HomeMy WebLinkAbout0066 THREE PONDS DRIVE - Health (2) 66 Three Ponds Road
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Commonwealth of Massachusetts /
4 AY i i 5Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville ,� MA 02632 May 14 2016
required for every y
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr, IRS
use the return Name of Inspector
key.
Eco-Tech Rapid Response
Company Name
155 George Ryder Road South
Company Address
Chatham MA 02633
City/Town State Zip Code
508 364-0894 1328
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
fib OF M,q .
❑ Needs F E gplgitio he Local Approving Authority
o� D.
CO H NOWR N .
C 0 1093 S<> � May 14, 2016
Inspector's Sign re `G/STEM Date
`I NI"r, , \ ,'- . 1
The system inspe Erb ... submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of,use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
r Z e
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is required for every Centerville MA 02632 May 14, 2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the-septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a,complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and•if a Certificate of
Compliance indicating that the tank is less than'20 years,.old is'available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every y
page. Cityrrown i State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than,5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this'form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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 '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
, 1 I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every Y
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14, 2016
required for every y
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'GSM a 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every Y
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 129 gpd
9 ( Y 9 (gpd)):
Detail:
2014: 45,000 gallons 2015: 49,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other describe below):
General Information
Pumping Records:
Source of information: Owner's agent
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 14+ years. Certificate of Compliance for a new system was issued 7/23/2001 (Permit#2001-
287 at Health Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron 2 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
8.5 x 5 x 6-1000 gallon
Sludge depth:
6 in
t5ins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14, 2016
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28 in
Scum thickness 2 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 13 in
How were dimensions determined? Design Plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year
round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence
of leakage in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every _ Y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):.
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is required for every Centerville MA 02632 May 14, 2016
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 at 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 adverse conditions observed.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 1
❑ 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.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. A bucket of water was poured into the distribution box and was observed to pass through
in a rapid and unobstructed manner, and could be heard splashing down into the leaching system.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is required for every Centerville MA 02632 May 14, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every y
page. Cityrrown 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
NOT
TO
SCALE L Oo CA T§ON1S
—OF SEPTIC COMPONENTS
EX§S TQN(3 —DISTANCES IN DECIMAL FEET
A 8
D W EL� NG 1 15.5 27
2 19.5 21.5
3 35.5 35.5
A 4 45 50
8
1000 GALLON
SEPTIC TANK Elk THIS SKETCH IS
BEST VIEWED IN
3 DISTRIBUTION COLOR FORMAT
BOX ZE
LEACHING n
> rn
40 O
w
GALLERY > Z T
rn
1995
THREE PONDS DR§VE 508 364-0894
I
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15
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: 5/14/2001
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows bottom of system is 5 feet above the
adjusted high groundwater elevation
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 66 Three Ponds Drive-Assessor's Map 173 Parcel 69
Property Address
Mikhael Rizkin and Irina Spektor
Owner Owner's Name
information is Centerville MA 02632 May 14 2016
required for every y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
T
Town of Barnstable
oFVE
Regulatory Services
BARxSTABIA ; Thomas F. Geiler,Director
ArE1639. Public Health .Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-8624644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
not does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
a
COMMONWEALTH OF MASSACHUSETTS
z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
> d DEPARTMENT OF ENVIRONMENTAL PROTECTION
G^ SJey
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 66 Three Ponds DR
Centerville,MA
Owner's Name: Ken Steele
1w
Owner's Address: 66 Three Ponds DR
Centerville,MA 02632
Date of Inspection: 4-10-08 ,� } -7)
Name of Inspector: Darrell Stone
Company Name: Cape Cod Septic Inspection
Mailing Address: P.O.Box 1466 l
Harwich,MA 02645
Telephone Number: (508)240-2500 t. .
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below
is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Y Passes
onditionally Passes
eeds Further Evaluation by cal Approving Authority
ails
Inspector's Signature: Date: 4/10/08
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)
within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,
the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should
be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority.
Notes and Comments:
Tank was pumped after inspection
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This
inspection does not address how the system will perform in the future under the same or different conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 66 Three Ponds DR
Centerville
Owner's Name: Ken Steele
Date of Inspection: 4-10-08
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
n/a One or more system components as described in the"Conditional Pass"section need to be replaced
or repaired. The system,upon completion of the replacement or repair,as approved by the Board of
Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exiiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain: _
Observation of sewage backup or break out or high static water level in the distribution box due to broken
or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if
(with approval of Board of Health):
broken pipe(s)are replaced
_ obstruction is removed
distribution box is leveled or replaced
ND explain: _
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system
will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Titles 17-All r,nnnn 2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 66 Three Ponds DR
Centerville
Owner's Name: Ken Steele
Date of Inspection: 4-10-08
C.Further Evaluation is Required by the Board of Health:
n/a 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 .
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Titles '; Tncn—tine Vn� All 3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 66 Three Ponds DR
Centerville
Owner's Name: Ken Steele
Date of Inspection: 4-10-08
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
X Number of times pumped _
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_ X _
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
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.
4
Titles G Incna Ml
ntinn V—411 S/) 1
l
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 66 Three Ponds DR
Centerville
Owner's Name: Ken Steele
Date of Inspection: 4-10-08
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
X Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
X Existing information.For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
I
Titles S Tnc—a tine Fnrm uT ci�nnn 5
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 66 Three Ponds DR
Centerville
Owner's Name: Ken Steele
Date of Inspection: 4-10-08
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): n/a
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 107 53,000 106 51,000
Sump pump(yes or no): No
Last date of occupancy: 4-08
COMMERCIAL/INDUSTRIAL
Type of establishment: _
Design flow(based on 310 CMR 15.203): _ gpd
Basis of design flow(seats/persons/sqft,etc.): _
Grease trap present(yes or no): _
Industrial waste holding tank present(yes or no): _
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use: _
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Discount Septic Pumping
Was system pumped as part of the inspection(yes or no): Yes
If yes,volume pumped: 1000 gallons--How was quantity pumped determined? Weight
Reason for pumping: Main.
TYPE OF SYSTEM
x Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
_ Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
_ Other(describe):
Approximate age of all components,date installed(if known)and source of information:
2001
Were sewage odors detected when arriving at the site(yes or no): no
Titles ; inenartinn V^r 4/1;1')nnn 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Three Ponds DR
Centerville
Owner's Name: Ken Steele
Date of Inspection: 4-10-08
BUILDING SEWER(locate on site plan)
Depth below grade: 27"
Materials of construction: _ cast iron X 40 PVC _ other(explain):
Distance from private water supply well or suction line: _
Comments(on condition of joints, venting,evidence of leakage,etc.):
Apparent good condition
SEPTIC TANK: Yes (locate on site plan)
Depth below grade: 22"
Material of construction: x concrete metal _ fberglass polyethylene
_ other(explain) _
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 Gallon
Sludge depth: 20"
Distance from top of sludge to bottom of outlet tee or baffle: 12"
Scum thickness: 12"
Distance from top of scum to top of outlet tee or baffle: 3"
Distance from bottom of scum to bottom of outlet tee or baffle: 7"
How were dimensions determined: Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tank was pumped after inspection Normal liquid level No sign of leakage Inlet cover to grade
Outlet cover 4" SCH 40 inlet and outlet tees
GREASE TRAP: n/a (locate on site plan)
Depth below grade:
Material of construction concrete metal fiberglass _ polyethylene
_ other(explain)
Dimensions: _
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle: _
Distance from bottom of scum to bottom of outlet tee or baffle: _
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
T;tl- G Tncnartinn l:nrn+�ii ci�nnn 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Three Ponds DR
Centerville
Owner's Name: Ken Steele
Date of Inspection: 4-10-08
TIGHT or HOLDING TANK: n/a (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene
other(explain) _
Dimensions: _
Capacity: _gallons
Design Flow: _gallons/day
Alarm present(yes or no): _
Alarm level: Alarm in working order(yes or no): _
Date of last pumping: _
Comments(condition of alarm and float switches,etc.):_
DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
H-20 DB-5 Cover to grade 2 outlets with speed levelers Normal liquid level No carryover
No sign of leakage Good Condition No sign of Failure
PUMP CHAMBER: n/a (locate on site plan)
Pumps in working order(yes or no): _
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Titles 5 Ir�cr�artin» P^—All siWnnn 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Three Ponds DR
Centerville
Owner's Name: Ken Steele
Date of Inspection: 4-10-08
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: _
x leaching chambers,number: 2
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.):
2(8.5X5.2X2)chambers with 4' stone A Clean dry stone No sign of Failure
CESSPOOLS: n/a (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: _
Depth of solids layer: _
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: _
Indication of groundwater inflow(yes or no): _
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: n/a (locate on site plan)
Materials of construction: _
Dimensions: _
Depth of solids layer: _
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Titles f Tncr a�f;— P—Ail ci'nnn 9
A B C D
2 19-8 21-4
3 35-4 35-4
4 45-0 50-0
5 45-0 44-10
6
I _
1 Dc
y .�
� 1
r 10
^>� '+94..,�na�nrm 1. 1 G.7lVV1
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Three Ponds DR
Centerville
Owner's Name: Ken Steele
Date of Inspection: 4-10-08
SITE EXAM
Slope _
Surface water Pond in rear of property
Check cellar Dry
Shallow wells No
Estimated depth to ground water 5 Feet
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed: 2001
Observed site(abutting property/observation hole within 150 feet of SAS)
X Checked with local Board of Health-explain: Plan on File
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Elevations from plan on File
SAS ELV.61.0
Water ELV.53.0
Adjusted Water ELV.56.0
Separation 5'
Titles G Tncrnrtinn Rnrm ail�i�nnn l l
TOWN OF BARNSTABLE
xrn
LOCATION :`.�3 +. 7lree /oh dS JOB,'✓e SEWAGE # �19 7
'VIL)✓AGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I
LEACHING FACILITY: (type) —a- 5004 .e�4..,d�•j '
(size) a5 -d2 N/;(.: �• ''.
NO. OF BEDROOMS 3
BUILDER 0. -OWNE Xc
FERMITDA 1 Et �.5'..-vkl
COMPLIANCE )ATiJ: - 3 ;e/
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom o€Le'aching Facility Feet
Private Water Supply Well and Leaching Facili
ty (If apy wells eyzist t
on site or within 200.feet of leaching facility) Feet
'.Edge af.Wetland and Leaching;Facrlity (If any wetlands eusc'
within 300 feet of leaching facility) Feet
Furrushed by
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4.
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Yi I Jt
I I;�.y� fPf9,•,
t 5
/n Y
g�y
- 3 3s' 3�
o v y
TOW OF BARNSTABLE
_ O
LOCATION 6 eea.S c SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY 000 ,a c)a F 1
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS ` IL/,
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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) L) Feet
FURNISHED BY C cq t C0,� SS4 <C 465peCf"00
41
A
Dc;v?
EE= .
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1
' TOWN OF BARNSTABLE v �,
LOCATION G,� -71,ee /oh dS Oa.'✓-c SE AW GE # a0l --70
VZLLAGE_ Cp^frr�a!le ASSESSOR'S MAP & LOT
`INSTALLER'S NAME&PHONE NO. S. 116 M
SEPTIC TANK CAPACITY `X%! 'n9 /00& -x,-H A
LEACHING FACILITY: (type) a— 5`a 0� . c .,Q.�,6��s (size) arm[ 13,2 MIX 0? �/Q
NO. OF BEDROOMS 3
BUILDER O1.OWNE � ,sfiP e
FERMITDATE: ���y—O� COMPLIANCE DATE: ` " 7-3-0/
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If ary wells exist
on site or within 200 feet of leaching faci'dty) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
'^
within 300 feet of leaching facility) Feet
Furnished by
� - A
a0;t
3 3
5°
e>
Fee'z
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
RppftCatton for Migogaf *p!tem Comaruction 3permtt
Application for a Permit to Construct( )Repair Z)Upgrade( )Abandon(,, ) ❑Complete System ❑Individual Components
Location Address or Lot No. �1Q y Owner's Name,Address and Tel.No.
C.egTt►�lt:{Z,,�Mtif✓�� ��1►/►�.10 �CL.V11�
Assessor's Map/Parcel
1 Cl
Installer' Name,Ad ress,and Tel.No. Designer's Name,Address and Tel.No.
�'�►V►�.� ( ,p`r AIL "'l<'t STEPHEN J. DOYLE & ASSOC.
42 Canterbury Lane
East Falmouth MA 02536
Type of Building: Telephone: 5 0 8/5 4 0-2 53 4
9 wel ' No.of Bedrooms�_ Lot Size Z L o Z sq.ft. Garbage Grinder( )
Cher Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33 6 gallons per day. Calculated daily flow 33 gallons.
Plan Date MA « 01 Number of sheets I Revision Date
Title Srey.1 lfi= '.-!�j 9-1-0-A AZWM4. 171-MA Foltz_ (.(, x.
Size of Septic Tank V I . T1 Type of S.A.S. -'fit M—ML6�' C4Xp%-AnC-X8
Description of Soil l &04
Nature of Rehr Alterations(Answer when applicable) ` "
I� Date last inspected:
Agreement: 1
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been' su b this Board of He lth.
Signed Date
Application Approved by _ Date
Application Disapproved for the following reasons
Permit No. Date Issued
Av
Fee ��
- Entered in computer
- -T THE COMMONWEALTH OF MASSACHUSETTS
.. PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
Application for-jD oogal *pgtent Congtruction Permit
Application for a Permit to Construct( , )Repair Upgrade( )Abandon( ) El Complete System El Individual Components
Location Address or Lot No.. 7t Owner's Name,Address and Tel.No.
tA
C f LV
�3G tam Y tr iLv»..i_r, b1J►l.1/] 10
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Desi ner's N d el.
r i.: c„� .� g a" ` ly f! bYLE & ASSOC,
l l��i�. rrj 42 Canterbury Lane
East Falmouth, MA 02536
rl�oe of Buildin 't"<yr �,` ,fr ` C -
2534
-" Dw'elling No.of Bedrooms Lot Size Z , G o sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow —,-2,6 gallons per day. Calculated daily flow s 4 �` gallons.
Plan Date h\A.\t kk .'D k' Number of sheets 1 Revision Date
Title ��ttit�i', i=�r � S�}t , +)�l(L 1-kul Fri) .•
Size of Septic Tank l40 F .ti-Yn#.kr, Type of S.A.S. 'T2C�i►�C� " Ct�Ae-nrs`:l�
Description of Soil' !r : arc �'rl=, "�L k
1Z
Nature of Repairs_ or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in o(p((eration until a Certifi-
cate of Compliance has been i sued b this Board of Health. '
Signed Date s-/-y- 0rl _
Application Approved by ._ o r !/'-r1 Date .�1
Application Disapproved for the following reasons t
l
Permit No. if Date Issued
r,
g THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded
Abandoned( )by IT, AI ////9
at 7�/fP 'fa r�/f Z�id v has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction P . yJ.• dated —0
Installer Designer
The issuance of this permit shall not.be construed as a guarantee that the syst ill fu a s desig.` d.
Date 7— 2 ?" z v/ Inspector
No. sVP4 _ Fee +- 4i
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
1=igpo9;a1 6pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair( )U grade( v)A�andon(, y)-
System located at �l T�ir P PQd� f ��r r C .%f_.�. ,11
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Consttrrucctti77 i000nn must be completed within three years of the date oof"tth�i� t. ,
Date: �+' �' (� Approve =ba 'yam``
..
e
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
d
FAILED INSPECTION
t
Y
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION p,
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner's Name: DONNA MELVIN
Owner's Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Date of Inspection: 4/26/01
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS Tp�
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 ,Stipp �?
c�y�TB�4 �O1
Telephone Number: 508-564-6813 FAX 508-564-7270 ti0 AST
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information ported 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
_ Needs Furt Evaluation by the Local Approving Authority
X Fails
Inspector's Signature: Date: 4/26/01
The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health orDEP)within
30 days of completing this inspe ion. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer,if applicable,and the approving authority.
Notes and Comments
THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING,
AT THE TIME OF THE INSPECTION THE PIT WAS FULL OVER PIPE;THERE WAS NO VISABLE LEACHING
LEFT.
****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.
err s11000 t
Page 2 of I 1
1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF
LEACHING,AT THE TIME OF THE INSPECTION THE PIT WAS FULL OVER PIPE;THERE WAS NO
VISABLE LEACHING LEFT.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
D
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
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
_obstruction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26/01
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
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 n/a.
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/Z day flow
X Required pumping more than 4 times in the last year NnT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this forma
X _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 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.
A
Page 5ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26/01
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_ X Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26101
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1978
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26/01
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 1011"
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness:3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: 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.):
THE SYSTEM FAILS,THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING. PROPER
MAINTENANCE FOR SEPTIC SYSTEM IS TO PUMP EVERY TWO YEARS.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
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
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
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26/01
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): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
n/a
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
I °
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT IS FULL OVER PIPE,THE PIT HAS NO
EFFECTIVE LEACHING LEFT.
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 or no): NO
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
4
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
Fool
A I
4h �S
48 3
in
Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 THREE PONDS RD CENTERVILLE,MA 02632
Owner: DONNA MELVIN
Date of Inspection: 4/26/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
•� I
C
,l
No.............7.T..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
lc% .. ..............OF..../�✓W.5.7 �. -..
Alipti:ration for Diipnaal Vorkg Tomitrnrtiun thrififf
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy tem at:
!! ..... .!x . .....�..tl_ll . .... ------ .�i� ---- --------------------------------------•--
• --
Coca' •A ress or Lot No.
. ..................................... .............. -- .......... ...
W S.S�lC�r=._. Wn- .SG. � t�f��`�' .... Addresc�e�L�'F✓. .................
a Installer / Address
< Type of Building Size Lot..,.9r,R 0. ,...Sq. feet
U Dwelling—No. of Bedrooms................. Expansion Attic ( Garbage Grinder
Other—Type of Building ...., f ....... No. of persons.....__-------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures .............. -._______
W Design Flow...... Q.......................gallons per person per day. Total daily flow.._..._-�Q._....................gallons.
W Septic Tank—Liquid capacity/_gallons Length....6Q------- Width--- Diameter________________ Depth................
x Disposal Trench—No.--_-----_---..._-- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------I----------- Diameter.................... Depth below inlet................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing k ( )�� -. (? /VC/k
.-.
Percolation Test Results JeSsPerformed b -. Date... ....`15....._Z ....
,a Test Pit No. LAP......minutes per inch Depth of Test Pit...../�_....... Depth to ground water........................
Test Pit No. 2...�:.9....minutes per inch Depth of Test Pit....Z..!E....... Depth to ground water.�,W' i.� 4i'
Rai r ��.... ---•----.•••.. ............
.. ........... �v
-...` `..
i7G!
0 Description of Soil. .a--............ .. o r. .......
...
l pZ .�L°C s1 - - ....
x
U -------
•------------------
•----------------------------
•-------------------------
---------
---------------------------------------------------------------------
-.--------------------•--•--------------
W --------------------------------------- -------------••------------------••----.....•--------•-•------•-------...-----------------------------------------------•....-----------•----•---------•--•----
VNature of Repairs or Alterations—Answer when applic .......
------------------------•-•------•-----------•---•-•----......------•-----------...._...................•---...-•-----------•-•------•-----------------•---•--•--••---•-•-•-------............_.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT?:;::. 5 of the State Sanitary Cod — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be iss d th ,bo alth.
Sied- ••---•-•------------- ............................................ .........................
/( Date
Application Approved By...... ': teA
L� ..................... /rT ,
D
--
ate
Application Disapproved for the following reasons:----•----------------------------•-•----------------------------------------------------------•------.........--
-•••-•--•-•---•....................•------•---------•------•--•••-•---------•-•--------••----••---.....•-•--------•----•----•---------•-----------------••-----........................................
Date
7
PermitNo......................................................... Issued....1 ..............................................
Date !
r
No....-� .�177... . - - Fxs..... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
o . /Il-
........................
_
Appliralion for UWpatiFal Workii Toniiratrtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: //�
..................................................................................................
Location Addresses or Lot No.
/ Owner f Address
... - ........:.:....................:. .
a Installer r Address a
dType of Building Size Lot___� d�.-��� ....Sq. feet
Dwelling—No. of Be drooms............................................Expansion Attic (.✓) Garbage Grinder (�('�)�
Other—T e of Building
g ...._...j----.'_.:" _._..... No. of persons.__.__ ............... Showers ( ) — Cafeteria ( )
al Other fixtures .............. :................
W Design Flow........�_.-"�.. .......................gallons per person per day. Total daily flow_......_T' _:��_.___._.._____.__...__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.__._____I.......... Diameter.................... Depth below inlet.................... Total leaching area.__.-._____--_----sq. ft.
Other Distribution box ( ) Dosing tank
j Date ��................................
a Percolation Test Results f Performed by._....__T__.`�_;,.,..;_:..__e.................
Test Pit No. 1.A.v....__minutes per inch Depth of Test Pit.....!. ........ Depth to ground water.........................
- r
LL, Test Pit No. 2... _ ?....minutes per inch Depth of Test Pit.... ........ Depth to ground water .................... -
r . - ,rT-
Descriptionof Soil....Z`-!--------r-----...............•-..------......= _......----'.-------•-- .....--:...........�.......................... -. -------•-----------------------
x
W. •--------------- -----------------------------------------------•-------•----•----••-•-•-•--••--••------•--•--------...........---••-........••----•••••--••--•-•...----........._....................._
UNature of Repairs or Alterations—Answer when applicable.-w-. ...................................................................................
............................-..........................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'a iE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the ,booaard.of,health.
Sighed..� _�/---=-�)----- ---- .---7--------
r Date
Application Approved By--------••-•. ' l t� ....7=4�---------7 t......
Date
Application Disapproved for the following reasons----------------------------------------------------•----------------------------------------------............
-•...................•--•-....---•------...-•--------------------------•--•--•----................................................... ------------------------------------------------------------------
Date
PermitNo......................................................... Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`' all......................OF.........1...r�.� ...�.........f......................................
..............
(9rdifirFa#r of Tootph anrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
-- �----•-----•-- ---------•-•------- -•------'i---------------------------------------------`
Installer I
at................................ ......• .---•-- --- .......... .... ........................................................... f ------.
has been installed in accordance with the provisions of 'UTr 5 of The State Sanitary Code as described in the
Yy
application for Disposal Works Construction Permit No., ................__ .7................. dated------ _---_-___-__-_.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FU CTION SATISFACTORY}
�" �. •. ............................................�,.., X ¢ .. ..
DATE n Ins ector .i
Y ry.* `. � `.���t Ry✓ t�',�.`� r -t':5r1r<J.A�•w �s�`'� ns.-}, ,w.-� �{ -,¢ �' +,.. ; - - � +'+ .� -
"'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�%
71 3
No.......... ./'......... r FEE........................
to rrottl Work$ Tonotrur#ion rranit fi
Permission is hereby granted.... ws :..T---1 ---
to Construct ( or Repair ( ) an Individual Sewage DisposalSystem
at -----••-- ..........................••---•-•---••--------.-•--•-•-----------•----------•-•-•--•----••---•--------•---•--•••----------•-•......•-•••-•••••
r Street
as shdlwn on the application for Disposal Works Construction PermitgNo______ _____________f Dated----7-�k__...7 ------------
`//.�GvL l
"t DATE../.A �=---� 7-�-•••-•-•-•--•--..----- Board of Health
FORMr 1255 HOB WARREN, INC., PUBLISHERS
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a r. I�pPERT /F/N ,C7R/VEy1/AY u 4
CO/VC�ETE
29
A Co✓Efz CL EA/V SAND
eAC/CF/LL
,, - L/QUlO LEVEL - �''•
t _ 2LAYER
d�.. w > - - ✓2.rlw• - ..
CAST Ql� 1B - �B
/ 8
it IRON
MIN. �TCN e 0 D GAG. p/ST, a o 1 • o • i.• • ' o "A� WA5HEO S7YJNE
/4"P--/s SEPTIC TANK• �' O h 0 1 • • • • • • 1 1 6 0 lu y
BOX 'C 11 8 1 • • 1 • 1 n°0�• ' -
r n . EFFECT/V .1_
:a y • c ► 1 •,D&PT{-/ -•.• ' ° o 0 WA5HED STONE
::a:.. P o o1e • • • s • 1o ' fo � 0
° v. ,a e • • •' s ..•" • • p y PRECAST SEEPAGE
'•. �V/v.
!N6/BR'T.ELE6/�iT/ONs - v � o � e • .• '� , e '� • � e • e to P/TOR .
/NYE•RT AT BU/LD/NG 63. 0 FTtT
FT. O/AM. �(� SEE T�IBULATION>
/�C ET'SEPT/C TANK
OUTLET SEPT/C TANK '� 2' FT. i r
/N,(,ET DISTR/A5!/T/ON BOX G Z•0, FT. GROUNo WA7l Eff TABLE
OUTLETD/STR/B!!T/ON BOX. SECT/O/V.OF" y
//VZ6T LEacN/NG PiT Fr SELVAGE AV/SROSA L SYSTEM
LEACH//VG P/'T T/16ULATlD/V
DIMEN3l,0_N A
DES/G/V CfZ/TER/A ScAL.E ,: �4•� _' / -O~ D/MENS/(3N $ . FT.
NUMBER OF BEDROOMS 3 ;. ; D/MENS%ON C FT. A, �N
GARBAGED/SPOSAL UN/T SD/L_ LOG SO/.L TEST
.. TOTAL EST/MXr"=D FLOry 3 30 G.ac./DA.y _.SO/L TEST */ SOfL 7ES7*2
%NUMBER OF Le°`ACN/NG /�/TS__L_ EL -7 r•P pATE"O)=, SO/.'L TEST
y 13, i✓.KrS
SLOE LLACH/NG PER P/T / �� SCt FT. U_ 2 U , RESULTS PW7 A E°SSED dY T� = •
90rTOM 1.E4CH/NG/PER P/T 7 $Q -77 [ o 04 n 1 - L.p.f}r✓� f'E�COLAT
TOTAL,lEACHINCP.AREA 2-& 6 So FT. 5 agSv/L Sue S-o> PIERCOL A7.,oN RATE AL-2 1 M/N,�1"IIVCH�
2 cJ.
- G RESERYELEAC'NlN6.AREA 2.G (� SQ FT. , :- -
-
/Z
i
2 2 / Z
l..4 ays ss► //�- -M�� v n� L 0 7 /l �Ti'f/ZC Pon/O s lv�er v.E _
�r(,A ., J'�P ` •fZ RJ1✓E L S/tom!!a - . } ,`c
CC
%W 7 _ ".,
ROBERT, �, _ E"/c�/LL-E,
rn
{` S O �...,.UN KIS
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No 16
No
' o F St �``,.. £, ! �t 3,e ^ v�q D } s; r w 7/2 MAr/y ST 33,N_ D:MA/M S'T
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• r. NO 6 Of1Ny}ye19 E°� E�/VCOCINTRt*s0 �- ,, I+YAN J MA s3 _SO Y,d R»90uT/!,MAS.
<
i6 7 Q_7
,JQB °D SHE:ET 2
''•, t'4 � v .} ,' � +. ^f'k 1 - t'i acres "iH "
7-5
LOICATION SEWAGE PERMIT NO.
L , it 7 A on- loo is V Z Z
� i rrrl .
INj,S, TA LLER�'S rNAME i ADDRE-SS
r
v
S U I L D E R OR OWNER
w
C-
DATE PERMIT ISSUED ,
DATE COMPLIANCE ISSUED ,
r
e �
o-
k0.+ at r
�
Lows
�, !7 s Lo r G 9 -`#--
4 7 rz
-20
k `
� N l2-
r _
t
60-00
of
r
�0 r'�'
r' L
l
Q TE /Gl/��. ��r 175
- t4•:
4w
7700
• k L��..G71t���•J�f' l ir�ie��G`s'�'J—�fr"•>'F".: -4 � �.�� '� ;r� :{ ; ''� e
i � ,
t
T 717- IV 7-7,
TOP FOUND. EL G(.• 0 1. 00
P
S80 V6'p5
V �1� ...-t_
INV. EL. >rx��• �GNva+N ` ' ___ M_.._._
FLOW LINE
WATER TIGHT COVER TOTAL AREA = 29,602 sq.ft
0 MIN. _ —C: FIETLAND AREA = 15,390 sq,ft.
---.._._. INV. EL. 2' LEVEL UPLAND AREA 14,272 s ft.
- - 10, MIN. / �.�___ J•. 4 UWtD DEPTH r`;'..,vie
,� �- �� -- Total Trench Length ?? 4
ltrashed Crushed Stone
INV. EL. _»�i�2�M�>4_� `. + L •C01N� • • no -
L__ _• .� INV. EL [�,
Q� ✓
_.... •mil/
Inv El. -'�
00
C� C= c_� r- c� �� c� c� c'� , o El.
and
Vo, of Trenches _ l___ r - o
52
PRECAST REINFORCED CONCRETE No. of 50:1 GaLlIon Precast Chambers `�- g•
MiN1MUM CONSTRUCTION MATERIALS PER 310CMR 15.226(2) DISTRIBUTION BOX
314" - 1.-11,2" ➢Mashed Crushed Stone �w T�trFTLA-ND V
TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND h'- ZO l_ep17 �� ` ,�'j7----
SHALL EXTEND A MINIMUM OF 6" ABOVE THE FLOW LINE INSTAL ON A LEVEL BASE ��1 , l �N W At�'IL :_._..__ ---
_ 54
OF THE SEPTIC TANK' AND BE ON THE CENTERLINE OF 'THE �EL.S•3.o �por>p� C='
SEP71C TANK LOCATED DIRECTLY UNDER THE CLEAN-OUT MINIMUM WALL THICKNESS 2-
MANHOLE. e
MANHOLE
, r r
MINIMUM INSIDE DIMENSION 12"
THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2' NOR
52
MORE THAN 3` ABOVE THE INVERT ELEVATION OF THE OUTLET INVERTS SHALL BE EQUAL 70 EACH
OUTLET PIPE. OTHER AND AT 2" MINIMUM BELOW INLET INVERT.
THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX , 56
ON A LEVEL STABLE .BASE THAT HAS BEEN MECHANICALLY SHALL ALL HAVE EQUAL INVERTS A5 DETERMINED BY FLOODING
•r . . — a.r` r r
ON
TANK SHALL BE INSTALLED LEVEL AND TRUE 70 GRADE THE DISTRIBUTION BOX TO THE HEIGHT OF THE DISTRIBUTION
COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE LINE INVERT AFTER ALL LINES HAVE BEEN SEALED IN PLACE. 2 of 1/8 - 11,2 Peastone 54 �� -. - �
HAS BEEN PLACED TO ENSURE STABILITY AND TO PREVENT INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH DURABLE -
SETTUNG. AND NON-DEFORMABLE MATERIAL PERMANENTLY FASTEND TO THE
LINE OR RECONSTRUCTING THE LINES UNTIL ALL INVETS ARE OF °�o°p 5B
o°`Qo° •• m� — " t1JT9
SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9'. EQUAL ELEVATION. �$ � 56 •_ ,,.•- '' ,-' eck _ _ .... - r
THREE 20` MANHOLES WVIT}I READILY REMOVABLE IMPERMEABLE' o
° `� N �' o Abo _ ! 100' Buffer
COVERS OF DURABLE MATERIAL SHALL BE PROVIDED WITH ACCESS
PORTS BEING PLACED AT THE CENTER AND OVER THE INLET AND 60
' - � � i` °
C►+JTLET TEES. _
• Trench ird th 1 s:L
68
THE OUTLET TEE SHALL BE EQUIPPED WITH GAS 6A, FLE. 3/4" - 1-1/2" yl'ashed Cr us ed Stone g1`,'-ri�,n—
' ._____ � n •tip^ _ .
.PROPOSED S. A. S. TRENCH SECTION -
H pBales ti 62
60 -~
--62- ` r _ - . _ - ' Assessors Da ta:
--64. . �,�` ,w \ 64 Map 173-69
�. . . .`. - 36 `
o. . . . . . . - Record Owner:-
. . `t! r r \ �� / Donna Af Melvin
ExIsting Tank To Remain ,.. . . . . '.' .'•••'•• •••,•••••,
. . . . . . .o- ! 66 Three Ponds Dr.
GENERAL CONSTRUCTION NOTES s ';r. Q,:.. • . . . `:i• " 66
Centerrille, MA 02632
Hap Bales . . . , • '► '' ,
Note: 70 �. i. ` v'6,i �' • •� ` \ , FEMA Da ta:
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 DESIGN DATA: \ % '. .' Zone "C"
AND THE TOWN OF S.:z,P�Qz,I,��_p�t-~=_ RULES AND REGULATIONS FOR __- _ _ .
E.aUsting Leach Pit Shell Be Pumped y �
' ` And Filled nth Clean Course Sand. 68 , s Deed Reference,
THE SUBSURFACE DISPOSAL -0F SEWAGE. STRUCTURE >=�.�s�•""�7w�w�cr 3 1`Jo 72 '
TYPE 0 BEDROOMS GARBAGE DISPOSAL � �;'':'�'• ,'' ` � \ tv i ✓ 7551 160
2. AT LEAST ONE ACCESS PORT OVER TANK TEES SHAD_ BE ACCESSIBLE DESIGN Flow Note.• water line shall be relocated 74,
WHITHIN SIX INCHES' OF FINISH GRADE WITH ANY REMAINING ACCESS 3 '`L" 3� ��� -�' s- a min. of ten feet from SAS22 + . ` PV9669 Plan Reference:
PORTS BROUGHT TO WTHIN TWELVE INCHES OF nNISH GRADE. - L ` 328-1 -
d
76 pose 'ate — ,Z � � � . ` N, 70
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF Trench
Drive --'"�°�, . •
GRAPHIC SCALE
WITHSTANDING H--t 0 LOADING UNLESS THEY ARE UNDEP, OR WITHIN 10' 76 s paved
OF DRIVES OR PARKING. N--20 LOADING SHALL 8E USED UNDER OR WITHIN SEPTIC TANK (pOp GT La1� �iz���s.� rb �Z y.�a��, � 20 0 ,o ,w so
• 27
10' OF DRIVES OR PARKING UNLESS NOTED. III _ . . . ►` `
LEACHING FACILITY n ,A< 'T"-rL�N L�} 80 , �
4. THE EXCAVATOR/CONTRACTOR SHAH- VERIFY THE LOCATION OF ALL
SITE UTILITIES PRIOR TO ANY EXCAVATION. � IN . } '' a •---------------- '72
s�o 3 t zS"� ZS��L t Z 1 inch 20 t ` $ 578�55,18,,1� -1 ��l�+ �,4
5, SEWER PIPES SHALL BE 4" SCHEDULE 40 PVC LAID AT 0.02 SLOPE. `I �Z W�'�' '`+ t
�ot-r• 1'3.,1_ bt_ 'z S'O_ — "3'S o
S TO BRING COVERS TO GRADE SHALL BE 9�Zk o ,`�q 3y(o ��w . �y�� =_��cr� ��o�� BO ' El. 75 60 VD
6. ANY MASONRY UNITS USED
N 7P3
MORTARED IN PLACE. - G -
B��: CB RIM a t��N°
7. FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF 0.02 FEET nFR I�OnT.
CB Rim .-----
Sewage System Repair Plan
SOIL OBSERVATION DATA:
Prepared For.
66 T.h re o Ponds Drive
TEST DATE �� o�, d 0 Note: Should soils be encountered durit� ins g y_ g fellation of Sewage system the are In
not before procent with soil logs,contact the designer and/or your local Health Department
SOIL EVALUATOR �!�\t-� ,mot L�ees ���n�1 Centerville, MaSSa ch use t tS
B.O.H. AGENT --� • '1-••�rz`�.n,�Sy L
EXCAVATOR Scale: I" = 20' Date: .Map 11, 2001
/ Zz J•,� Prepared .8y
PERc RATI ` a s I� Stephen J. Doyle And Associates
t 42 Canterbury Lane, E Falmouth, MA '02536
Telephone: 508,1540--2534
-T.7�1;- Jll Ii �l� . O •�•.7�1� l' �l - . 4. � AfIt
J.
°'.•� g 7,S_ 2 "� DOYLE
• ; 7 p, fin.\ •-per � S.� �': �
e
-- NO. DATE DESCRIP77ON BY