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0015 TOMAHAWK DRIVE - Health
1.5 TO1*ahaw Drive Centerville A = 190015 kv SMEAD No. H1630R UPC 10259 smead.com • Made in USA V&cvct4b -e �n Sq ,p2 r RM k TOWN OF BARNSTABLE LOCATION SEWAGE# � VILLAGE �— yj 1i Qi" ASSESSOR'S MAP&PARCEL JJ0111 INSTALLER'S NAME&PHONE NO. �, 0� S cA q ,.(, SEPTIC TANK CAPACITY _^`G� LEACHING FACILITY. (type)`�.1 JA—I Cl lea (size) t X]?1 NO.OF BEDROOMS A OWNER g.A/leN PERMIT DATE: Z) , COMPLIANCE DATE: �CI Separation Distance Between the: ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY CL R�,K o� i TOWN OF BARNSTABLE LOCATION DMAAAW k SEWAGE# VILLAGE CG/1 Vy,14. ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY Ct S S p Qp 1 LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3n 1 OWNER l�/� r 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) Feet FURNISHED BY = r1 Se6G1�pn � FOr� Balk � 1 t � ► 1-10 So a- 30 31 Z� ��z- No. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitation for Disposal Opstem Construction 3pPrmit Application for a Permit to Construct(�/�Repair( ) A.Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.i S pa 1��;4.�/� � Owner's Name,Address,and Tel.No. ,/�n �t—ids— Assessor's Map/Parcel i j t\W%j Installer's Name,Address,and Tel.No. - Are-7 Designer's Name,Address,and Tel.No. j�� Ca�� r�L�• 62 afar 1_4 #N . ti'r y iAPA Type of Building: Dwelling No.of Bedrooms 3 Lot Sized /, i , _sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) P gpd Design flow provided gpd Plan Date 'D ��A%Q Number of sheets Revision Date Title Size of Septic Tank M4-�A 1�O� Type of S.A.S.CA� V—t f% SA Description of Soil q R � Nature of Repairs or Alterations(Answer when applicable) n/C-w 5Vsa-,o Ono 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 and not to place the system in operation until a Certificate of Compliance has been issued by this Bo of ealth j( Sign DateQ11.,.1 lei Application Approved by Date c Application Disapproved by Date for the following reasons. Permit No. — (1( 7 . Date Issued 1 '�,1 '—_f _ ---' �— ------------ --------------- No. Fee, THE COMMONWEALTH OFWASSACHUSETTS Entered in computer: r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21pplication. for Misposal 6pstent Construction 3oermit Application for a Permit to Construct(V}ll'Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Add ess or Lot No.I'S korRal�a Owner's Name,Address,and Tel.No. Vr i X o f y c--�v� . Assessor's Map/Parcel �C�„ is ( �, �114 CS t\�C�+;�, 5�f 4La, i ao•i q C.t � Installer's Name,Address,and Tel.No.+or-j ttl�.lW� Designer's Name,Address,and Tel.No. hU yd � Q. �*eru��pai;i /o$ :.vr Sfit tt..sr ��'� - �MrS nn+� �+.;�.�" �SP$� �1,LSt-c.i•77 `t .,B'! -711-14.1-PA Type of Building: Dwelling No.of Bedrooms Lot Size ka*T sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ', gpd Design flow provided gpd Plan Date 0 0 11 P ,4 Number of sheets , Revision Date ` Title _ Size of Septic Tank -^ �� -p J/�.t,sJ ,� y'C!> Type of S.A.S.( l�.� k�- �. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1h� �� Date last inspected: Agreement: The under signed agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ealth. )(, Signed Date. 01 jq Application Approved by Date Application Disapproved by' Date + r W o r for the following reasons Permit No. ;7')I d 6 7 Date Issued 1 �-91-7 1 _ ,_ __.. - --- - - - --- - - -- --- -- - -- -- -- --- --•------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS 6. MASSACHUSETTS. BARNSTABLE, - -- -- -- -- _ Certificate o tnp Lance - TIES IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( �Repaired( ) Upgraded( ) Abandoned( )by +A �.. It - U- - If^s l Tf.t A at w 1p1 _ l 't, has been constructed in accordce with the provisjji��on//s of Title 5 and the for Disposal System Construction Permit No. Q.�(}/,^�_dated Installer ,// Designer �� #bedrooms kpproved.design flo- f" _j gpd The issuance of this permit s13a/11 not be construed as a guarantee that the system will function as de igned. Date / /� �f//f Inspector , ---—-------------------------- - - - ------------------------------------------%---^---------- No. /9 Fee J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Misposat 6pstem Construction Vermit Permission is hereby granted to Construct( Repair( ) Upgrade( ) Abandon( ) System located at 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 jocal provisions_or,spec ial conditions—,, Provided:`Construction must be completed within three years of the date of this permit Date ( /:/z0 / Approved b -- -- �. . Town of Barnstable 'THE Regulatory Services Richard V. Scali, Interim Director sAaxsrnaLE, ` MAN. ` Public Health Division 03ig. iOrFnn►n'�°' Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Sewage Permit# Assessor's Map\Parcel Designer: ��ra' /qc-41,vd Installer: Address: Vv of�ee_ Pr t wL Address: rX 46V P4 A On was issued a permit to install a (date) (installer) septic system at 15 /o MA1*WV 4 based on a design drawn by / (address) dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow i requi ) was inspected and the soils were found satisfactory. I certify that h stem referenced above was construc c ith the terms of the I\A a al letters (if applicable) d Scott A. ro o McGann (Installer's i ature) U #1224 °0 4 (Designll Signature) (Affix Desig Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc Town of Barnstable P# f 5: cg Department of Regulatory Services An Sri ,,,u,gi,�� r Public Health Division DateD MAESL r+:r 200 Main Street,Hyannis MA 0260i P•.:.I Date Scheduled 16/V Time 1� Fee Pd. C 'S Soil Suitability Assessment for S e Disposal= Performed By:_ sGn t' �1 ,�� Witnessed By: �v LOCATION&.GENERAL INFORMATION " Location Address / (A t9✓'IVY. Owner's Name -� CeVI kv v'l/ �{ Address''1 315 IP>n11 / „�CQ ejK6+ l Assessor's Map/Parcel: o / T Engineer's Name 5 ,o ` NEW CONSTRUCTION REPAIR �'� Telephone �0 6)26,Y —3-7-3 3 . Land Use Y,-r( Slopes(%) % Surface Stones _ Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way .tlzoo ft Property Line 0� ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands fn pmximity to holes) ,.r .) t is t W•J � �t Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: 1pl Weeping from Pit Fpce /V Estimated Seasonal High Groundwater Zr^ DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soil mottles: Ip, Depth to weeping from side of obs.hole: In. ©roundwater Adjustment f[. Index WC114 Reading Date: Index Well level Adj,-thetor, q. Adj.Groundwater Level, PERCOLATION TEST Date Timm /oldu AM Observation Hole# Time at 9" Depth of Perc ,L Time at 6" Start Pre-soak Time @ to;I Z �Z 0 nhe 'lima(9"-6") q:e3r7 End Pre-soak TZ Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)4 Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:ISEPTIC%PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,,Boulders. Consistency,%Gravel) --I Lca'W� i13✓��, Z r •r C Ge4 t1 . -L s y a 3 DEEP OBSERVATION HOLE LOG Hole#—_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% y v ri 91) ci �. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%O DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, Cons' to F - T . Flood Insurance Rate Map: Above 500 year Mood boundary No— Yes Within 500 year boundary No= Yes. Within 1()0 year flood boundary No,T_. Yes Depth ofNaturaIly Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring ervious material? Certification I certify that on CC& . V4A (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 an experience described in 10 CMR 15.017. Signature t, Date 2A Q:\S.I3PT WBRCFORM.DOC �n 0 2016 21:57 Jim The Inspector Man 5085349919 page 1 �a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Tomahawk Drive • Property Address Richard Bloomfield cr; Owner Owner's Name information is required for every Centerville ✓ MA 02632 6-7-16 °•�' 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. Y. Important:When A. General Information filling out forms /i# /� ``\►`�u► OF Igry�, on the computer, J� � \��` �N, Mq use only the tab . I key to move your 1 Inspector: � �•, �y. y O G ' cursor-do not James D.Sears =` JAM ES r use the return Key. p Name of Inspector g, Ca ewide Enterprises, LLC ay Company Name 153 Commercial Street "'94/m5 Company Address Mashpee MA 02649 ka, CItyrrown r 3k State Zip Code 508-477-8877 S1623 :l Telephone Number License Number ,r c S 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 r ❑ Needs Further Evaluation by the Local Approving Authority f s 6-7-16 ' A' orrspector's Signature : Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board ^p 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 i 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 P y the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 a Jun 09 2016 21:57 Jim The Inspector Man 5085349919 page 2 ' r Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Tomahawk Drive Property Address Richard Bloomfield Owner Owner's Name information is required for every Centerville MA 02632 6-7-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The sytem is two old block c pool's 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 exhitration 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 E 1 Jun 09 2016 21:57 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 15 Tomahawk Drive Property Address Richard Bloomfield Owner Owner's Name information is Centerville required for eve MA 02632 6-7-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpsialarms 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 ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (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 ' t,5ins•3/13 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 3 of 17 Jun 09 2016 21:57 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form 8 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Tomahawk Drive Property Address Richard Bloomfield Owner Owner's Name information is required for every Centerville MA 02632 6-7-16 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: ih 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 N,4 ❑ ❑ 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 Y day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 4 of 17 ` Jun 09 2016 21:57 Jim The Inspector Man 5085349919 page 5 44 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Tomahawk Drive Property Address Richard Bloomfield Owner Owner's Name information isequired or every Centerville MA 02632 6-7-16' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped; . ❑ ® Any portion of the SAS, cesspool or privy is below high.ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply_ ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified }° laboratory,for fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, € provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,0009pd. ❑ ® The system falls. 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 Offidal Inspection Form:Subsurface sewage Disposal System•Page 5 of 17 Jun 09 2016 21:57 Jim The Inspector Man 5085349919 page 6 f' Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .•' 15 Tomahawk Drive Property Address Richard Bloomfield Owner owner's Name information is required for every Centerville MA 02632 6-7-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No i. ® ❑ 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 manholes uncovered, opened, and the interior inspected for the condition of the 010ow 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): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewpge Disposal Systan•Page 6 or 17 - r Jun 09 2016 21:57 Jim The Inspector Man 5085349919 . page 7 : S • ii I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Tomahawk Drive ' Property Address Richard Bloomfield : Owner Owner's Name information is required for every Centerville MA 02632 6-7-16 page. Cityrrown State Zip Code Dale of Inspection D. System Information Description: The system is two old block c pool's. I F . I Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No i information in this report.) .I Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2014-54,000Gals g y g (gPd))' 2015-55,000Gal's Detail: y - i Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): Gallons per day(gpd) Basis of design flow(seatslpersons/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: [Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r' Jun 09 2016 21:58 Jim The Inspector Man 5085349919 page 8 f i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Tomahawk Drive Property Address Richard Bloomfield 4 Owner Owner's Name . information fo is Centerville MA 02632 6-7-16 required far every page. City/Town , State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i f z; r , d General Information Pumping Records: Source of information: 1/ 19/16 € 1 Wass stem pumped as art of the inspection? q; Y P P P p Yes ® No If yes, volume pumped: 1000 Gal. gallons How•was quantity pumped determined? Pump Tank Gage I Reason for pumping: Part of inspection W/Cpool's Type of System: ❑ Septic tank, distribution box, soil absorption system f 5 ® Single cesspool ® Overflow cesspool ❑ Privy, ❑ Shared system (yes or no) (if yes, attach previous Inspection records, if any) r : ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest g inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): (Sins-3113 Title 5 Official Inspection Form:Subsurraoe Sewage Disposal System•Page B of 17 F. d _ I. Jun 09 2016 21:58 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , t 15 Tomahawk Drive r Property Address l: Richard Bloomfield Owner Owner's Name information is required for every Centerville MA 02632 6-7-16 page. Citylrown Stale Zip Code Date of Inspection D. System Information (cont.) s' F Approximate age of all components, date installed (if known) and source of information: NA ) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet 8 . 3 Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): i Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC �I Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain) i. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No r; Dimensions: Sludge depth: s t t5lns-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 9 of 17 Jun 09 2016 21:58 Jim The Inspector Man 5085349919 page 10 3 Commonwealth of Massachusetts = Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments y 15 Tomahawk Drive e• Property Address Richard Bloomfield 4 Owner Owner's Name ) information is Centerville required for every MA 02632 6-7-16 t page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) . i Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness i r. s 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.): ' e• B e f 1 F ; Grease Trap (locate on site plan): ) s Depth below grade; feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness t t t 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 "ins•11 a - Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 10 of 17 i Jun 09 2016 21:58 Jim The Inspector Man 5085349919 page 11 s 1. Commonwealth of Massachusetts ( • Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 15 Tomahawk Drive Property Address j Richard Bloomfield i C< Owner Owner's Name information is required for every Centerville MA 02632 6-7-16 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.): . I t t" is I 3' r i 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); I t ; : i Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No i k ; Alarm level: Alarm in working order: El Yes ❑ No t. Date of last pumping: Date s Comments (condition of alarm and float switches, etc.): F' � I 8 fa a_ *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No tSins•3113- - Tioe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 �, i Jun 09 2016 21:58 Jim The Inspector Man 5085349919 page 12 F Commonwealth of Massachusetts j Title 5 Official Inspection Form g Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Tomahawk Drive Property Address Richard Bloomfield Owner Owner's Name information is required for every Centerville MA 02632 6-7-16 page. City/Town I State Zip Code Date of Inspection , D. System Information (cont.) f Distribution Box(if present must be opened)(locate on site plan): l Depth of liquid level above outlet invert No Box i 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.): a #, 3 € I Pump Chamber (locate on site plan): Pumps in working order: a, ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I r S, x i " 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•N113 Title 5 Official Inspection Forth:Subsurfaoo Sowage Disposal$yetem•Page 12 0117 Jun 09 2016 21:58 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts > - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments h 15 Tomahawk Drive ' Property Address Richard Bloomfield Owner Owners Name information is Centerville. MA 02632 6-7-16 required for every page. citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: . ❑ leaching pits number: r ❑ leaching chambers number: ❑ leaching galleries number: ' I i ❑ leaching trenches number, length: i ❑ leaching fields number, dimensions: 3 ® overflow cesspool number: 1 ; ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 7' deep old block c pool w/cover at 17". Level in pool at 2"below inlet line. No sign of over loading. E Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): � Number and configuration 1 F Depth —top of liquid to inlet invert 4" , Depth of solids layer 2" Depth of scum layer 1" Dimensions of cesspool 6'-6' Block Materials of construction ! Indication of groundwater inflow ❑ Yes ® No ) a. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of V i Jun 09 2016 21:58 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts i 4- Title 5 Official Inspection Form ' a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments E 15 Tomahawk Drive ` Property Address Richard Bloomfield Owner Owner's Name information is Centerville MA 02632 6-7-16 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.).- Main pool is 6-6" Deep Block C Pool w/cover at 9". One line in w/no tee. One line out w/tee. Level in pool at outlet line No sign of overloading 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.): 4. �i V 6, L i f . r 8 E yk I4 g„ 7 INns•3113 Tide 5 official Inspeclion Form:Subsurface Sewage Disposal System•Page 14 of 17 i i t 7 i 1 Jun 09 2016 21:59 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Voluntary or-y Subsurface Sewage Disposal System Form Not f Vl a rY Assessments r r 15 Tomahawk Drive Property Address E Richard Bloomfield r, Owner Owner's Name information is required for every Centerville MA 02632 6-7-16 page. CItyFrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: , s ;j t ® hand-sketch in the area below €; ❑ drawing attached separately 3 ' ' f 134�: IV 7, t4 T U, 16 O O 4 a r, r . g i a e , (Sins SM 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 15 of 17 _ Jun 09 2016 21:59 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts . Title 5 official Inspection Form ' o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments << y 15 Tomahawk Drive Property Address Richard Bloomfield Owner Owner's Name information is required for every Centerville MA 02632 6-7-16 i page. Cityrrown State Zip Code Date of Inspection sj D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells I I Estimated depth toltiigh ground water: 14' feet j 1 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 � i ® Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: ' t. 1 b ❑ Checked with local excavators, installers -(attach documentation) j ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: F Ck abutting property. Bottom of pool at 8'-6" below grade. Bottom of pool at 5'-6"above e M 0 Before filing this Inspection Report,please see Report Completeness Checklist on next page. ' t5ins 3/13 Title 5 Official Insped:on Form:Subsurface Sewage t)isposal System-Pape 16 of 17 Jun 09 2016 21:59 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F a' i r 15 Tomahawk Drive Property Address Richard Bloomfield - Owner Owner's Name information is required for every Centerville MA 02632 6-7-16 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked E : ® 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 f f { t t e i i i yh - t P ' 4 9 r. F� 3 ' a 4 3 r Y 15ins•3,113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 15 Tomahawk Drive Centerville. MA 02632 Owner's Name: Nancy Baker 39s.� Owner's Address: Date of Inspection: September 7, 2006 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone.Number: (508) 862-9400 . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information:rreporte,.4 below is true,accurate and complete as of the time of the inspection. The inspection was performe based ony CD training and experience in the proper function and maintenance of on site sewage disposal systems. 'I am a IDEP - approved system inspector pursuant to Section 15.340'of Title 5(310 CMR 15.000). The syaj` : ✓ Passes : Conditionally Passes • Need urther Evaluation by the Local Approving Aut lority Fails E5Cn s cry Inspector's Signature: Date: Sevtembek 12 2006 The system inspector shall sub m 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 ****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 I Page 2.of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Tomahawk Drive Centerville, MA Owner: Nancy Baker Date of Inspection: September 7, 2006 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Tomahawk Drive Centerville, MA Owner: Nancv Baker Date of Inspection: September 7. 2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 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 Y manner that r g 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Tomahawk Drive Centerville, MA Owner: Nancy Baker Date of Inspection: September 7, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 I 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 15 Tomahawk Drive Centerville. MA Owner: _ Nancy Baker Date of Inspection: September 7, 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ 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(arid 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 ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: IS Tomahawk Drive Centerville MA Owner: _ Nancy Baker Date of Inspection: September 7, 2006 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): n/a 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: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAVINDUSTRIAL Type yp of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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): Pumping Records GENERAL INFORMATION Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for.pumping: TYPE OF SYSTEM 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: Installed in approximately 1969(per owner) Were sewage odors detected when arriving at the site(yes or no): No 6 I Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Tomahawk Drive Centerville MA Owner: _ Nancv Baker Date of Inspection: Sgptember 7, 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Cort nents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank) Depth below grade: 12" Material of construction: concrete _metal _fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 5'W x 5'T x 7'bottom to grade Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I" 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: Measuring stick 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 cesspool had 2'of liquid on the bottom The cover was 12"below i7rade. GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSM ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property.Address: 15 Tomahawk Drive Centerville MA Owner: Nancv Baker Date of Inspection: September 7 2006 TIGHT or HOLDING TANK: None (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: ;allons/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: None (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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Cormnents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 f Page 9 of 11 OFFIC IAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Tomahawk Drive Centerville MA Owner: Nancy Baker Date of Inspection: September 7 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ✓ overflow cesspool,number: 1 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.): The overflow cessiool was 5'W x S'T x 7'bottom to grade and was dry The cover was 1 S"below grade There did not appear to be anyst¢ns offatlure CESSPOOLS: None (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: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: .15 Tomahawk Drive Centerville MA Owner: Nancy Baker Date of Inspection: September 7 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at.least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1 l y� S0 a 30 3 10 a ' Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Tomahawk Drive Centerville, MA Owner: _ Nancy Baker Date of Inspection: September 7. 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to;determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150.feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 25'+/ to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system was inspected and passed as of the date of inspection. This report is.not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantee s,s,either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 V J . j Z NEW � DECK W Q (o N CoNcDo 22'-1" 16'-0" 21'-1 1 LLJ M �- c/) WC'J W D_o <4 * V Z>a.U_ NEW M FAMILY CV ROOM (VAULTED CEILING) 15'-0" GAS F.P 6'-8" N N a NEW CLOS <( BAT 00 II W 4Itp W ■ ■ J J a � _ S0"X44'6/� D I V ' N 0 > LL � W _ J � O5'-4" 6'-0" In■ W BATH 0 U DINING KITCHEN O BEDROOM (VERIFY KITCHEN W LAYOUT W/OWNER) 2 FCLQISET W z - - DN GARAGE W rl j - - - - - - - - - - - - - - - O o � z _ Q N OS N O � O 0 W LO El O BEDROOM ® Lo <C LL. BEDROOM LIVING SCALE L SEJ 1/4" = 11-011 FIRST FLOOR PLAN DATE : LEGEND: 12/26/2018 4 DRAWING NO. : M 0 EXISTING WALLS CONSTRUCTION TO BE REMOVED 24'-0" jj� 22'-0" 14'-0" NEW CONSTRUCTION CENTERVILLE, MA CONSTRUCTION NOTES _y o TOP OF FOUNDATION MINIMUM 20" DIAMETER COVERS 3 ° o 1.) ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE, TITLE 5 (310 CMR 15.000): EL=50.0± RAISED TO WITHIN 6" OF FINISH mI aF Stoney Cliff Rd c STANDARD REQUIREMENTS FOR THE SITING, CONSTRUCTION, INSPECTION, UPGRADE, AND GRADE (OR AS NOTED) '---- o �o� EXPANSION OF ON-SITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT EL=49.5± EL=48.9± EL=47.8± 5 of G\e AND DISPOSAL OF SEPTAGE, AND THE LOCAL BOARD OF HEALTH REGULATIONS. Muskeget LOCUS e�cJ 2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE IS POTENTIAL FOR �/�/i�/� \///;� ��\/ !i�,/f� Lone VEHICLES OR HEAVY EQUIPMENT TO PASS OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20 _ O LOADING. IF UNDER AN IMPERVIOUS SURFACE, SYSTEM SHALL BE VENTED TO THE ATMOSPHERE. p �; GEOTEXTILE � o o� 3.) TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS AND D-BOX SHALL BE INSTALLED ON A STABLE 47.2± 44.8 FABRIC e\- MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. H + Waer Norn `IJOy 4.) COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK, THE DISTRIBUTION BOX, AND J Po THE SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN 6" OF FINAL GRADE. LEACHING 47.0± 4 46.0 45.3 F 45.1 FIELDS, TRENCHES, AND OTHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL o 45.8 3/4" to SITE LOCUS �r 1 N 44.3 c\1 1-1/2 STON E HAVE AT LEAST ONE (1) INSPECTION PORT CONSISTING OF PERFORATED 4 PVC PIPE PLACED ! NOT TO SCALE 00 DB-3 (Double wash) VERTICALLY TO THE BOTTOM OF THE SOIL ABSORPTION SYSTEM WITH A CAP, TIED WITH MAGNETIC GAS BAFFLE H-20 Rated MARKING TAPE, ACCESSIBLE TO WITHIN 3" OF FINAL GRADE. TWO (2) 500 GALLON PRECAST 5.) PIPING SHALL CONSIST OF 4" SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A D-BOX 42 3 CONCRETE LEACH CHAMBERS WITH 4' OF MINIMUM CONTINUOUS GRADE OF NOT LESS THAN 2% FROM THE BUILDING TO THE SEPTIC TANK, 15, STONE ON ENDS AND 4' ON SIDES 20'± 4 4--24'± �- 1,500 GALLON Longest Run LEACH CHAMBERS 6.3' 6.) DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4" DIAMETER SCHEDULE 40 SEPTIC TANK (END VIEW) PVC (OR EQUIVALENT) LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED. LINES SHALL BE CAPPED 7.) LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO (2) FEET BEFORE FLOW PROFILE EL=36.0 Bottom Test Hole PITCHING TO THE SOIL ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATER TESTED TO NOT TO SCALE 1.) Assessor's Map 190 Parcel 15 8.) GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES 2.) BK. 29864 PG. 45 IN ORDER TO PROVIDE A WATERTIGHT SEAL. � 3.) Plan Bk. 204 Pg. 117 Lot 35 4.) This property is in the Saltwater 9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE \�� f�` Estuary Protection District DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. 5.) This property is not in the Flood Zone 10.) IN ACCORDANCE WITH 310 CMR 15.221, ALL SYSTEM COMPONENTS SHALL BE MARKED WITH �`�G�o� '�' / ohW MAGNETIC MARKING TAPE. 11.) THERE ARE NO KNOWN WELLS WITHIN 150' OF THE PROPOSED SOIL ABSORPTION SYSTEM. �4 ape ' � �t� \ SYSTEM DESIGN CALCULATIONS f � � Ma 1 12.) FROM THE DATE OF THE INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL RECEIPT OF � ' °c hod Gam` oh pop eg�4 SEWAGE DESIGN FLOW REQUIRED: 3 BEDROOM DWELLING @ THE CERTIFICATE OF COMPLIANCE, THE PERIMETER SHALL BE STAKED AND FLAGGED TO PREVENT `r 9- `� c--moo �y 110 GPD / BEDROOM = 330 GPD REQUIRED USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. ' \. SEWAGE DESIGN FLOW PROVIDED: TWO (2) 500 GALLON LEACH CHAMBERS 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UNLESS WITH 4' STONE ON THE ENDS AND 4' STONE ON THE SIDES UNLESS � �l �� (49.5) c sq� CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE \ \ \ z Vt = [(25.0 x 12.83) + 2(25.0 + 12.83) (2) x .74 = 349 GPD PROVIDED DESIGNER. �1 �\ � House #15 Osr 349 GPD PROVIDED > 330 GPD REQUIRED BOARD OFBOHEADLTOHF AND HEALTH REQUIRES RD INSPECTION THE DESIGNER SHALL OF ALL CONSTRUCTION BY AN AGENT OF THE \ Poved D/w \ 3 Bedroom \ TOF = �49.$) F _ °, CERTIFY IN WRITING THAT THE �, �j �� > Full Cellar _ �o __. _, SEPTIC TANK CAPACITY REQUIRED 330 GPD X 200 SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE PERMIT �, �- `� �� Existing b D kd ti SEPTIC TANK CAPACITY PROVIDED: 1,500 GALLON SEPTIC TANK AND THE APPROVED PLANS. 48 HOURS ADVANCE NOTICE IS REQUESTED. Garage (48.4 A GARBAGE DISPOSAL IS NOT PERMITTED WITH THIS DESIGN FLOW 15.) LOCATION OF UTILITIES IS APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR �._ `�� 495) \ ., 'tyt4s.9) o DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO aadit° , 5T 25.0' COMMENCEMENT OF ANY WORK. THIS INCLUDES, BUT IS NOT LIMITED TO, REQUESTS TO DIGSAFE, ANY PRIVATE UTILITY COMPANIES, AND THE LOCAL WATER DEPARTMENT. 8.5) (49•5) see Note 0t9 Proposed Map 190 4 8.5' 7641 EL 49. Deck Parcel 13 16.) CONTRACTOR SHALL VERIFY THAT ALL WASTELINES ARE CONNECTED BY WATER TESTING T of Concrete step \ (Assumed Elev.) WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. 17.) CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY _ o SAS SEPTIC SYSTEM COMPONENTS. s - _ s� OD 00 18.) TEST HOLES COMPLETED PER STATE ENVIRONMENTAL CODE, TITLE 5. SOILS CAN BE n' See VARIABLE AND TEST HOLE DATA IS NO GUARANTEE OF SOIL CONDITIONS IN OTHER AREAS. IF (47\ \Excovotion N SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS, DESIGN ENGINEER IS TO INSPECT THE (47.4) Hole �/ Note o SOILS PRIOR TO PROCEEDING WITH INSTALLATION OF ANY SEPTIC COMPONENTS. PiTest s Map 190 {`��'} 4.19.) EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND Parcel 16 Z (4T9) �o ABANDONED IN PLACE OR REMOVED AS REQUIRED. AREA TO BE COMPACTED TO MINIMIZE SETTLING. s�. Lot 35 �o D-Box 17,685± Sq. Ft. � EXCAVATION .NOTES Map 190 1) EXCAVATE ALL MATERIAL ABOVE SOIL HORIZON C (SEE DEEP OBSERVAr10V Parcel 115 HOLE LOG) AT APPROXIMATE ELEVATION 43.4, FOR A LATERAL DISTANCE OF 5' /� (WHERE POSSIBLE) IN ALL DIRECTIONS BEYOND THE OUTER PERIMETER OF THE LEACHING AREA. Test Hole #1 (EL=47.9±) TEST HOLE LOGS 2) FILL MATERIAL SHALL CONSIST OF CLEAN GRANULAR SAND, FREE FROM ORGANIC Bedroom t45.a) MATTER AND OTHER DELETERIOUS SUBSTANCES, WHICH M££TS THE TEXTURAL Lo er CRITERIA PUT FORTH IN SECTION 15.255(3) OF TITLE 5. Depth Elev. Y Soil Class Soil Color Comments #2 Bedroo 3) SCARIFY THE BOTTOM SURFACE OF THE EXCAVATION PRIOR TO PLACEMENT 0"-14" 47.7 A Loom 1OYR 3/2 #3 Bedroom OF FILL INTO THE RETAINING STRUCTURE. 14"-30" 45.4 B Loom Sond #1 r of�1 ,I O°' 4) PLACE FILL ONLY WHEN BOTTOM SURFACE IS DRY. Y 10YR 5/6 oO SS, 1 30"-54" 43.4 C1 Loamy Sand 2.5Y 6/3 Living Bath R� 4d, 54"-132 36.0 C2 Medium Sand 2.5Y 6/3 Dining Scott A. (p 5 Note: Garage Kitchen 0 McGann � This plan is only valid for current regulations and may DATE OF TESTING: 10/03/18 Mop 190 #1224 in not be suitable for future regulation changes that may occur. q SOIL EVALUATOR: SCOTT MCGANN � L% t~ Parcel 11 BOARD OF HEALTH AGENT: DONALD DESMARAIS _ Proposed S e C� e w a e D I S O S a System PERCOLATION RATE: LESS THAN 2 MIN/INCH 078" r d s p g p NO GROUNDWATER ENCOUNTERED Floor Plan N.T.S. 15 Tomahawk Drive Centerville, MA I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF ENVISOILREVALUATIONSONMENTAL RAND TIHOATPURSUANT TO 310 THE ABOVE ANALLYSISRHASO17 BEEN PERFORMED Prepared for: Prepared by: BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE GRAPHIC SCALE All Cape Septic LLC Kevin Fries DESCRIBED IN 310 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY INDICATEDSOIL EVALUATION AS IL EVALUATION FORM, fi18 Route 28 SOIL EVALUATION, ASNDICAT D ON THE ATTACHED SOIL EVALUATION FORM, 15 Tomahawk Drive ARE ACCURATE AND IN ACCORDANCE WITH 310 CMR 15.100 THROUGH 15.107 30 0 15 30 60 120 Centerville, MA West Yarmouth, MA 02673 (508) 771-4200 allcopeseptic@gmoil.com ( IN FEET } SCOTT MCGANN, CERTIFI S L EVALUATOR 1 inch':= 30 ft. Date: 1/03/19 Sheet 1 of 1 By. MA Check: ;;F Project No. AC-149