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0057 WARWICK WAY - Health
57 WARWICK WAY, CENTERVILLE - A= 171-100 6 �.'. NO. 0 a Fee CJu THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for �igpont 4p.5tem Con0trUCtion Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. W�C L` w�TY Owner's Name,Address,and Tel.No. cT�rv>u� 6,7 Assessor's Map/Parce �7/�O, -.�-1b9v (feed 7 LZ Jyf� Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. �� Type of Building: Dwelling No.of Bedrooms T� Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �� Design Flow(min.required) �� C� gpd Design flow provided � zi? gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank !000 f �7 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Jc� f/►r, "` I %` Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board oftalth. Sig$b : Date Application Approved by Date Application Disapproved Date for the following reasons Permit No. :2 04— 7-0 Date Issued 7 No. U 1� 5� to { 1 Fee /00 �f w THE COMMONWEALTH O'Fy�VIAS'SACHUSETTS Entered in computer: V PUB�QJC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ;Yes Rpplicatiou for Dioont 6p5tem Con5truction Permit Application for a Permit to Construct( ) Repair(�) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No.j Q Owner's Name,Address,and Tel.No. G Tom, Assessor's Map/Parcel 1,,? Installer's Name,Address,and Tel.No. 'Designer's Name,Address and Tel_lo. g� � 1� � >2/ . //7 Type of Building: Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.yof Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) aj C> gpd Design flow provided �i gpd Plan Date r Number of sheets Revision Date Title Size of Septic Tank s 'OX J Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ./V yU r "�j '�i� 0► d Date last inspected: J., Agreement: I- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of;eAlth. q Sign / Date e Application Approved by A _i f Date ! r Application Disapproved b Date for the following reasons ` _... _ Permit No.��(1���"�u�z�s��` . -Date-Issued� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (gUpgraded ( ) Abandoned( )by at has been constructed in accordance /� j�ith the provisions of Title 5 andththe or Disposa-1•System Construction Permit No. �2 ad I^�J dated / ?IV I Installerili� / /I / r!� Designer #bedrooms Approved d grg-h-\ow gpd The issuance ofth•l pe m t s�all not be construed as a guarantee that the system will u ,i shdesigned. Date Inspector 'W t * + rc3fFfrsi �3r �ssisC�se3tieiseriiseiasiri�i $alai xsyszs—————— No. dd n-! Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Migogal gyp! tem Corrgtruction Permit 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,recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction 7st be completed within three years of the date of t`h p it. p(` Date I I /U�l Approved by CU(_ No (f'Vkr atlo U3�c1 rf C� jr Jl t APPLICANT: I >�C� V V i 1t4 ADDRESS: S 7 WAR yV1Gy— WA`( (�>�1LVLVl LL DESIGN FLOW: 33y gpd REVIEWED BY: DATE: N/A OK NO Le al boundaries denoted [310 CMR 15.220(4)(a)] X Street, Lot, tax parcel number and lot number noted on plan [310 CMR 15.220 4)(u ] X Locus Provided [310 CMR 15.2204 t Plan proper scale?(1"=40'for plot plans, 1"=20'or fewer for components) [310 CMR 15.220(4)] x Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- i not, a variance is required r310 CMR 15.412(4)] X Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d)] X Location all buildings existing and proposed 310 CMR 15.220(4)(c)] X Location and dimensions of system components and reserve areas [310 CMR 15.220(4)(e)] X System Calculations [310 CMR 15.220(4)(f)] daily flow X septic tank capacity (required andprovided) x soil absorption system (required andprovided) X whether system designed for garbage grinder North arrow [310 CMR 15.220(4)( )] X Existing and ro osed contours [310 CMR 15.220(4)( )] �( Location and log of deep observation holes(existing grade el. on each test) [310 CMR 15.220(4)(h)] X Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)] Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] �C Percolation test results match loading rate? [310 CMR 15.2421 X , Certification statement by Soil Evaluator [310 CMR 15.220(4) ')] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Location of every water supply,public and private, [310 CMR 15.220(4)(k)] k. Address w A I-w v—t WA� Sheet 1 of 7 within 400 feet of the proposed system location in the case of surface water supplies and grayel packed public water supply x within 250 feet of the ro osed system location in the case X within 150 feet of the proposed system location in the case of private water supply wells Location of.alI surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins X located within 50 ft. [310 CMR 15.220(4)(1)] Water lines-and dtheF"subsufface utilities located [310 CMR 15.220(4)(m) (if water line cross see 310 CMR 15.211(1) 1 Profile of system showing invert elevations of all system components and the bottom of the SAS 310 CMR15.220(4)(o)] Stamp of designer 310 CMR 15.220 1 and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] >C . Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2)or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] �( Test hole adequate to demonstrate four feet of suitable material? 310 CMR 15.103(4)] X Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] X Benchmark within 50-75'of system [310 CMR 15.220(4)( )] �( Materials specifications noted? [various sections of 310 CMR 15.000] x System components not> 36" deep (unless Local Upgrade Approval or LUA requested)f310 CMR 15.405(l(b) Address tA/412w jUC- W M `E#jTVkYI LQ--I Sheet 2 of 7 r — Size OK? -[310 CMR 15.223(1)] Inlet tee located ten inches below flow line 310 CMR 15.227(6)] Outlet tee 14" or 14" +5"per foot for increase ft depth [310 CMR 15.227(6)] X Outlet tee with gas baffle or approved filter 310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] X Separation between inlet and Outlet tees (no less than liquid de th) 310 CMR 15.227(2) -- X Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5))or permitted for X upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1)and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (b 7/07) [310 CMR 15.228(2)] X Access to within 6 " of grade -one port for systern9<1000gpd, two fors stems>1000 d 310 CMR 15.228(2) �( All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] Y > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done 310 CMR 15.221(8)] K H-20 Where. a ro riate? 310 CMR 15.226(3)] Setbacks from resources 310 CMR 15.211 x Required when other than single-family dwelling or flow>1000 d [310 CMR 15.223(1)(b)] X First compartment 200%daily flow; Second compartment 100% daily flow 310 CMR 15.224(2) and (3)] "U"pipe through or over baffle, outlet of each compartment with as baffle or approved filter[310 CMR 15.224(4)] Address s? W � lj - j , l�/� / Sheet 3 of 7 " Q N - Mal Located atleasi ten feet from any water l me?'[310 CMR 15.222(2) Dis osal i ing at leas 18"p p p b t below water line (when water and sewer cross, see 310 CMR 15.21 l(1)[1]) K Cleanouts required/provided ? r310 CMR 15.222(8)] Thrust blocks specified in force mains?310 CMR 15.221(6)(c)] X Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] X Proper pitch on all runs?(.005 within gravity-distributed trenches and beds) 310 CMR 15.251(9) and 310 CMR 15.252(2) c)] )( Siphonproblem/ leachfield below pump chamber) Endca s or vent manifoldspecified? X Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 k CMR 15.252(2)(h)] Materials specified (310 CMR 1.5.251(5) specifies various pipe types allowed) �( .a Stable compacted base [310 CMR 15.22](2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] �( Riser if deeper than 9" [310 CMR 15.232(3)( Inside minimum dimension 12" 310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity(emergency storage above working=design flow)? [310 CMR 231(2)] X Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20"MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep,with piping, disconnects accessible) Alarm floats -alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and (8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed ?Provided? [310 CMR 15.221(8)] Address �� 1✓V t'`l1 b�l W I I �e � Sheet 4 of 7 15 Calculations correct? X 4 feet of naturally occurring material demonstrated?[310 CMR 15.240(1)] Y .. Required separation-togroundwater? 310 CMR 15.212).] K Aggregate specified as double washed [310 CMR 15.247(2)] •X , System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] x Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] k Each structure with one inspection manhole (if>2000 gpd must be tograde) 310 CMR 15.253(2)] Aggregate I'minimum-4' maximum. 310 CMR 15.253(1)(b)] 2'sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)] Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] 100 feet-maximum length 310 CMR 15.251 1)(a) Minimum separation 2x effective depth or width whichever eater(3x if reserve between trenches) [310 CMR 251 1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] minimum 2 distribution lines 310 CMR 15.252(2)(a)] l Maximum separation between lines 6' 310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e) X Aggregate depth below discharge pipes 6"minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10' minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only 310 CMR I5.252(2)(i)] Address 17V�� °�G R� ���` j Sheet 5 of 7 Pressure Dosed System ? Provided pump and piping calculations as re uired_ 310 CMR 15:220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems undfWmmedial approval [310 CMR 15.254(2) and UA Remedial Use Approvals] If used in gravelless system - make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000 dgood to note on plan [310 CMR 15.254(2)(d)] X Construction in fill - Did the plan specify that the fill shall meet k the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer (310 CMR 15.255(2)(a)] �( Side slope not exceed 3:1 ? 310 CMR 15.255(2)] Ar Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] Y At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMRy15.255 (2)(e)] -Y Check DEP Approval letters for credits and design conditions X' If used with pressure dosing do not allow pressure discharge to scour soil interface � � 2 Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for erpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? }� Has a licant submitted a co y of a maintenance Are the variances listed on the plan ? [310 CMR 15.220 . (4)( ) RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed - [Refer to 310 CMR 15.414] Address K WA� . CV, 1 Sheet 6 of 7 Is the system in a Designated Nitrogen Sensitive Area(Zone I1 for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such x existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR X 15.216(1)] Pumping to septic tank? [310 CMR 15.229] Shared System [310 CMR 15.290 Address �� wlL ""�`"Il `�a` _ Sheet 7 of 7 Town of Barnstable 1'E'°Q, Regulatory Services Thomas F. Geiler, Director HABNSfABLE. MASS. Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 503-362-4644 Fax: 503-790-6304 Installer & Designer Certification Form Date: Sewage Permit# _WfVJ (Assessor's Map\Parcel 17-1_ 0 Designer: DamInstaller: (Xl �Vli��� 1��h�� - Address: Address: �� /J t?r `7 �. On 25 1 was issued a permit to install a (dat ) (installer) septic system at �75� �� WA � based on a design drawn by (address) dated � � O (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 an&'or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or anv vertical relocation of anv component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF MAss�c DARR ME R ( nstaller's ignature) No: 1 0 I /�/ SANITAA�P� CAS 1 S/ v I (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COiNIPL1ANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-26-41doe Town of�3arnstable r���--� �� o`er Department of Rel•tilatory Services r �urrarset$, Public Health IN vision Datc .AS& •6Jy �e 200Main Street,IIyaruris MA 02601 I Date Scheduled 1'inte I nA tee Pd. Soil Suitability Assess»tr.c;n for Sewage Disposal V � ��� C;, Performed By j,,, Witnessed By: LOCATION& GENERAL INIt•OItMATION Location Address•iJ i/y�lQ W 1 1/�/A Owner's Name MA-Ale— EA,-J,9£ S� wAf wI_iV_ VVA� MA Address CENTEIC VJL Lx KAA Assessor'sMap/Parccl: �, / Q� Engineer's Name " NEWCONS1RU!nON REPAIR x Tel ephone# SUSS 362— VIZZ, LandUsc qr i�Cj����li Slopcs(go) ` �. _ Surface Stones Distances from: Open Water Body ft Passible Wet.Arco `� ft Drinking Water Well IZvo ft �` ft Drainage Way � ` �O ft PCOpC;Iy IJnr ft Other SKETCH:(Street name,dimensioris'of lot,exact locations of test holes&pere tests,locate wetlands in proxitnity to holes) \ o c Jo 00 } c ar m0 O0 0 m G „2 k L- 1 O p n } O N O > p Y o J of i< :.1 WAY Q QJ I 01 U ° -- -- ID n O a O lD O �' ix F,,O, lii�1 1 u Parent material(geologic) 0 V I W 44" Depth to Sedroek r.. Depth to Groundwater. Standing Water in Hole: Q Weeping from Pit Focie — Estimated Seasonal;High Groundwater PIP, ---- DI TE TION FOR SEASONAL liaGI3 WATER TADLE N,Icthod Used: Depth db$erved standing in obs.hole: In. Depth to soil 11101d03: Depth toiweeping from side of obs.hole: in. Oroundwttter Adjustment Index Wetl# Reading Date Index Well Icve) Adj.factor,,,,.��- Ad).Ctwundwater Level PERCOLATION TEST Dote $ tY T1t°e----' Observation & Time at 9" 13 A -.----- Hole 0 t u Time at V Depth of Pere —�I-- 0-7 Time(9"-6 .------ Start Pre-soak Time.@ i f ") End Pre-soak Rate Min./Inch Site Suitability Assessment Site Passed Site Failed: Additional Testing Needed(YIN) Observation Bole Data To Be Completed on Dick Original: Public Health Division --- ***If percola�ion test is to be conducted within I IN►' t)f wetland,you must first notify the „__....,.a.ro i Airicetr'vation Division at least one (1) week prior to beginning. DEEP OBSERVATION IiOl,l, LOG Hol e# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. I Consistency,9'o Gravel � DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones, onsis nc %Gravel fit) �. k DEEP OBSERVATION I-IOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, G vel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders. Consistency.%OraveI Flood Insurance Rate Map: Above 500 year flood boundary No— ':,'es Within 500 year boundary No Yes Within 100 year flood boundary No Depth of Naturally 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'? \,i C( If not,what is the depth of naturally occurring perviuus material? Certification I certify that on 0 Ck (date)I have passed the soil evaluator examination approved by the Department of EnAr8rimental Protection and that the above analysis was performed by me consistent with the requ' ed trair expertise and experience described in 3.10 CUR 15.017. Signature JJ `— Date ;5 F Y SECTIONi SENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. .Signature Item 4 if Restricted Delivery is desired. c ❑Agent ■ Print your name and address on the reverse' 1 X so that we can return the card to you. ❑Addressee ■ Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date !Dpli� or on the front if space permits. st 1. Article.Addressed to: D. Is delivery address different from Item 1? ❑Yes If YES,enter delivery address below: ❑No usav� S���e r 5-7 (Naru1 i�k /GYid�, 1er2Y 3. Service Type / A („ ^ O Certified Mall ❑Express Mail v �(J3 v ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number -----—--- — ___�_ (rranster from servlcelabel) 7008 1830 0002 0500 9663 PS Fom,3811,February 2004 Domestic.Retum Receipt - A p 102595-02-M-154o 4 UNITED STATES POSTAL SERVITo -, t✓�; ....s,.�:sue^" F.i[st-Cl�ss..RAaib-�,. tage UeerR4.USPS_ �a e'tmitKo. Sender: Please print�iue n�Te,•Wclress, and#ZIP`+ this-t u"4 ' i PUBLIC HEALTH DIVISI ���.,. ......, TOWN OF BARNSTABLE 200 MAIN STREET HYANNIS, MASSACHUSET-h8l ) j j)) j) � '��1L till 111111111111!l111M111111I11111111111111111111111.1M11111, , Town of Barnstable Barnstable Regulatory Services Department Public Health Division ' ' • 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205009663 7/10/09 Susan Sander 57 Warwick Drive Centerville, MA ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 57 Warwick Drive, Centerville MA was last inspected on June 18, 2009 by Patrick O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health f . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments w„ 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville , MA 02632 June 18 2009 every page. Cityrrown State Zip Code bate of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any t way. Important: A. General Information When filling out forms on the computer,use only the tab key 1. Inspector: to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name VV—w--�j 189 Cammett Road Company Address Marstons Mills MA 02648 ` 'B00" Citylrown State Zip Code 508-428-1779 SI 12855 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 t io TH61rispn was performed based on my training and experience in the proper function and maintenance c on sewage disposal systems. I am a DEP approved system inspector pursuant t' Section 1k 340 o� Title 5(310 CMR 15.000). The system: t,_._ ❑ Passes ❑ Conditionally Passes ® Falls ❑ Needs Further Evaluation by the Lo I Approving Authority ) i ca /�'�\ ( June 18, 2009 Ins ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. **,**This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. I/v 09-108 Sander.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• ge 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w _57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is Centerville MA 02632 June 18, 2009 i required for every page. CitylTown 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: 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 09-108 Sander.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 15 Commonwealth of Massachusetts Title 5 Officinal Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville MA 02632 June 18, 2009 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. 09-108 Sander.doc•08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 officinal Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville MA 02632 June 18, 2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cant.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: " This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy.of the analysis must be attached to this form. 3. Other: 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_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. 09-108 Sander.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 f Commonwealth of Massachusetts W Title 5 Officinal Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville MA 02632 June 18, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 Depaltrhent. 09-108 Sander.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Porm a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville MA 02632 June 18, 2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? M. ❑ 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 br 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 El approximation of distance is unacceptable) (310 CMR 15.302(5)J 09-108 Sander.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Officinal Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville MA 02632 June 18, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate.inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Currently it Occupied 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: Last date of occupancy/use: Date Other(describe): 09-108 Sander.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville MA 02632 June 18, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped 2-3 years ago. 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 8/21/95 Were sewage odors.detected when arriving at the site? ❑ Yes ® No 09.108 Sander.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville MA 02632 June 18, 2009 every page. City/Town. State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ----------------------------------- ------------------------------------------------------------------------------- Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 6" Distance from top of sludges to bottom of outlet tee or baffle Scum thickness 3" 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? Measured 09-108 Sander.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 9 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville . MA 02632 June 18, 2009 ' every page. Citylrown 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.): Liquid level was found at top of tank, soils over tank are damp. 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 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): 09-108 Sander.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page i0 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville MA 02632 June 18, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Informabon (Cont.) . Tight or Holding Tank(cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Full to top. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No } 09-108 Sander.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 iI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is required for Centerville MA 02632 June 18 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: . ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of SAS was probed, stone and soils are saturated. Leaching system is in hydraulic failure 09.108 Sandecdoc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewag e Disposal System g p y m Form Not for Voluntary Assessments 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is Centerville MA 02632 June 18 2009 required for , every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 09-108 Sander.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 57 Warwick Drive _ Property Address Susan Sander Owner Owner's Name information is Centerville MA 02632 June 18, 2009 required for - State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) 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. Front r J / J J ♦ ! / . . . . .. . . . . 0 31 27 53 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Warwick Drive Property Address Susan Sander Owner Owner's Name information is Centerville required for MA 02632 June 18, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: N/A feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 09-108 Sander.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 i DATE:_3/10/00 PROPERTY ADDRESS:, 57•..Warwick Wad!________ -------- ---Centerville�Magg.,_____ ---02632---------------- On the above date, I Inspected the septic system at the above address. This .system consists of the following: 1 . 1 -1000 gallon septic tank. / / / 0 d 2. 1 -Distribution box. 3. 1 -1000 gallon precast leachin nit Based on my Inspection, ig eertify the.followin9 conditions: 4 . This is a title five septic system. ( 78 Code ) 5. The septic system is in proper working order at the present time. 6 . Pumped septic tank at time of inspection. 7. Waste water is 38" below the invert pipe of the leaching pit. /� SIGNATURE: ./ -1_1A Name:_,L,3.,..Hss.smkat•.si�______ Company: Joae,ph_P: Naccmbor_& Son, Inc . Address Box_66 _ __CentervilleL Na__02632-0066 Phone: __508 775_3338_______ THIS CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH"PMA(, OMBER & SON, INC. Tank:•Ce:spool:•Leichflelds Pumped rw Installed Town sewer Connection: P.O. box 6�75.3338erv1775.641226g2-0066 �{ECEIVE® MAR 2 12000 TOWHEALTH DEPT BLE COMMONWEALTH OF MASSACHUSETTS VjEXECUTIVE OFFICE OF ENviRONMENTAL AFFAIRS ` DEPARTmmNT OF ENVIRONMENTAL PROTECTION ONE W1N'fER STREET, BOSTON MA 02108 (617)292.6600 TRUDy Sac ARCEO PAUL CELLUCCI DAVM B. STi Governor C°==-A. SUBSURFACE SEWAGE DISPOSAL SYSTEAI•WSPECTION FORM PART A CERTIFICATION Property Address: 57 Warwick Way Name of o,~Bill Rutherford Centervill ,M s 02632 Address ofOwn+rt ta Daof inap tlon: /187Ob J.P.Macomber & Son Inc. Name of hapeetor:lPtaas+Print) I am a DEP oved sym Inspector pursuant to Section 15.340 of TW@ S(310 CUR 15.000) t,p,,n�o, y Na,t,e: J.P *ta.Macomber & Son Inc, MaXaVAddreu: BOX 66 CpIritpruillefMass 02632 Talephma Numb-: 5 Q 2--Z1;-j •�S CENTIAr,ATION STATEMENT certlty that I have personally Inspected the sewage disposal system at this address and that the Information reported below la true. accufato and complete as of the time of Irupection. The Inspection was performed based on my training and experience In the proper function ano maintenance of on-sits sewage disposal systems. The system: XPasses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails�copyof S49—tors: 7Date:The System Inspect shall submit a thla Inspection report to the Approving Authority(Board of Health or DEP)w1Nn thirty (301 osyr completing this Inspection. If the system Is a shared system or has a deslgn flow of 10,000 gpd or greater,the Uupattor and the system o. ' stall submit the report to the appropriate regional office of the Department ohfnvironmeraW Prvteetion. The original should U,sent to-TV system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND CONIMENTS revised 9/2/98 Pegg lofII �'j rMI*d on R qAW Papa SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART A r CERTIFICATION(condrhued) PropertyAddreas: 57 Warwick Way Centerville,Mass. Owner. Bill Rutherford Dote of M"p."I«" 3/1 0/0 0 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any Information which Indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any fallwe ���--- criteria not evaluated are Indicated below. COfrtl✓<FTITS: B. SYSTEM CONDITIONALLY PASSES: Alf' One or more system components as described In the'Conditional Peas'section need to be replaced or repaired. The system, upon completion of the replacement or repair,u approved by the Board of Health,will pass. indicate yes,no, or not determined(Y. N.or ND). Describe basis of determination In all Instances. If'not determined',explain why not. The septic tank Is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was Installed wlthln twenty(20)years prior to the date of the Inspection: or the septic tank, whether or not metal,Is cracked,structurally unsound,shows substantial Infiltration or sMustion, or u%k failure Is Imminent. The system will pass Inspection If the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. �} Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass Inspection If(with approval of the Board of Health). broken pips(s)are replaced obstruction Is removed distribution box Is levelled or replaced The system fsquired)wmphi more tim-iour-tfines ta-yeardus to broken or obstructed pipe($). The systsm wilt"p-r— Inspection If(with approval of the Board of Health): _.._. broken pipe($)are replacid obstruction Is removed revised 9/2/98 Page 2orit r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA r , PART A CERTIFICATION (continued) Property Address: 57 Warwick Way Centerville,Mass. Own«: Bill Rutherford Date of Insp.ction: 3/1 0/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: . 9D Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PRO]ECT THE PUBLIC HEALTUAND SAFETY AND THE BtWBONMENT: 0 Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less then 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of tammonie nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance •A� (approximation not vaild). 3) OTHER revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 Warwick Way Centerville,Mass. owner: Bill Rutherford Date of Inspection: 3/1 0/0 0 D. SYSTEM FAILS: You must Indicate either"Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of'ewegs irrw feciBty"er*/eten+com n poent d an overloaded orcbgged 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 I t a disfy'bbuu_tior� bove Qutlet invert due to an overloaded or clogged SAS or cesspool. YOU Liquid depth in eeaopeof is less than 6" below invert or available volume Is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for +coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen. - E. LARGE SYSTEM FAILS: 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: -44 The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public i health and safety and the environment because one or more of the following conditions exist: Yes No , the system is within 400 feet of a surface drinking water supply ythe system-ie•wiWn 200 4etof•.&4F;butar"oa surfso"4nkiwg-wator-oupplY _ • . .----• _ _ the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area r IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infognation. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B t CHECKLIST Property Address: 57 Warwick Way Centerville,Mass. Owner: Bill Rutherford Data of trupecdon: 3/1 0/0 0 Check if the following have been done:You must Indicate either"Yes" or "No" as to each of the following: Yes No// ,�/ Pumping Information was provided by the owner,occupant, or Board of Health. None of the system componanu hausimon pusnped4ovatJeast twowo&ka aadtbe'aystem hasbaaovecaiwr+gwaud flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was Inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The site was Inspected for signs of breakout. Ale _ All system components, occluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on•the site has been determined based on:- _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable) 115.30213)(b)) _ The facility ownsr(and.oc_.c,-p-nts,Jf difleraoi lafartaatiomon the ��•�-�p`pe.�rasnt f SubSurface Disposal Systems. ` revised 9/2/98 Page 5of11 I , I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION Property Address: 57 Warwick Way Centerville,Mass. Owrw: Bill Rutherford Date of kwP-6—: 3/1 0/0 0 FLOW CONDITIONS RESIDENTIAL: Design g.p.d./bodrWn. Number of bedrooms(de ig 'v► Number of bedrooms(actual):� I Total DESIGN Number of current residents: Garbage grinder(yes or no):jr Laundry(separate system) ,�Y�s or( ._; If yes, sepa 4%telnspection.required Laundry system inspected ( es o►no) Seasonal use eyes or no): ? Water meter readings,if available(last two year's usage(gpd): ! ��%TT Sump Pump(yes or no):—"., Last date of occupancy: 7! & 'J COMMERCIALAN DUSTRIAL: Type of establishment: Design flow: d ( Based on 16.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no).226* Non-sanitary waste discharged to the Title 6 s st m: (yes or no)& Water meter readings,If available: Last date of occupancy: _44— OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sotIrpe of information: System pumped as part of inspection: (yes or no).i — If yes, volume pumped: lions Reason for pumping: ,.. ATy �2� ✓�/��i'1S yd� 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) 1/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank IV7 Copy of DEP Approval Other j A M��ATE AGE f aLL11 components, date instaN diif known►•and source of4Mermation: Sewage odors detected when arriving at the site: (yes or no44b revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Warwick Way Centerville,Mass. Owner: Bill Rutherford Dab of Inspection: 3/1 0/00 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:_cast iron Z40 PVC At other(explain) Distance from private water supply well or suction line_ M174 Diameter IV'( Comments:(condition of joints, venting,evidence of feak"c-etc.) Joints appear tight No evidence of lPakagP_ S t SEPTIC TANK:_ D9 (locate on site plan) i Depth below grade Material of construction: �oncrete.{bmetatUFiberglassol!pPolyethyleneAAther(explsin) If tank is(note], list ag))e A&I �1ss.age.c�onfirmed by Certificate of Compliance i�(Yes/No) Dimensions: Sludge depth: Distance from top of udge to bottom of outlet tee or tmMi: � Scum thickness: Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottrn of outle tee or baffle:_ How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, structuroHntegrity, eviden of teak ge,etc.) ' Inlet & ou �e tees are n p ace, a an is s ruc u a v souns and - shows no evidence of leakage_ GREASE TRAP: (locate on site plan) Depth below grade:14e Material of construction4mconcrete�U�metaif Fiberglass dePolyethylenePother(explain) Dimensions: Scum thickness: elf Distance from top of scum to top of outlet too or baffle:&, Distance from bottom of scum to bottom of outlet too or baffle:AO Date of last pumping:—A& Comments: (recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Grease trap is not prPsPnt _ revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirwed) Prop"Addreaa: 57 Warwick Way Centerville,Mass. Owner: Bill Rutherford Data of Inspection: 3/1 0/0 0 TIGHT OR HOLDING TANK.A &,,(Tsnk must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade: Material of construction:AA—concreteA/AmetaL/aFlberglasa4QPolyethyleno&,#Other(explain) AAA AIA Dimensions: - Alit Capacity: gallons Design flow: AM gallons/day Alarm present Alarm level: Alarm in working order:Yes/VA No,40 Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) Tight or holding tanks arp not prpgpnt DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidenoe of solids carryover,evidence of leakage Into or out of box, etc.)Distribution box hag nnp l af-pra l Mn guidencia of colids casrreue . No evidence of leakage into nr nut of thin hnY, PUMP CHAMBER:AkAlt (locate on site plan) Pumps in working order:(Yes or No) N4 Alarms in working order(Yes or No),7W Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) umo chamber is not orpspnt revised 9/2/98 pages oriI . .. . . ... . ._ . . . _. .. __ . _. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(continued) PropmWAddre": 57 Warwick Way Centerville,Mass. Owner: Bill Rutherford De"s''&P-eion:3/1 0/0 0 SOIL ABSORPTION SYSTEM(SAS)`!/ (locate on site plan,if possible:excavation not required,location may be approximated by non-Intrusive methods) If not located, explain: Type: leaching pits,number: leaching chambers,number: leaching gallerles,number: leaching trenches,number,length: leaching flaids, number,dimensions: overflow cesspool,number: Alternative system: Name of Technology:_Ti tie Fivp ( 78 Code Comments: (note condition of soil, signs of hydraulic failure,level of pendin damp sell, condition of vegetation, etc.) No signs- of h or In of s are y� VAa 'Minn i c nnrmal, CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to Inlet Invert: Depth of solids layer: Depth of scum layer: Dimerulohs of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of Inspection) esspoo s are not prPGPnt Comments: (note condition of soil, signs of hydrauUc failure...level of pending,condition of.vegetation, etc.) Cesspools are not =rPcanf PRIVY:•�. (locate on site plan) Materjals of construcpon: /irf� Dimpnalons: /-- Depth of sollds:-dz� Commsnu: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation;etc.) Privy is not rPGPnt - revised 9/2/98 Poer9orii I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM WFORMATION(cont)nwd) P.op*MAd&"S:57 Warwick Way Centerville,Mass. Ownw: Bill Rutherford Date of Inspection: 3/1 0/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include tea to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) i Nu f� �Q/ �% Pet to c and ,!3 con l / Alt Dal 417 ---r"' revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C ► SYSTEM INFORMATION(continued) Prop"Add►ess: 57 Warwick Way Centerville,Mass. Owner: Bill Rutherford Date of Inspection: 3/1 0/0 0 NRCS Report name___ Soil Type_ Typical depth to groundwater USGS Date wobsite visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater;J_+ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record served utti o art , bservation hole, basement sump etc.) _ZD.termined from local conditions Checked with local Board of health Checked FEMA Maps hocked pumping records hocked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours Map. Gahrety & Miller Model 12/16/94 revised 9/2/98 page it or it c 5 � ► r •rrnr++-nrrr*-.-rr-trnrmr•nmr.+r�rrt rerrrr..ern'r.++�►r�s.rmm��ne•rni+nr�rwn� T+rrirnr--n--...-.,.-..,` TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I•-1.•••1•T••.'::t-T.ti►-.ITT:1tT�1'R.'TTR/R.IITTT.•1-.S-I r'IIT117IR�1-T���� AA1 •,TrrT"'TT`1• -..A -TYPE OR PRINT CI,EARLY- P1zOPERTY INSPECTED STREET ADDRESS 57 Warwick Way Centerville,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Bill Rutherford PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & SorK 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Tort, or City stet• LIP COMPANY TELEPHONE ( 508 775 - 3338 FAX (508 790- 1578 R A CERTIFICATION FICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and omplete as of the time of.-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : ��Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or' the environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con acted has found that the system fails to Protect the public health and the environment in accordance with Title 6 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date „Q ane copy of this certification must be provided to the OWNER, the BUYERhere applicable ) and the BOARD OF HEAL71H. * If the inspection FAILED, the owner or""operator shall u within one year of the date of the inspection, unless allowed dort required he m otherwise as provided in 3,10 Chln 16 . 305 . partd .doc TOWN OF BARNSTABLE Y LOCATION � % �.0 �C,U �C� I�SEWAGE 4 VILLAGE , ���a VI LL ASSESSOR'S MAP&PARCEL -- Q INSTALLER'S NAME&PHONE NO. /L.4-liQ�fi( ���' SEPTIC TANK CAPACITY �0C) LEACHING FACILITY:(type) �7 ' (size) 54 . NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance etween e: 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 Ieaching facility) feet Edge of Wetland and L-aching Facility(if any wetlands exist within 300 feet of leaching ac'lity), feet FURNISHED BY Az-35 A � - 3IY 83 -39 TOWN OF BARNSTABLE 1,6CATION S-7 War iy°(- C - SEWAGE#-,nSP (Cc, -� VILLAGE &yAt_xryAW- ASSESSOR'S MAP&PARCEL 11 i . I00 I3dST-A44,RW S NAME&PHONE NO. r t C-lL 3;14 0 A r\A l SEPTIC TANK CAPACITY k000 LEACHING FACILITY.(type) (size) 1600 NO.OF BEDROOMS -- q OWNER CX�� PERMIT DATE: COMPHMI DATE:a�.,S 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 leac ' cility) Feet FURNISHED BY \ t \ k \ t t \ Y \ L Y \ L \ \ 1 4 4 1 \ 4 1 k \ L Y \ \ L h \ 4 \ \ \ 4 Y \ t Y•h k Y 4 \'Y \ \ Y 4 Y Y'4 \ Y t \ \ 4 1 \ \ \ 4 \ 4 \ 4 4 \ \ \ \ t o t \ \ 4 4 Y 4 4 Y 4 4 4 4 1 4 \ 4 4 \ \ \ 4 h 4 1 \ 4 4 4 \ \ L \ \ 4 4 4 \ Y k 4 4 4 \ 4 \ 4 t L 4 4 4 4 t 4 \ 4 4 \ \ 4 \ 4 \ L Y \ L k \ \ t \ 1 4 4 \ t \ \ L t 1 \ t t \ \ \ t 4 \ • 4 \ \ \ \ 4 t \ \ 4 \ \ t \ 4 4 \ \ \ \ 4 t \ t 4 \ \ \ 4 \ L t k \ 4 \ \ \ \ \ \ \ \ L \ t \f\/Lltf\f♦/tr\/\ O Y \ \ 4 \ L L \ \ 31 I 27 53 TOWN OF BARNSTABLE LOCATION S7 /,cJQJzcvtc.K SEWAGE # vu.LAGE,Cz--h4er y r i ASSESSOR'S MAP&LOT l 71 INSTALLER'S NAME&PHONE NO. VY117C'�VVj ;S©ri .aL h G SEPTIC TANK CAPACITY 10 0 LEACHING FACILITY: (type)L (size) V00 NO.OF BEDROOMS �. I UELDER OR OWNER i PERMTTDATE: / ' COMPLIANCE DATE: 7C _1 i _ �i o Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 J W I����� 4i 0 / i g Y�� A�a.Lv1�O�/n��7'WYN� Fee �CJ No. PARCEL THE COMMONWEAL PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprico.tion for Migpoml *pgtem Construction Vermit Application is hereby made for a Permit to Construct( )or Repair X an On-site Sewage Disposal System at: Location Address or Lot No. n r ame,Address and Tel.No. CAM IAA w1Ck (,J,4y Wiff►ctwA L "Ou f-�ep4A Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3bSt M P Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when ap licable) y Avo- tea dlm!i PiT AEI b ?ux Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Boar of ealtb. Q Signed Date Application Approved by ' Application Disapproved for the following reasons Permit No. �J �!✓ �C� Date Issued �L s' z�'J . No. Fee -4!!!> THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2ppricatiou for. Migooal *patent Construction permit j Application is hereby made for a Permit to Construct( )or Repair X an On-site Sewage Disposal System at: 1 Location Address or Lot No. Owner's Name,Address and Tel.No. t " GjARwick WAY tit ll►AkA L '�)UT�eV44 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. To5e PN P. rvt,q cow d FR Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Mature of Repairs or Alterations(Answer when ap licable) maVk tea c!1mq PiT A�t� ?0X 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 a not to place the system in operation until a Certifi- cate of Compliance has been issued b this Boar of e I Q Signed Jtt Date // &G 1� Application Approved by Application Disapproved for the following reasons ti Permit No. 4,�, Date Issued "" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS r Certificate of Compliance - -' THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/re laced(x)on by(M+4CowtReR Soot/ /Oc. for 6)k1t,1&, LQv7�t. 1,,d as. has been constructed in accordance----, with the provisions of Title 5 and the foc Disposal System Construction Permit No. dated j?- Use of this system is conditioned on compliance with the provisions set forth below: , ----- No. �551j� Fee c/Q'/v------ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS ligpogal 6p5tem Con5tructionVermit Permission is hereby granted to A4 AC'OwI 41 se � $otV /A/C to construct( )repair(x)an On-site Sewage System located at 57 L-)k1,eQic/f t,.)A)/ Ce.uTf k U//k IAA QZ4 3 Z 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. All construction must be cD-mpleted within years of the date below. Date: .. / O1.� Approve � U �� rY i 00 j" op 1� '00 o 40 � w o � o LOT 24 --__=-----==----- -_r-=__ #5 7 he' L ' 2� LOT ,26 0 / o pp' 0 Z 100. 0 40 ' s 5 RES. ZONE.• "RC" This MORTGAGE INSPECTION Plan is For FLOOD ZOYVE- "C" Bank Use 'Jnl TOWN: �'E�YT�' LE _ _ _ R EG IS TRY OWNER: LAMES & JANICE C CO URTAW Y --- DEED REF: 7 ?12� — —BUYER: _UX1xL1AM_L &_PEMY J R=FEE'09 _DATE: 2114!94 PLAN REF: 35o�-sC _ SC ALE: r"= _30_" _FT_ I HEREBY CERTIFY TO ___5VBUBBAAf 40RW.J. __-_ OF COMPANY" INC_ __ __ ________THAT THE BUILDING ��A��H YANKEE SURVEY SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS L y� CONSULTANTS SHOWN AND THAT ITS POSITION DOES _ _ CONFORM A. �, TO THE ZONING LAW SETBACK REQUIREMENTS OF THE ' � MERiTHEW y 40B (SUITE 1) TOWN OF BARNSTABLE-------------A\D THAT 9 N0 . 32�8 o INDUSTRY ROAD IT DOES_ NOT _ LIE WITHIN THE SPECIAL FLOOD HAZARD �Fs 9FGiSTER`�� Qa MARSTONS MILLS, MA. 02648 AREA AS SHOWN" ON THE H.U.D. MAP DATED V_19(85 _ s�orugL Lp��osJ TEL: 428-0055 Co unity-Panel ;Y 250001 0015 C FAX: 420-5553 �' THIS PLA\' NOT MADE FROM AV ItiSTRUMENT BALL A. 'ufEITI-I plc ----- SLRVEY \OT TO BE USED FOR FENCES ETC. 14161 KlH 1 3 t � FRim j................ y THE COMMONWEALTH OF MASSACHUSETTS ---y BOAR® OF HEALTH [..CJ.��.............OF............... /� / 'G ..............__ Appliration for Diipuiial lgorkii Tonstrnrtiun ramit Application is hereby made for a Permit to Construct �K_) or Repair ( ) an Individual Sewage Disposal System at: ` �/� J ocation Address or Lot No. . ^ - ...........................................•... --...----._............................... -•....._...---•--.........................._-- .. Owner Address a ........................Z-------- A44�2`.................................. Installer Address Type of Building 3 Size Lot_I ® .4.....Sq. feet F-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ..___._.. No. of persons.................•..._______ Showers — � YP g ------•------------ P ( ) Cafeteria ( ) Otherfixtures .......:::.................................-•---•-----•-•--------•--•-•-••--•-•-••-•----.._...._...--------....--•--............-------•-..........--•- W Design Flow..............615 .....................gallons per person per day. Total daily flow._._..........._f?.. ............gallons. WSeptic Tank-Liquid capacity/P.00gallons Length...... Width..... `._... Diameter---------------- Depth.... .. x Disposal Trench—No. .................... Width....................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No._-.:_._/_._.______- Diameter.. Q._6_'.__ Depth below inlet.....6......... Total leaching area.6.Z3.L4.scl.+4t . Z Other Distribution box (p<� Dosing tank ( ) 04 Percolation Test Results Performed by..�_�.... ..__ EL-L: - __.L , Date... a Test Pit No. 1_ -...minutes per inch Depth of Test Pit._lf l.`'.. Depth to ground water.A-�07' 6---/J " 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wat�r�..�v ---•----------------------------------------------•---•-----------------••---------._.... O Description of Soil--------------- ...............................C.-/�.�................................... x -------------------------------------------------------- W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ••----------------------------------•-----------------------------------------------------------------------------------------------------------------....------------------------------.._.._........_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 5 of the State Sanitary Cod n signe further agrees not to place the system in operation until a Certificate of Compliance has bee e oar iealth. igned ...... . ...---•. -----• --------•-•---------•-------•------••-- ................................ Date Application Approved -- ••• 'L -- . . ................................... ............ ..... ....................•-----............. . Date Application Disa roved or he Bowing reasons________________ ........... ........................................................... ................................... -•--•--••... --•••-------------•--•---•-------•....•-------.......-----------•-------•------•---............................................................... Date PermitNo......................................--------------•--- Issued-........................................................ Date T .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �U -• .--...-..OF............. 1. ,.G3 .................. ApplirFatiou for Uhipati al Workii Toutitrnrtion thrutit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: /� -f• Location ........-Address -••-•-or Lot No. . :..._k9.k-_ .,f}I.. ............•---..__.................._........ ................-...---------..... ._.............--•---.......... ......... Owner Address ......................%�--•••-_.. ..Z ••- ----•-•--------------- --•-----•-- ---..,_:_.................... ............................................. Installer Address Type of Building 3 Size Loth ,._O ��_______Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ______ No. of persons____________________________ Showers — Cafeteria a1 Other fixtures _________________________________ w Design Flow...............r ......................gallons per person per day. Total daily flow------------- .................gallons. WSeptic Tank—Liquid capacity'0la0.gallons Length____,_'_._ Width_.. . _•____._ Diameter................ Depth__'._.... x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area__.....:............sq. ft. Seepage Pit NO-------I............ Diameter/U_:_;5.'._.__ Depth below inlet.... ............ Total leaching areas-43._4_.S � tf ;, Z Other Distribution box ( .) Dosing tank ( `-' Percolation Test Results Performed b L..o t-J ,.a Test Pit No. _.___minutes per inch Depth of Test Pit/ Depth to ground watertie77__195'! . f1 Test Pit No. 2................minutes per inch Depth,•of Test Pit............. ,Depth to ground wat0?!?^...�'Q•. a ---------------------------------- •••---••--------•----•----------------•---•.......... •--------------------------------•------•-- ____-•-••-------- Description of Soil_.. ���, F� r••, f3� /� -•••••E4--= _e!t-----------------•--------------•-----------------------------------• x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... •---------------------------•----------------------------------•--••-••--•-------••-------•--•_.....---...•--•-•••••----•-----••-------••----•---••-•--•-•-----•--•-•--•---•-----••-----•-......•_-•••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT12 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 board of health. Signe ---------------------------------------••---••------••-----•• •----•--•---•------•-•----•----- Date Application jprove fir e •- .......:.-•----•----------------------- 1 -•--•----•---•---•------------------ Date -------------- Application r t�Ifollowing reasons:______________K�._,....I"�c____.___'`�'`���1_.__ �1 Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH .. . (9rdifiratr of Tontphaurr 2TH �S O C FY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by• • �` �'fir. , ............................. •••. . --•• _ / Installer at- has been installed in accordance with the provis-bins of T "LE ` of The State Sanitary Co as escribed in the application for Disposal Works Construction Permit N _.�."••�!�'!__�.�____________________ dateyYfx '�l ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL/ NCTION SATISFACTORY. DATE---- / Y ------•-------•-----•--•--•-••-------•----------------- Inspector-------' -•---•--------------------------....---•....-•----------............-•--- THE COMMONWEALTH OF MASSACHUSETTS BOA OF Ak ..........................OR;....c�,.k„ . ...... ��/'' ...................... FE ••--•-•--•...._•-•-_.... 'Ethip rk mitn lion ramit Permis • ,n ereby granted__,,!''_. r = = a, ° T ,' ..------ to Cons rfict ) or Repair ) an Indio' ual Se e'Disposal System at N `� ---- -- 2 .. Street f as shown on the appli ion for Disposal Works Cons lction Perrl it/No.%_ __________z Date ...�.�f�'___� .................. fr s l f 20 /�L• � Board of Health DATE------------/---- ---d------ --•---------------•----------•------------------•- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS f / 'LOCATION -7v SEWAGE PERMIT N ,. knT VILLAGE INSTALLER'S WA ME A ADDRESS /<_ ® UILDE R oR OWNER � DATE PERMIT ISSUED IUD AT E C 0 M P I. I A N C E ISSUED _ —� `� �,�.�._: i �a'� �J �� 3�� 2�� 3��� �� 9-1 � i 1 � ,�� e i LEGEND PROPOSED CONTOUR K �a 100.0 ft. ® PROPOSED SPOT GRADE EXISTING CONTOUR I I I I + 96.52 EXISTING SPOT GRADE P 56 I W— EXISTING WATER SERVICE III A c , TEST PIT - - - s m LOCUS MAP N.T.S. � I I 'CD GENERAL NOTES: I� / 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY HE LOCAL d" / I I BOARD OF HEALTH AND HE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO HE REQUIREMENTS DEN OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE LIV. BED LOCAL RULES AND REGULATIONS. _ ROOM ROOM 3' TO INSPECTION DISPOSAL OVAL B1THT E BOARD OF NOT BE HEALTHANDPRIOR HE GAR O DESIGN ENGINEER. V O o 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING BED FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN KIT. BATH ROOM 5. ENGINEER BEFORE CONSTRUCTION CONTINUES. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. HE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF BED ATH I _ _ ___ HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. BENCH 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. ROOM — ' - , MARK 8, ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED _ _ _~ _ TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. F "`T E'r' �' 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY FAM. ----------� CO(vCRE TE �C(VvTvEt THE LOCATION OF ALL UNDERGROUND UTILITIES. PRIOR TO BEGINNING ELEVATION = 56. 25 CONSTRUCTION. ROOM Existing 1,000g BARNSTABLE CIS DATUM 10. EXISTING LEACHING TO BE PUMPED AND REMOVED. FILL WITH CLEAN MEDIUM SAND PER TITLE V. / Sep tic Tank 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 56 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING Existing Leochpit 14. ALL PIPING TO BE 4" SCH 40 O 1/8-/FT (UNLESS SPECIFIED OTHERWISE) NO to 10) 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW hmp Par FOR THE USE OF A GARBAGE GRINDER 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING OF {GIs Z4 32.00' I 17. PROPERTY IS IN ZONE 11 OR NITROGEN SENSITIVE AREA. oZ DA E No. 1140 7 TH-1 TH-2 �N11AR�p� 100.0 o ft.g 17J�� PROPOSED. SEPTIC SYSTEM UPGRADE PLAN ( 57 WARWICK WAY, CENTERVILLE, MA MAP.171 Prepared for: Mike Dedecko SURVEY REFERENCE: LOT- 100 Engineering by: Surveying by: SCALE DRAWN JOB. NO. PLAMBOOK.• 15516 DARRF.NMM,MEYER R.S. Eca-Tech Environmental 1..=20 DMM PLAN OF LAND BY YANKEE SURVEY CONSULTANTS PO Box gel DATED: FEBRUARY 14. 1994 PLAN PAGE30? EASTSANOw9�MA02537 (508) 364-0894 GATE: CHECKED SHEET N0. 50&86Y,2= 08/15/09 DMM 1 of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:52.89 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. T.O.F. EL.=57.25 INSOUTLALL ET ANDSRS SET8TO COVERS6* OF OFI/NISH GRADE SET TO INSTALL 6"RISER OF GRADE ONE CHAMBER (MIN.) AND SET INSPECTION TO 3 PORT F.G OVER �F sS�� F.G. EL.=56.Ot F.G. EL.=56.0t F.G. EL: 55.75f F.G. EL: 55.75(MAX.) DA( ftf� y� l No. 1140 L a 10'"f 9" MIN COVER/ L a 32' L a 10'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) O S=1X MIN.) 36' MAX COVER ( 4"SCH40(PVC O Sa1R (MIN.) TEE O SCH4 (MIN.) 4"SCH40 PVC 4"SCH40 PVC /) 10' 14 a 11.3" TO INV.= 53.50 4e'uouw INVERT c tEt�Et �INV.=53.25 PROPOSED 3 ROWS OF 5 UNITS AT 6.25'/UNIT + 0.75' WEDGE 32.0'/ROW GAS BAFFLE D BOX INV.=52.65 DS-3(H-10) INV.= 52.50 NV.=52.85 SOIL ABSORPTION SYSTEM (PROFILE) EXISTING 1.000 GALLON SEPTIC TANK RESTORE VEGETATIVE COVER EXISTING SEWER OUTLET LL WITH CLEAN PERC SAND 75" TO TO -� TO TOP OF CHAMBERS NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INVERTS PRIOR TO CONSTRUCTION e 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV.=52.89 GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 52.50 INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 51.56 EXISTING SUITABLE 310 CMR 15.221(2) 2.83' MATERIAL 3) REPLACE EXISTING 1.000 GALLON SEPTIC 5' MIN. ABOVE BOTTOM OF I -I TANK WITH 1500 GALLON SEPTIC TANK T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 3 x 2.83' = 8.49' 76" IF FAILED. DAMAGED, OR LESS THAN 1.000G IN CAPACITY. (8.31' PROVIDED) USE 3 ROWS OF 5-HIGH CAPACITY PROFILE 4) INSTALL INLET & OUTLET TEES AS REQUIRED BOTTOM OF TESTHOLE EL.=43.25 -_ ADS BIODIFFUSER UNITS-NO STONE W/ CONTOURED WEDGE SEPTIC SYSTEM PROFILE TYPICAL SECTION N.T.S. KY.& 11.2" DESIGN CRITERIA SOIL LOG P#: 12670 II NUMBER OF BEDROOMS: 3 BR DESIGN DATE: AUGUST 12. 2009 1 34"-� SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE. SECTION END CAP •DESIGN PERCOLATION RATE: <2 MIN/IN WITNESS: DON DESMARAIS, BARNS B.O.H. DAILY FLOW: 330 G.P.D. Elev. TP-1 De th Elev. TP-2 Depth 16'�" HIGH CAPACITY (H-20) BIODIFFUSER UNIT 55.75 0" 55.75 p" DESIGN FLOW: 330 G.P.D. FILL FILL GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) s4.92 A 10` 54.92 A t0" MODEL 16" HICAP SANDY LOAM SANDY LOAM LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT PROPOSED SEPTIC TANK: USE EXISTING 1,000 GALLON CAPACITY 10YR 4/1 10YR 4/1 EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY LEACHING AREA REQUIRED: (330) = 445.94 S.F. 54.42 B 16" 54.42 B 16_ SIDE WALL HEIGHT 11 2" DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. .74 SANDY LOAM SANDY LOAM OVERALL HEIGHT 16" DISTRIBUTION BOX: 3 OUTLETS (MINIMUM) 52.59 10YR 5/8 38" 52.59 10YR 5/8 `' 38. OVERALL WIDTH 34" 4640 TRUEMAN BLVD PRIMARY S.A.S. C1 Ct 13.6 CF a HILLIARD, OHIO 43026 USE 3 ROWS OF 5 - 16" ADS BIODIFFUSER H-20 UNITS-NO STONE MEDIUM SAND p 151.. MEDIUM SAND CAPACITY (113 GAL) ADVANCED DRAINAGE s51EM5, INC. AND ,EXTENDED 0.75' Wf CONTOURED WEDGES 2sY 6/a 2.SY 6/4 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODUFUSER) PROPOSED SEPTIC SYSTEM SITE PLAN (BIODIFFUSERS) 15 UNITS x 6.25 LF x 4.70 SF/LF = 440.63 SF 43.25 t50" 43.25 150" 57 WARWICK WAY CENTERVILLE MA (CONTOURED WEDGE) 3 ROWS x 0.75' x 4.70 SF/LF = 10.58 SF PERC RATE <2 MIN/IN. ("C" HORIZON) Prepared for: Mike Dedecko 'TOTAL AREA = 451.21 SF NO GROUNDWATER OBSERVED P DESIGN FLOW PROVIDED: 0.74GPD/SF(451.21 SF) = 333.89 GPD > 330 GPD req'd Engineering by: Surveying by: SCALE DRAWN JOB. NO. DARRENM.MEVEI,R.S. Bco-Tecb Ahvinonmental NTS D.M.M. • I. Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 AOBOX901 (508) 364-0894 to conduct soil evaluations and that the above analysis has been performed by me consistent with the DATE CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October. 1999. FJ13T SANDYYICH,A�a2537 1' � 08/15/09 D.M.M. 2 of 2 IAJ/") E M n i } y yrl cl" f-/oA21Z. SC,-g VE• Tc' T vc^ C !9LE ECy ;'H SE �'rrG g tiJD/57- BOX 74, o i n { ,ti• � r'%il�14, � f= ,__ , , _ .. .: . . _ ..._ - � - GH�_S• /DF-1 r' DH 43/- 1 x r _ _ ? S"T.. H!3 L E- ? E S 7- f O L L- 0. 1C �p / 7 ��� S , DG v✓mil G `Y. �� � 110 _-� �.:_ _ J-� / t] Pfc oPOSETJ vn,/ THE G�CC 1�,' f1 S -- / T'E _ v G/LJ f� '��' ..- _ r C _ i 1 S H O LN AJ C:).'V 71 / S r- CONFO,ef75ET- r_ 8 44 C A:f mac'E Q V/k'E 7-1N E- EVER Err H Q HtN �i t; •� L> ti 01 - O A'E'Q u 1,2 M 1,J?"S , n-f con f�vrS f ,a lq > t2OV� J : cOnfOC�'rs de - - E3Ca.�,2Z] or NFHL TH a.r-- r MSS$. - J