKean,CHO Feb 61 2007 Rev. 5/11/16 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 ❑ Any 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) Leaching pit or cesspool with high liquid level, <12" below inlet(per Town Code §360-9.1) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc i Commonwealth of massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syf#erz Form. N.00 for V0!`tntary Asses;;,nents re� Property Address ---- � ��2 OWN rler �, _,!,=_ G s c Owner's Name •--__.,_,..._._��. �-` information is /' f �`" required for every (��t yP{/1%l` Dc�6 3:�' jlns4pec* vPage• Cdylfown --"- State ZipCode Dateof d/ a .La 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. fnportaft outfoWhen A. General information Bing out forms on the computer, TJ use only the tab Inspector. key to move your l , cursor- et not GpV� o �S P/l//use the return key Name of Inspector .��✓�o - j CorrPanY Name 0<2 Company Adciess z., i��N-r City own Soy QO // D State / ,O �� Zip Code Telephone mber O 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 �y Vspector's Sig rf dure pate 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 DER The original should be sent to the system owner and copies ssnt 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. t9ns•3M3 TiveSofficiallns tionF—Subsuface per Sewage Disposal Sysmm•Page 1 of 17 Commonwealth of Massachusetts lugTitle 5 ®ffi:. l Inspection Form Subsurface Sewage Di System System Forth -Not for Voluntary Assessments Property Address 7-Are, d ON ner C information is Ory ner's Name requiredforevery C" feo 4e.' /� vt 6 ,0 0.)6 (o page. Citylrown _� o�Y State Zip Code Date of In pection �o Certification (corn.) 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 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes., "no"or"not determined"(Y,N, ND) for the following statements. If"not determined,"please exVain. 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 existirrp 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): a 19rr•3M3 Title 50Ffidal Ire pection F ortrc SuDsirface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage�Disposal System Form A Not for Voluntary Assessments / '/j / h✓`ea e-J LI/ Property Address information is Ow ne s Name information I- / l / required for every Cev-14VV6 ` t /¢ OTC 3j a �b page. own State Zip Code Date of fsi n B. certification (corn.) ❑ 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 pi pe(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 mannerwhich will protect public health, safety and the environment: I ❑ 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 tare•3M 3 Title 5 official Irepection f omc Subsurface Sewage Disposal S)mm•Page 3 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON ner information is Owner's Name requrcedforevery Ce,,levvt Ile page. Cilyfrown State Zip Code Date of inspectio B. Certification (cont.) Z 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 heats, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. t� D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ��Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6°below invert or available volume is less than'/Z day flow t5m-3M3 Tii1e50ffideltrapeetienForm SubstOaceSexageDisposd system-Page4of17 Commonwealth of Massachusetts Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property address GG Ojv ner ON ner's Name � mforrru fon is required for every C / 4�4 eH ✓V1! 'e oo1C 3a G/1) �� page. Crty/Town State Zip Code bete f Inspection Bo certification (coat.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or , / obstructed pipe(s). Number of times pumped: . El15 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. ❑ ny 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. ❑ Anyf portion o 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 nd chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 11 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. t5m•3/13 Title50fficial InspecfianFom SutsufaceSevageDisposal Syiem•Page 5of17 t Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Forms -Not for Voluntary Assessments / 7 �r�e�d ire,J le- ON ti Property Address --- n� C4 /C.T-� information is O�vner's Name dforevey page 114 Off-6 n 6 d�° page. CRy/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 ❑ ping information was provided by the owner, occupant, or Board of Health ❑ e any of the system components pumped out in the previous two weeks? ❑ the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(if they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ::�rExisting information. For example, a plan at the Board of Health. m Determined in the field (f 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �Iry tUs•M3 Title50ffiaal InspecUonFomt Subsu'faceSex2geDisposal S)chem•Page6of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not fbr Voluntary Assessments 7�tyAd �d/e- Z-- Property Address ON ner � rJ� information is ner's Name required for every Cle A �7 � i°vC �/4 Qo�� 3� G b 4f page. 5Ff Fown State Zip Code Date of Inspec' n D. System Information Description: / //00 0 //o� fr a Number of current residents: 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 CAI o Seasonal use? ❑ Yes ul o Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? X es No Last date of occupancy: to Commercla III ndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: t5iirs•3f13 Title5 Official Inspection Form Subsutace Sewage Disposal System-Page 7of17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address aN ner information is mi ner's Name required for every �Vr lk� 0.d (,z) page. City/Town State Zip Code Date of I specU6n D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: /v Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy m: Septic tank,d 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(desch be): tSns•3M 3 Yule 5 official trupection F onrc Subsurface Sevme Disposal system•Page 8of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow ner Ow ner's Name �' itfornnation is / b,p'-6 required for every yti�-2,/(/G t page Q)/ own State 7 Code Gate of Inspection®. System Information (cont.) Approximate age of all components, date installed (if known) and source of info ation: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;40 ❑ cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: a / feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material o traction: 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: S Sludge depth: —✓ // t9ns•3h3 Title 5 official lm pection F arts subsufam sewage Disposal system•P<ge g of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foan e Not for Voluntary Assessments Property Address Owner information is Ow ner's Name required for every CP"► 7S�" Vl/Z G�� a page. City/Town — y/iown State Zip Code Date of In pectic D. System Information (cost.) 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.): n,9 Co 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 f5ns•3H3 Title50fficiallnspec tionFomcSubsufaceSe Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / -:-A , Property Address - Owner G I inforn tion is QM n�S IV3Ttte I_ required for every CP��e//iG /%4 bArol, page. (lyRown State Zip Code Date of Inspection D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, e%idence of leakage, etc.): Tight or Bolding 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 worldng order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(requited). Is copy attached. ❑ Yes ❑ No t5ns•W T1050ftidafIns tionFam[SubsurfaceSe peG Sewage Disposal System•Page 11 of 17 i' i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not far Voluntary Assessments Property Address C� '1 ON ner Aw ner's Nameinformation is I_ / required for every 0;) Y//-,/ page. City/Town State Zip Code Date of Inspection D. System Information (cons.) Distribution Box (f present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Commentsappurtenances, etc. : e (note condition of pump chamber, condition of pumps and ) * 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: t5irs•YI3 Tide 5official Impaction Form Suburface Sewage Disposal System*Page 12 cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments Property Address / Ow ner information is Owner's Name / required for every C'�e iA ` �� o�i a Page. atyrr01N0 D. System Information (cont) State ZP Code Date of Inspection O/ ` � Type. / to 9 leaching pits � number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology* Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S .�. /G vv /tC � /4 , Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Eris-3M 3 Title 5Official Inspection Form SulsWace Savage Disposal System•tte/3 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form _Not for Voluntary Assessments Property Address / - - / �'✓1�q �/(/ Owner information is Owner's Name / required for every /� page. Uty/Town �146 State Zip Code Date of Inspection ®. System Information (cost.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 19rs•3r9 3 TiUe50ffidal irspecfionFo m Subsuface Sewage Disposal S"M*Page 14 of 17 Commonwealth of Massachusetts lugTitle 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Properly Address Ow ner Ow ner s Name information is required for every CI LA page. Cllyliown State Zip Code o� Date of Inspection U. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two pe anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pu water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately o� 33. 193 - a C 1-t3 - � 9 C q. .3 tSns-3M3 Me5official InspectimForm Subsrface Savage Disp-A System•Page 15d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /t�d� Z, Ow r er QN rter s N2me (✓--L— iflfornutiotl is required for every page. City fit b of spectio ®. System Information (cont.) State Zip Code Date Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 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 ❑ bserved site(abutting property/observation hole within 150 feet of SAS) Checked with o rd of Healt -explain: 4- �� f ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must descrQ w you estabji shed the high ground water elevation:/ -- !/'tare �a H 11i O !p� r — s s s � u Before filing this Inspection Report, please see Report Completeness Checklist on next page. t9ns-3h3 Title50ffidal Irnspea6aiFaro Subsufaoe Sewage Disposal system-Page 16 of 17 Commonwealth of Massachusetts YJTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - / 11� ^�0 � d � Properly Address V ON ner QN ner's Name infOr abon is Maukwforevey e v►IL,Ay Page• y/Town State Zip Code Orate of Inspection E. Repo Compleftness Checklist �.,�Inspection Summary: A, B, C, D, or E checked u inspection Summary D(System Failure Criteria Applicable to AM Systems)completed :�Sketch Information—Estimated depth to high groundwater of Sewage Disposal System either drawn on page 1S or attached in separate file 16s6.3h3 TM50ftidg trspecBmForm SubsWawSm%e Sy;am-t%e nd 17 Town of Barnstable P# Departlent of Regulatory Services STABIA i Public Health Division MASS. Date �A i639 ,b� 200 Main Street,Hyannis MA 02601 lf��.1A Date Scheduled Time D N' Fee Pd. /00, co _ Soil Suitability Assessment,f or S e e �Performed By: /"Cf y"c-C� �ll�e S���S Z�,imessed V LOCATION& GENERAL INFORMATION Location Address /7 77)fvutOIf ,t^tec��2 C� 's Name 'l/ � OwnerPo,, O Address c ,, Assessor's Ma /Parcel:. Z °^K-SqS Le M�' G U p zzo _Q 2 Engineer's Name G NEW CONSTRUCTION REPAIR Telephone# 8'--7-3 (0 Z7 Land Use / S f � Slopes(9'0) Z 'Surface Stones_A)O tV_ Distances from: Open Water Body 23 6 to ft Possible Wet Area ft Drinking Water Well Drainage Way 6— ft Property Line eft Other _ ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands(n proximity to holes) Parent material(geologic) �� 5~ Depth to Bedrock _ Depth to Groundwater. Standing Water in Hole: N`0e7.4 Weeping from Pit Face Estimated Seasonal High Groundwater �� / DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: _in. .Depth to still mottles: _ in. ?.Depth to weeping from side of obs.hole: in, Groundwater Adjustment _,.___„m -„_ft. Index Well# Reading Date:— Index Well level AdJ.factor...... Adj,Groundwater"Level PERCOLATION T.E+ST bate_. _. Thne..�,e,_ Observation Hole# 1 Time at 9" Depth of Perc 3 Time at 6" Start Pre-soak Time @ Z 4)Ck Time(9".6") End Pre-soak �' 1 M. Rate Min./Inch. Z Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(Y/N)_ original: Public Health Division Observ�ition 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:\SPPTIC\PERCFORM.DOC i DEEP-OBSERVATION HOLD,LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,%Gravel) 6 L DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% a ]DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other.,. Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones,Boulders. C nsistency. o Gravel) :DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consist n o t , Flood Insurance Rate Map: ,�/ Above 500 year flood boundary No— Yes Within 500 year boundary No_K1_Yes . Within 100 year flood boundary No-,& Yes ,. . Depth of NatumflT Occurring Pervious Material Does at least four feet of naturally occurring pervi° s material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? _.. Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 310 CMR 15.017. Signature �I�,`1� Date ?J z6 Q:\.SBPTI(1PBRCFORM.DOC Commonwealth of Massachusetts ; } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Thread Needle Lane, Centerville _ Property Address Jonathan Green_ _ Owner Owner's Name information is Centerville MA 02632 Ma 11, 2010 required for every __ 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. filling out forms A. General Information filling out fonts �M on the computer, I� rn 6�3 use only the tab 1. Ins ector: key to move your p cursor-do not TroyWilliams use the return — - -- — — --- - ke Name of Inspector --; { y Troy Williams Septic Inspections __— ,� Company Name 19 Hummel Drive Company Address--- — --- ------ ------- -�- � --�►- �:, South Dennis MA 02660 City/Town State '2ip Code 1508)385-1300 _ _ S1682ft 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 May 11, 2010 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Di sal System•Page 1 of 17 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Thread Needle Lane, Centerville _ Property Address Jonathan Green Owner Owner's Name information is Centerville MA 02632 May 11 2010 required for every — —__—_— _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only. This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes or components, or the future structural integrity of system components and represents conditions found on the day of inspection only_ 13) 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): N/A t5ins•09108 - Title 5 Official Inspedion 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 17 Thread Needle Lane, Centerville Property Address -- Jonathan Green Owner Owner's Name information is Centerville _ MA 02632 May 11 2010 required for every �/ _ , page. CityfFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): N/A ❑ 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): N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -- 17 Thread Needle Lane, Centerville___ Property Address Jonathan Green _ Owner Owner's Name information is Centerville MA _02632 May 11, 2010 required for every _ _y page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A 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 '/z day flow t5ins•09/08 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 17 Thread Needle Lane, Centerville Property Address Jonathan Green Owner Owner's Name information is Centerville MA 02632 May 11 2010 required for every _ _ , _ 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: N/A. ❑ ® 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•09/08 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 17 Thread Needle Lane, Centerville Property Address Jonathan Green Owner Owner's Name information is Centerville MA 02632 May 11, 2010 required for every _y page. Citylrown 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? ❑ 0 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.- 0 ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design). 4— Number of bedrooms(actual): 4 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Thread Needle Lane, Centerville Property Address Jonathan Green Owner Owner's Name information is Centerville MA 02632 May 11, 2010 required for every --__ _Y page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 09=48,000 gals. g ( Y g (gp )) 08=58,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate Commerciallindustrial Flow Conditions: Type of Establishment: N/A N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Thread Needle Lane, Centerville Property Address Jonathan Green Owner Owner's Name ------------------------ --- ----information is Centerville MA 02632 May 11 2010 _required for every _ _�_, page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/ADate Other(describe below).- NIA General Information Pumping Records: Source of information: Last pumped in 2007 per home owner. _ Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A _ gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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): no d-box t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts ' W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Thread Needle Lane, Centerville Property Address Jonathan Green _ Owner Owner's Name information is Centerville MA 02632 May 11, 2010 required for every y page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank& block pit are original to home. Leach pit was added on 6/12/90 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"+ — feet Material of construction: ® cast iron ® 40 PVC orangeburg ® other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank (locate on site plan): Depth below grade: 1. feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'X 9'X 6' 1000 gallon ' Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Thread Needle Lane, Centerville _ Property Address Jonathan Green_ _ Owner Owner's Name information is Centerville MA 02632 May 11 2010 required for every _Y_, page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 2, 8„ Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet and outlet tees were present. No evidence of leakage or damage was found at the time of Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A_ Date t5ins•09/08 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 17 Thread Needle Lane, Centerville _ Property Address Jonathan Green Owner Owner's Name information is Centerville MA 02632 May 11, 2010 required for every _y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A gallons _ Design Flow: N/Agallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A — - Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•09108 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 17 Thread Needle Lane, Centerville_ _ Property Address Jonathan Green_ _ Owner Owner's Name information is Centerville MA 02632 May 11, 2010 required for every _ y page. City/Town 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No d-box on as-built or found Pump Chamber(locate on site plan),- Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A t5ins•09/08 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 0 17 Thread Needle Lane, Centerville Property Address Jonathan Green Owner Owner's Name information is Centerville MA 02632 May 11 2010 required for every — _ � page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Type: ® leaching pits number: 1 -6'X6'with 2' of stone ❑ leaching chambers number: 1 -5'X 5' block pit ❑ 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.): Soil was sandy. Leach pit was found with water level 18" below inlet invert with walls found clean above water level. Water level in block pit was up to outlet tee. No evidence of hydraulic failure or roblems in the past at the time of inspection.__ Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A _ Depth —top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts wl v Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 17 Thread Needle Lane, Centerville Property Address Jonathan Green Owner Owner's Name information is Centerville MA 02632 May ,11 2010 required for every _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. N/A Privy(locate on site plan): Materials of construction: N/A_ Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts �X Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.H 17 Thread Needle Lane, Centerville Property Address Jonathan Green Owner Owner's Name information is Centerville MA 02632 May 11 2010 required for every _ , 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 I � GY i b � L: 1 •1 1 r 33f (oil 3 z& r C y ; 33'9 '' 6 1` j l5ins•09/08 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 ;M 17 Thread Needle Lane, Centerville _ Property Address . Jonathan Green Owner Owner's Name information is Centerville MA 02632 Ma 11, 2010 required for every _ _� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells _ Estimated depth to high ground water: 16' +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: AIW 247 Zone B 20.0' .0' adjustment You must describe how you established the high ground water elevation: Hand augered 4.0' below bottom of leaching with no water found at 12.2'. Groundwater adjustment at the time of inspection was .0'. Bottom of leaching at 8.2'was found not to be located in the high groundwater level at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,. 17 Thread Needle Lane, Centerville Property Address Jonathan Green Owner Owner's Name information is Centerville MA 02632 May 11 2010 required for every y_ , page. Cityrrown 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 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Bk 24782 P:o339 -Qw-43042 08-27-2010 „"t 02 m 2?g:► (aF)y Deed Restriction Whereas, Kathryn G. Green, Trustee of the Green Realty Trust udt dated August 7, 2001 being recorded in Book 14460, Page 261, is the owner of property located at 17 Thread Needle Lane, Barnstable (Centerville), Barnstable County, Massachusetts, by Deed recorded in Book 16855, Page 39, said land being shown on Barnstable Assessor's Map 210 Parcel 76 and being shown as Lot 12 on Plan recorded in Book /9/ Page 2/j. Whereas, Kathryn G. Green, Trustee, as the owner of said Lot, has agreed to a restriction as to the number of bedrooms which can be included in any home existing or to be built in the future on said lot as a pre condition to obtaining a building permit for this lot; Whereas,The Town of Barnstable, as a pre-condition to granting the building permit for - the conversion of a garage into a library/piano room existing on this lot is requiring that the agreement for the restriction of the number of bedrooms in any house existing or to be constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document. Now Therefore, Kathryn G. Green, Trustee does hereby place the following restriction on the above referenced land in accordance with this agreement with the Town of Barnstable, which restriction shall run with the land and be binding upon all successors in title: 1. Lot 12, Plan Book 191,Page 47, house# 17 Thread Needle Lane, Barnstable (Centerville), Massachusetts, may have a house containing no more than four(4) bedrooms. Kathryn G. Green, Trustee hereby agrees that this shall be a permanent deed restriction affecting the above described premises. For title see deed recorded in the Barnstable County Registry of Deeds Book 16855, Page 39 and Book 16778, Page 261. Executed as a sealed instrument this c�Z day of , 2010 Kathryn d Gr en, Trustee COMMONWEALTH OF MASSACHUSETTS Barnstable, ss Ith -- On this day of , 2010, before me,the undersigned notary public, personally appeared Kath ' n G. Green, Trustee, proved to me through satisfactory evidence of identification, which was a Massachusetts Driver's License, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purpose, Notary Public: Com Ex : p =SL TRUSTEE CERTIFICATE I,Kathryn G.Green,Trustee of the Green Realty Ti ust u/d/t dated 8/7/01 and recorded in the Barnstable County Registry of Deeds in Book 14460, Page 261, of 17 Thread Needle Lane, Centerville, Massachusetts 02632 hereby certify in accordance with the terms of said Trust: 1. That I am the incumbent Trustee of the Trust; 2. That said Trust has never been amended or modified to date. 3. That said Trust remains in effect and has never been terminated; and 4. That the Trustee has been duly directed by the beneficiaries, who are of full and legal age, owning 100% of the beneficial interest in and to the aforesaid Trust to place a deed restriction on the property located at 17 Thread Needle Lane, Centerville for nominal consideraton and that the Trustee has the authority to execute such documents as the Trustee deems necessary in order to effectuateetthe above-described transaction. EXECUTED as a sealed instrument this Gj / day of , 2010. 61 Kathryn G. Gee , Trustee COMMONWEALTH OF MASSACHUSETTS Barnstable, ss 0n this day of , 2010, before me, the undersigned notary public, personally appeared Kathryn G. Green, Trustee as aforesaid proved to me through satisfactory evidence of identification,which was a Massachusetts driver's license, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purpose as an authorized person for said Trust, Notary Public: Commission Expiration: DONNA M.ROBERTSON s- NoWn Public corttiranwum of masuchmm My Coiw*sion EVfts MY 9,2018 Affidavit I, Kathryn G. Green, Trustee of the Green Realty Trust u/d/t dated 8/7/01 and recorded in the Barnstable County Registry of Deeds in Book 14460, Page 261, of 17 Thread Needle Lane, Centerville, Massachusetts 02632 hereby state the following: 1. I purchased the property located at 17 Thread Needle Lane on January 15, 1999 by deed from Nancy E. Frangione being recorded in the Barnstable County Registry of Deeds in Book 11995 Page 51. 2. I conveyed my proprety to the Green Realty Trust u/d/t dated 8/7/01 and recorded in the Barnstable County Registry of Deeds in Book 14460, Page 261 in which I am the Trustee of the Trust. From the beginning of my ownership commencing with the Deed dated January 15, 1999, the property has always been a four bedroom residence and will continue to be a four bedroom without interruption. Witness my hand and seal this day of August, 2010. Kathryn pG. dreen, Tru tee COMMONWEALTH OF MASSACHUSETTS Barnstable, ss On this 21pday of(7A ', 2010, before me, the undersigned notary public, personally appeared Kat ryn G. Green, Trustee as aforesaid proved to me through satisfactory evidence of identification, which was a Massachusetts driver's license, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purpose as an authorized person for said Trust, Notary Public: Commission Expiration: DONNA K ROBERTSON No"y Public oww wiw9am of Massachusetts My ow nwaion Evtes July 9,2D18 TOWN OF B jARNSTABLE LOCATION I ��`e �`'�%' 'L� -1 SEWAGE VILLAGE( (�U I I ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY�� LEACHING FACILITY:(type) Q (size) i K NO. OF BEDROOMS PRIVAT E WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No a 0001 b` I ,----. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apptiratiun for Diupuutti Works Tonstrnr#inn 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( !n Individual Sewage Disposal System at: ........... ........N...i.X.�l_ ........................................... :... ... ............. _-........................................................... -. Location-Address or Lot No. . ---------------�P ........ Q ----------- s. ..----........--------------------................ Ow�r A dress Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......._�-�...............•._-_-_---•-___-__--Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures -------------------------------------...........--- . W Design Flow------ .....................gallons per person per day. Total daily flow......... _0.................gallons. WSeptic Tank—Liquid'capacity......_.....gallons Length.............•.. Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......L------------ Diameter----V&...... Depth below inlet.....(Q(-......... 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---------------------- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---•------------------------•--•-••-----•-•----....._...----------..........-------•---•----.------......................................................... 0 Description of Soil............................................................................... ------------------------------------...-•---------------------•----•--•--------------•-- x (� ---------------------------------------------------- •--------------------------------------------------------------------------- •---------------------------- ..... ---------•••-----------•--•-------- W U Nature of Repairs or Alterations—Answer when applicable__;;P-kSQ3�19__A........$Q� .?:............_.._. -!. ..eZ.............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Corn liance has been ' sued by the boar of health. Signed ... ....... . . ....... ....---6--7--PILP---- LY�ce Application Approved By ............... 1�,,e„r-�. '`-•-u,: .. ----------------- ....... '�..n../'. Application Disapproved for the following reasons- ---------- --- --------------------------------------------- -------------------------------------------- ------------------- ----........................................................... ........................................ Dace PermitNo. .........C�G' ..� ----------_------- Issued ----------------- ......................................----------- a ip THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Ton,strnrtion firrutit Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal System at: .._ n Location-Address or Lot No. C X_n emu. c I' ' I--,. 161(ti- _ ►:�_. = + i ---• -• t Own r ' Address - Installer Address Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms-------�,�__--------------------------------Expansion Attic ( ) Garbage Grinder ( ) WOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------•--•••-•-------------------------------------•---•••-•••----------..........--------••--•. W Design Flow........ _......................... 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......A------------ Diameter.....V.0(..... Depth below inlet.....kel(....... 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........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.....................Depth to ground water........................ 9 --------•-------••----------••-•--•-•-•-----••.............••--•------•--•-•--------......••-•----•-......................................................... 0 Description of Soil........................................................................................................................................................................ x U --------------------•--....---...•--------•••--••••------------._.......--••-•----•-......-••-•---•••--•-----•--------•--------•-•-------------•----------•-•••••...........--••--••-•----•-•---••-•... w Z. ----------------------------------------------------------------------------------------------------------------------------------------------------------- - :. ---- U Nature of Repairs or Alterations—Answer when applicable_-7 yL'5�(,.K-f k�.... _tu_ ?._.! .................� ---------------- ',Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in�operation until a Certificate of Compliance has been issued by the board of health. - Slgne ... 4 -- - ---.....: �- 1 G—` Dare Application Approved By .......... ------------------------- --------------- G ----------------------------------------................. Dace Application Disapproved for the following reasons: --------------------------------------------------------------- - ------- -------------------- -------- -------------- I ..............................................---------------------- ----------------------- ---------------------- - Dare PermitNo. �'- - -U--.................... Issued -------------------------------------- -------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ciertifirak of CZIImyYtttnce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by - - ------- Installer at � h'r .c�_ -.+ r,..... ------..�::� ... ..:........... .....:_r-'-T---------..................--------------- has been installed in accordance with the provisions of TITLE 510 The State environmental Code as described in the application for Disposal Works Construction Permit No. ----.-/.-��..'--.)-'.�U.-- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ��'�� DATE-------- '`'��! Inspe torte.... - � ' .........----- -------------_-_-_------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No................... FEE.. ..........----- Dioposal Workii Tonstrudiott prrufit Permission is hereby granted--------.�bj-rl( '1 = -C...-------•--••--------------------•---•-•---..0.0...--••-----••-.•. to Construct ( ) or Repair ( an Individual Sewage Disposal System at No.---•-----•--..IJ..t"'1 1 ,=��� .vu __ C,a.�.......................................... Street as shown on the application for Disposal Works Construction Permit N .?U_�_('_G Dated.......................................... Board of Health DATE................................................................................ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS LOT 11 LEGEND N 11 Wequaquet x 100.98 EXISTING SPOT GRADE ® ��, Lake 11 - 102 -- EXISTING CONTOUR d - •O.ftlk - OVERHEAD WIRES � '� �' ✓ a LOT 13 Z ,� Wy EXISTING WATER SERVICE o ce Th�epd Needle �r C, cry 00 G EXISTING GAS SERVICE PG o oA 1;� TEST PIT �, x as,2 I o o+ BENCHMARK Great Marsh Rd P� 5 g0 EXISTING SEPTIC TANK LOCUS e�� i I TOP OF TANK; EL.=44.67 Bey LbT 12 INV.(OUT)=43.34f(VERIFY) Route 28 Qr�� MBL 210-076 ��'�� � LOT 9 ,. LOCUS MAP 29,591\ ±SF EXISTING CESSPOOL & LEACH PIT GENERAL NOTES: NOT TO SCALE CONTRACTOR SHALL PUMP, 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL ,f ��n. 7•s FILL WITH SAND & ABANDON BOARD OF HEALTH AND THE DESIGN ENGINEER. if 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS f x 49.30 OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE CP. . . . . . . . . LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: LOT 18 \ p 'swing set -310 CMR 15.405(1)(b): \\6'- Y• 49.51 x 1) A 10' variance< sas to cellar wall, for a 10' setback o; LOT 10 2) A 2' variance to the maximum cover requirement of 3', for up to 5' of cover over the S.A.S. System shall be vented. VENT PROPOSED S.A.S. os 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR ` SkIED to ret. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 28 ADS Arc 36 HC HD Units 8 `yam/i ` DESIGN ENGINEER. STONELESS 11.5' x 35' BED b 4 45.7 46.57 ` x 48.85 47.50 � r „ a �r 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING P 2' 5.64 - 1 - . FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN v, TP-1 �� t ENGINEER BEFORE CONSTRUCTION CONTINUES. BENCH +as. 45,51 MARK 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. OUTSIDE COR./BOTT. STEP a5.90 x a EL.=46.09 45.'). ShrUbs x 45.4e 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF INSPECTION PORT :r 4609 Q.32 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 6.0 + 3 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. DECK 00 rn 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE 46.25:k 46.05 45.98 Q; PATIO �� t 8. THERE ARE NO ABUTTING WELLS WITHIN 150' OF THE PROPOSED S.A.S. o EXISTING o U'- I 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS LOT 17 'r HOUSE(#17) �n�. o� AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 46.19 T.O.F.=46.5f 45,93 "i DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 00 O 46.2� COS; I THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING shrubs v, CONSTRUCTION. GARAGE 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS t^ + 5 46.33 ° OF MqS IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 46.33orb. Q�� sq� REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 45. 46.� �� '- '•I" 4 �� o PETER T. 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE McENTEE INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. o . CIVIL 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 45.24 :%PAVE•�;;.� 44,94 x No. 35109 IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. x 45,79 DRII% AY. fG/SZER�`� `�� 14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC 'P F.� SYSTEM COMPONENTS NOT SHOWN ON THE PLAN. x 43,90 PROPOSED SEPTIC SYSTEM U-PGRADE PLAN 4426' 41.79' _ ��.5r"3�" �" �`-44�/43,49 x ' ': � 44 93 17 THREAD NEEDLE LANE, CENTERVILLE, MA 421 Prepared for: Timothy Calise, P.O. Box 1290, Barnstable, MA 02630 42.33 42.49 42.30 _4 _-✓ i'�l OWNER OF RECORD Engineering by: SCALE DRAWN JOB. N0. 42,07 \ CAUSE, TIMOTHY K & THR�'�11> N�'�'I�L�' LAN ASHLEY J Engineering Works, Inc. 1"=30' P.T.M. 258-14 P.O. BOX 1290 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. BARNSTABLE, MA 02630 (508) 477-5313 9/1/16 P.T.M. 1 of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL.43.3 SEPTIC TANK FOR A DISTANCE OF 15' AROUND THE INSTALL RISERS & COVERS OVER INLET PERIMETER OF THE S.A.S. AND SET TO 6" OF FINISH GRADE. PROPOSED D-BOX PROPOSED S.A.S. INSTALL 2 INSPECTION PORTS(MIN.) CHARCOAL VENT INSTALL WATERTIGHT RISER & AT END OF S.A.S. (CONNECT ALL LINES) TLF.GEL.=46.0± .5t COVER SET TO 6" OF GRADE F.G. EL.=45.7f F.G. EL.=45.7t F.G. EL.=45.7 to 47.5t MAINTAIN 2% GRADE (MIN.) OVER S.A.S. GARAGE mom ' L = 8' L = 8' INSPECTION PORT S=1% (MIN.) p S=1% (MIN.) TWO (MIN.) EXISTING 5 - 4"SCH40 PVC 4"SCH40 PVC HOUSE(#17) 14" 6• 10.75" TO T.D.F.=46.5f t0"I EXISTING 48" LIQUID INVERT LEVEL GASADeADFFLE INV.=43.17 PROPOSED INV.=43.00 r 4 ROWS OF 7 UNITS AT 5.0'/UNIT = 35.0' DECK INV.=43.34 D-BOX SOIL ABSORPTION SYSTEM (PROFILE) INV.=42.90 EXISTING SEPTIC TANK �9 656'8 ESTABLISH VEGETATIVE COVER 2 BACKFILL WITH CLEAN NATIVE OR �. _ 1 PERC SAND TO TOP OF CHAMBERS p^PROP. 1 BREAKOUT=TOP '• '••,` ����'Sr�' NOTES: TOP ELEV. =43.33 INV. ELEV.=42.90 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INVERTS, PRIOR TO INSTALLATION. BOTTOM ELEV.=42.00-` 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE 4' MIN. OF NATURALLY OCCURRING 2.83 ON A MECHANICALLY COMPACTED SIX INCH CRUSHED PERVIOUS MATERIALS EFFECTIVE WIDTH=11.5' STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 5' MIN. ABOVE HIGH GROUNDWATER (LEAVE 1" BETWEEN ROWS) EXISTING SUITABLE SEPTIC LAYOUT 3) INSTALL INLET & OUTLET TEES AS REQUIRED. BOTTOM OF TEST HOLE, EL.=35.4 = MATERIAL 4) CONTRACTOR SHALL INSTALL A GAS BAFFLE ON THE OUTLET TEE. 63.2s" USE 4 ROWS OF 7-ADS Arc 36HC HD UNITS IN A STONELESS CONFIGURATION WITH BED DIMENSIONS OF 11.5' x 35.0' SEPTIC SYSTEM PROFILE TYPICAL SECTION 16" 34.5" DESIGN CRITERIA SOIL LOG DATE: AUGUST 26, 20.16 (REF#15,139) NUMBER OF BEDROOMS: 4 BEDROOMS SOIL EVALUATOR: PETER McENTEE PE(SE#1542) TOP VIEW WITNESS: DAVID STANTON R.S. HEALTH AGENT SOIL TEXTURAL CLASS: CLASS 1 60' DESIGN PERCOLATION RATE: <2 MIN/IN ELEV. TP-1 DEPTH ELEV. TP-2 DEPTH END CAP END CAP 0" 0 DAILY FLOW: 440 GPD 46.4 q 47.8 " FRONT VIEW SIDE VIEW q END CAP DESIGN FLOW: 440 GPD SANDY 4/2M , SANDY 10YR 4/2M REAR/TOP VIEW 45.9 . 6" 47.3 6" GARBAGE GRINDER: NO-S.A.S. NOT DESIGNED FOR GARBAGE GRINDER B B NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY SANDY LOAM SANDY LOAM DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. LEACHING AREA REQUIRED: (440 GPD) = 594.6 SF 10YR 5/6 i 10YR 5/6 74 GPD/SF 43.4 C 36" 44.8 36" HL L ARD40 U OH 0 EMAN B ozs PERCc Are 36HC HD DETAIL a EXISTING SEPTIC TANK: 1000 GALLON CAPACITY 6/5 ADVANCED DRAINAGE SYSTEMS,INC. UNITS MUST BE STAMPED HD 36/54" ; PROPOSED D-BOX: 1 INLET, 4 OUTLET (MINIMUM), H-10 RATED M-C SAND M-C SAND PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 4 ROWS OF 7-ADS Arc 36HC HD UNITS IN A STONELESS 2.5Y 6/4 2.5Y 6/4 17 THREAD NEEDLE LANE, CENTERVILLE, MA CONFIGURATION WITH BED, DIMENSIONS OF 11.5' x 35.0' >10% GRAVEL >10% GRAVEL Prepared for: Timothy Calise, P.O. Box 1290, Barnstable, MA 02630 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF UNIT) Engineering by: SCALE DRAWN JOB. NO. (Arc36 Units) 28 UNITS x 5.0 LF x 4.80 SF/LF = 672.0 SF 35.4 132" 36.6 134" Engineering Works, Inc. NTS P.T.M. 258-14 DESIGN FLOW PROVIDED: 0.74 GPD/SF(672.0 SF) = 497.3 GPD NO GROUNDWATER, PERC RATE: <2 MIN./IN. 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. NOMINAL AREA OF BED = 11.5' x 35.0' = 402.5 SF (508) 477-5313 9/1/16 P.T.M. 2 Of 2 as W4r 1 ee as a$ a-r ar a s-r . a.c�(.b O /� `� ANDERIBI AIDEREEn ANDERIEM AsmN ANDERSEN MDEREEH ANOB,IB) . V V 'Vn V MNs2R _ �N AaH 321a AuxD"301E AyLN gaA!- -- AON 321E I isuILT-IN iCABNET ANDERM EXIST. /- REMOD. REMOD. REMOD. ° " DEC NM ANDERM MASTER B MASTER pETa°Ls'af�ivowNEasROOM�R FAMILY "�E"'DDN DROOMBATH1'✓ 2e.Or CABINET EVITALLNEWr E0.BTEB CABINET POSTSUOFIlEEWIR)RE6W� NEW I a II I'ae ' I ` NEWANDER11M NEW STEEL BEAM ABOVE A-BB,IES"movV ' Fi ------------------------ r.r m —- -__�_—=__—=_-_---_�-- - LED 3 I------------J h ® --- -------- S - - - - - _-_ TALL -- --- -_-_---- am A .i7 ® :-i i ------�--� . h 01MADERSB, I WALL Iuic E - EXIST. a ~�WHOM REMOD. b REMO I owB� �� REMOD. DINING BEDROOM (w BATH O I n�YOG_Sro +EW 4 KITCHEN ANDE,� B I RANGE RBE © i — O O Q ---.... -- BT. J- I E106T -- ^' a NEW EaaE1CLOS. ;BATH- u k ---- ® EXIST. IK >Y -Q-- © HALLt 1 NEWAIDERSEM -- JL' NEW ` i A.SBtEeYY►pOMY . sa $ I ® L'DRY. i ® EXIST. MENGIN ® ® f 1 --- ® LIVING I Los. NEW y EXIST. i�� BEDROOM 'a I rr.vv GARAGE a 4 BEDROOM NEWFM RATW HALL NEWtj I so MUDROO moo, B k CLOS. b. ANDERSBI " AAN DERSEN TxNDOW 46EREBANB WIDOW — — ------ NOTES: `°`a 1.) C.t3NTRACTOR. IS TO VERIFY-ALL EXISTING CONDITIGNS a UIMBNSIONS')N THE FIEF , $ NEW a $ " 2.) CONTRACTOR,TO dER)FY ALL IIQTERIOR a EXTERIOR MATERIALS, I CRAFT ti c DETAII S;a FINISHES:IN THE FIELpVFlljil OWNER ev.YvoxDOOR Asa ay.To• .,L000p s; 3.) ROUGH OPENING HEAD HEIGHT OF WNDOWS AT '. FIRST FLOOR TO BE 8'-10'ABOVE$UBK90R I C0N0' 4.) ALL CONSTRIL!", TR'CONFORM TO-M-tMR'MPSSACMUSETTS I A � _7_ STATE 6UILMH'[#CGDE:6ESIEMITH EDRION B g•) 1101APH E)EPO:SURE♦9 WAN�1 ZOflE t:2arASRISC swno; �lE vAl rpow a a 7) ALL�SHEETSOFPLgWOp QWALLSHEgL INGjDBEINSTAUMVeMCALLY. +: OR HORIZOI ALLY W/91 OCIUNq.Al EOGES lSDGEA2'FIELD NAILING el e) ALLIA&LL'MB-IEWSEAMS TU BE 1)le[l48DJ RAD e) TPLAKO SD,#,ATIpER&GyJLEY.P.E.FOR FIRST FLOOR P LA N I "4 FOLLOW ALL MWEP 4WAC-WRER S SPECI0V-ATK9WS FOR INSTALLATION OF ALL SIMPsoNCOMO- LEGEND: 11)'ALL.CONLREjE.GI8Ep'FO1tFOUNOPFRON W4LS,FOOTIW&SLABS I ToBE3ooDPsl,. �7 EXISTING WALLS 12)VERfFYAL�pLVKIgINGgFLEOT1iICAL{i1 jAl{SyWaWNER8ONTHESITE C__7 CONSTRUCTION TO BE REMOVED pURING FRAMING CONSTRUCTION P= NEW CONSTRUCTION 1 13)TIMBER FRAMING TO BE SPRtiCE1PINJFIR ND ZL9RADE' IEGG2009 p SIPENTIAL EMI#=RGY.EFFICI NCY DETAILS (3)sMoKEDETECTOR CLI1IFAjEZO4E SA:;(LISEFl HER P{iE$G&IPiIVE dP1UES9R.ISCHECK CALCULATION ©CARBON MONOXIDE DETECTOR jABLE'4G221 1 N1IFIIMUM •REBORIVTIV INSULAM a FENE .; TION REQUIREM iWAtIIE HEAT DETECTOR CP,RiO FENEBTRATIpN BKYUDNT: -- ERAIFDNuIi ELopR =BAIEMEMYYAIR BA9EataTT W cRAuwlvAfiEwAu . 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LOCATION OF SEPTIC -COMPONENTS ACCORDING / r i' , 43 TO THE OWNER. new garage, mudroom and bath. rn 10 - ca YDRANT #63 tK o \ IV A01 S ,16 �� Oct /r O 1 SITE PLAN 82 00' LAMP 1 / / CS PREPARED FOR POST TIMOTHY COLISE. / r\ OF` �/ , �'�' 17 THREAD I�a NEEDLE LANE BAR NSTABLE, MA v s Tao �' J.E. LANDERS—CAULEY, P.E. LOT 18 46 40'� r' �or' / CIVIL ENVIRONMENTAL ENGINEERING KN; r P.O. BOX 364 WEST .FALMOUTK MA 02574 LOT 17 �508) 540 L 7733 ph. 508 540 — 3344 fax ASS. 210-076 DATE: 09 16 10 SCALE: :1" _ 20. DRAWN BY .;. JDR REV.11' 01 1.. JDR JOB NO. 1936 ISHEET. i OF 1 jA= 5 J J \V7'VYI F 1 ------------- LL l Pl D r6a- AUG 7 REC'D CASED i y4 1 � nu�ec�