HomeMy WebLinkAbout0068 WATERMAN FARM ROAD - Health 68 WATERMAN FARM RD.
CENTERVILLE
A = 226 001
• 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
System#2
Property Address:. 68 Waterman Farm Road
Centerville, in 02632
Owner's Name:, David Ensfein
Owner's-Address: :
Date of Inspection: April 13. 2009
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'infonnation 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
eeds Further Evaluation by the Local Approving Authority
F ils
Inspector's Signature: Date: __ April21..2009
The system.inspector,shall su it a copy of tLis 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 Coimnents
**"This report only describes conditions at the time of.inspection and under the conditions of use at that
time. This inspection does not address h6 w the system-Will perform in the future under.the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 68 Waterman Farm Road
Centerville, MA
Owner: David Enstein
Date of Inspection: April 13: 2009
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any infonnation 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 iimninent. 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: 68 Waterman Farm Road
Centerville, MA
Owner: _ David Epstein
Date of Inspection: April 13, 2009
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless.Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is.within 100 feet of a
surface water supply or tributary to a'surface'water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within,50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliforn
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 I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 68 Waterman Farm Road
Centerville, MA
Owner: David Epstein
Date of Inspection: April 13, 2009
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 ''/z 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 groundwater 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 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 copyof the analysis must be attached to this form.]
No (Yes/No)The system fails. I have detennined 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 1%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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a_significant threat,or answered .
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304; The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 68 Waterman Farm Road
Centerville, MA
Owner: David E stein
Date of Inspection: April 13, 2009
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out.?
✓ _ Were all system components,excluding the SAS; located on site
_ Were the septic tank manholes.uncovered,opened,and the interior of the tank inspected for the condition
of the.baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
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)].
i
5
I
Page 6 of 11.
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 68 Waterman Farm Road
Centerville. MA
Owner: David Epstein
Date of Inspection: April 13, 2009
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 6 Number of bedrooms(actual): 7
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n1a
Is laundry on.a separate sewage system(yes or no): Wa [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
COMMERCIAL/INDUSTRIAL
Type 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):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): Yes
If yes,volume pumped: 1000 gallons--How was quantity pumped determined?
Reason for pumping: Pumped for maintenance
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:
Date of installation 51143174 per as-built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68,Waterman Farm Road
Centerville, MA
Owner: David Epstein
Date of Inspection: April 13, 2009
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:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 16"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 211
Distance from top of sludge to.bottom of outlet tee or.baffle: 30
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10
How were dimensions detennined: Measuring stick
Comments(on pumping recarmnendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.).
The cement tees were present The liquid level was even with the outlet invert There did not appear to be any sins ofleakage.
The tank was pumped after inspection The tank is under brick walk
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
f
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: 68 Waterman Farm Road
Centerville, MA
Owner: David Epstein
Date of Inspection: April 13, 2009
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: gallons/day
Alarm present(yes or no):
Alarm level: Mann in working order(yes or no):
Date of last pumping:
Comments(condition of alarm.and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Commments (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.):
The D-Box was broken down.A new H-20 D-Box was installed see ermit#2009-077. The cover is 16"belowgrade in driveway,
PUMP CHAMBER: None (locate on site plan)
Pumps in working.order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8 ,
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 0 Waterman Farm Road
Centerville,MA
Owner: David Epstein
Date of Inspection: April 13, 2009
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-1000 gal. H-20 Pits
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.):
The Pits were dry and clean There did not appear to be any signs of failure
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: 68 Waterman Farm Road
Centerville MA
Owner: David Epstein.
Date of Inspection: April 13, 2009
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.`
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10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Waterman Farni Road
Centerville. MA
Owner: David Epstein
Date of Inspection: April 13, 2009
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+/- 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 mans
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 snaps were showing approximately 20 +I to Qround water at this
site.
This report has:been prepared only for the septic system and components described herein. This septic system has been
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 guarantees, 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 -
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
System#1 .
Property Address: 68 Waterman Farm Road
Centerville, MA 02632
Owner's Name: David Epstein'
Owner's Address:
Date of Inspection: Ani'il 13. 2009
Name of Inspector: (Please Print). Janes 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 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
eds Further Evaluation by the Local Approving Authority
'Is
Inspector's Signature: Date: April21. 2009
The system inspector shall subl,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 Cormnents
****This report only describes conditions at.the time of inspection and under the conditions of use at that
time. This inspection does not address hoiv the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page a e 1
�(/
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 68 Waterman Farm Road
Centerville, MA
Owner: David Epstein
Date of Inspection: April 13, 2009
Inspection Summary: Check A,B,C,D of 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 imtninent. 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: 68 Waterman Farm Road
Centerville, MA
Owner: David Epstein
Date of Inspection: April 13, 2009
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface.water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private.water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"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: 68 Waterman Farm Road
Centerville, MA
Owner: David Enstein
Date of Inspection: April 13, 2009
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 ''/z 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 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 coliform bacteria and volatile organic compounds
indicates that the well is free fro
m 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
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 68 Waterman Farm Road
Centerville, MA
Owner: David Epstein
Date of Inspection: April 13, 2009
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 nonnal flows in the previous two week period?
_✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was.the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes.uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with infonnation 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: 68 Waterman Farm Road
Centerville, MA
Owner: David Epstein
Date of Inspection: April 13, 2009
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): 3 Number of bedrooms(actual): 7
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n1a [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
COMMERCIAL/INDUSTRIAL
Type 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):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): Yes
If yes,volume pumped: 1500---gallons--How was quantity pumped determined?
Reason for pumping: _ Pumped for maintenance
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)
inn ovative/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:
Date of installation 4113101 per as-built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Waterman Farm Road
Centerville, MA
Owner: David Epstein
Date of Inspection: April 13, 2009
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:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 4'
Material of construction: ✓ concrete _metal fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: . 10"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
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 tees were present. The liquid level was even with the outlet invert There did not appear to be anyssi ns of leakage The
tank was pumped after inspection The inlet cover was 4"below grade
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 too-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 ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART-C
SYSTEM INFORMATION(continued)
Property Address: 68 Waterman Farm Road
Centerville, MA
Owner: David Epstein
Date of Inspection: April 13, 2009
TIGHT or HOLDING TANK: None (tank mustbe pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Corn ments(condition of alarm and float switches;.etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Commments(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.):
The D-Box was normal: The cover is 1.5'below jzrade.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Waterman Farm Road
Centerville. MA
Owner: David Epstein
Date of Inspection: April 13, 2009
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-500 Qal. chambers 12 8'x 25'x2'yer as built
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,dainp soil,condition of vegetation,etc.):
The Chambers were dry and clean There did not appear to be an si ns o allure.A camera was used or tlse inspection.
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):
Commnents (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: 68 Waterman Farnt Road
Centerville MA
Owner: __.David Epstein
Date of Inspection: April 13, 2009
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.
i
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ROCk (-All
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( 1835
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Waterman Farm Road
_ Centerville: MA
Owner: David Epstein.
Date of Inspection: April 13, 2009
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+/- 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: Tonokravhic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you estab
lished the high gh ground water elevation:
Using Barnstable tonoQranhie and water contours maps the mans were showin ppiroximately 20'+/ to Around water at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in die future. There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic systenr, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
11
No. 2 od I — t9 7 7 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Mi5pooal *pztem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ` (�A-re,r MAI\ q(/b\ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
001
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Cp<8or, CCU W Foy
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) \J" (Z�® % C
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 by Pis Boa�of Health. / I
Signe Date
Application Approved by Date 5
Application Disapproved r the following reasons
Permit No. )CL0 r1_0? 7 Date Issued 7 U
No. 2 rid / 077 Fee l ao —
" THE COMMONWEALTH OF MASSACHUSETTS r Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF`BARNSTABLES MASSACHUSETTS7.
application for Migpogal 6pgtem Congtruction Permit
1� Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. CC6 w 4—tt`r MArk i'' rM Owner's Name,Address and Tel.No.
Assessor's Map/Parcel Gt/^TLr V r6L A� ST%I n
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) � - `JoK re pt f
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 operatiomuntil a Certifi-
cate of Compliance has been issued by this Boar of Health. /��O
Signe ,t� � Date
Application Approved by J, A Date t1 _2 d 5
Application Disapproved the following r asons
Permit No. gn Date Issued JCI
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS " —`(3pX (1. AIr 0,1
BARNSTABLE, MASSACHUSETTS /
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(Xp'graded( )
Abandoned( )by G f(�An aor- Q,S
at LX IA N—kL(MAn i;*A(N\ I WAS e,(VAX has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. bJq -0 7 7 dated t/ 77 if c1
Installer Designer r\
The issuance of qlu s ermi!t shall not be construed as a guarantee that the s 0temA, li function desiig ed.
Date ( I r) Inspector 11/: N.
No. o lJ t)�l U _7? Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migpogal *pgtem Congtruction Permit - x
Permission is hereby granted to Construct( )Repair( ✓ Upgrade(' )Abandon.( )
System located at lauL4"-r (mAn F1,(AN
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. n
i
Provided: Construct i n must be completed within three years of the date of,#thYs permit./
Date:_._ . / 1 Approved by
WA.
TOWN OFBARNSTABLE �
LOCATION SEWAGE #
VII.LAGE C w�w�`�'z ASSESSOR'S MAP & LOT :7:1 — �D
i
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) S� `'v � (size) 12 7�2_S
NO.OF BEDROQ,vIS
.1\Liv .
PERMIT DATE: ?+ COMPLIANCE DATE:
Separation Distance.Between the: JJ
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 leactung.facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet off leaching facility) Feet
Furnished by ,)n-
r-
i
�J1 �
i
• a
5. A
N,5. 24?0j_ �y� r` i' Feed
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for 30igpogar bpotem Cottgtruction Vermit
Application for a Permit to Construct( )Repair X Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Co S W/9fE12MA1V PA Rtrt R D Owner's Name,Address and Tel.No.,SO rs-68 3- -76 O O
CE/vtcrviL��,�yJ/�sS Ddv 1 D 13. E PS'1-6.1V
Assessor'sMap/Parcel 5-oo l3oL)w&L-L- strEE'T Ekl%
/4AF Z-2 L A✓o!t/,1nAS5 0Z,322
Installer's Name,Address,and Tel.No. f]� �j L: Designer's Name,Address and Tel.No. 6 a Sr-yZf%'3 3 4 44
11ff r SULLivAili ENS-1JVE�2 t11i�
L f,{� , &� "7 PArKE 2 RoA D
Type of Building:
Dwelling No.of Bedrooms Lot Size 21(02 3 sq.ft.
.t Garbage Grinder((V)Q
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 640 gallons per day. Calculated daily flow gallons.
Plan Date a LY 7, z,Oao Number of sheets I Revision Date
Title SI TE PLAN- Prc POSED S&P'r1 c U PCrq&F
Size of Septic Tank 16-00 G/�[.LoN Type of S.A.S. 12'X 53' OvP CAM[3M
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Q t M O V& ANDZo r fi RANnoA w D
r cT_,;, D-Box 6- SAP ic_ " nyj::K , l Ns7-gLL P--W SEPt/c 7,9NK P CA,41113EP—,
D— Q3OX 4 L_-Achtty, C�iAMi3Ei2
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 his Bo of Health.
Signed Date 4 1'
Application Approved by LlzxDate 7 -d
Application Disapproved for the following reasons
Permit No. ZOVV -W6 Date Issued O
46C IN
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes
ZIpprtcation for Migoml *pgtem Congtructiou Permit
Application for a Permit to Construct( )Repair(X Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. &$ WAtcaMAP I=ARM RD Owner's Name,Address and Tel.No. -5-0 ' 68 740 O
C6/11rSrVILLiF1 ,45S DA,V'ID B. FP5T61X'
Assessor's Map/Parcel ;5-0 0 C3 o D W E L t-- St rEE T E J!t-
A1,02 Z.-2-L. PW6 4. 00 I AVoAv,Iniq s 5 023'2.'2-
Installer's Name,Address,and Tel.No. JJ�� Designer's Nam 6-e,Address and Tel.No. 6-a —q ze— 3 3 q q
Dr- 5UL.6.11 AAW ENalAlsaIL ING
'7 P,41-4 2 C2oA 0
Type of Building:
Dwelling No.of Bedrooms Lot Size 21(,��!93 sq.ft.* Garbage Grinder
Other Type of Building No. of Persons Showers(•, ) Cafeteria( )
Other Fixtures
'a Design Flow G G P gallons per day. Calculated daily flow b gallons.
Plan Date -u L Y •7, Zoao Number of sheets I Revision Date
Title S1 tE PLAN- Prc PbSED SEPtIG U PGrANF"
Size of Septic Tank 1500 GRL.LoN Type of S.A.S. 12,X 53'1-e,,9 gVR cAm am
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) R.G M 0 V E AND/or
1Y5, D-Box d• 5EPt]L 1)904 , I Ns-f-gLL Meal 5e)97'/4 TANK P4/A1 P C'/►A/i'i13&R-
O X J LEACAjVg 4fA,4,w RE 1z
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 his Bo of Health.
Signed °. Date y 1 11-1 o
Application Approved byY. Date ? ZO VZ
Application Disapproved for the following reasons
Permit No. ?.OM '4/06 Date Issued 7 '
———————————————————————————————————————t
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY that e On-site Sewage Disposal System Constructed( )Repaired (X)Upgraded( )
Abandoned( )by f J AAlr'1 tek(V.-1
at 66 WA TER M 14 w FgrM R D, , OS-ler 1 L LE , ,41 AsS has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. -'V106 dated
Installer Designer
The issuance of this permits 'a11 r1bt be construed as a guarantee that the syste ill cC" as-des'gned.
Date y �3 Inspector r
------------------------------------ /--/—
No. 4 / 0(; Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
lwigpool *pgtem Cougtruction Permit
Permission is hereby granted to Construct( )Repair(X�)Upgrade( ')Abandon( )
System located at 4,8 UZAI E RM141V FaCM fRrp Dr 0-5t VI L,LE
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 must be completed within three years of the date of this
Date: ����/ Approved by
c w a ✓L �
1�IO...... �� ..... FEx...........; .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.O—ZfYL...........OF..... .:. ..C�' � 1 .
Appliration -for DiBpvii l Worko TouBtru fivtt Pprutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
PP Y ( ) P ( ) a P
a _ � r
ys�, >_, ,,.. ......... --� - ...._ �.r_�Lot Loc on-Address No.
.. . .... ---- --•- -- -------------------- -------------•----------------..------..........------..-------•----------------------------------
ner Address
a " ........... -----------------------------------------------------------------------•---•--•----•-•---------•-
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms------------- ____s---------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ----_--------------------___ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QOther fixtures ------------------------------------------------------------------------------ .......-------------------_--- 0---•-------..........-----
W Design Flow--------------------------------------------gallons per person .per day. Total daily flow-__•__-______-__•---__--_--.-.---...--------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width-------- ------- Diameter----.___.------ Depth----------
x Disposal Trench—No_ ____________________ Width-------------------- Total Length____-__-_--_-__-__. Total leaching area.........-----------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq. it.
Z Other Distribution box ( ) . Dosing tank ( )
aPercolation Test Results Performed bY.......................................................................... Date-----•----------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit---___-_•-._ -_.--. Depth to ground water........................
( Test Pit No. 2................minutes per inch Depth of Test Pit__._-___.._____-____ Depth to ground water-._.-.-..-_.__-__-.-.___
19 ----------- ------------- -------------•---................................................................................................................
ODescription of Soil----------------------------------------------------------------------------------- -----------------------------------------------------------------------------------
x
U ------
x ------------------------- -------------------------------------------------------------------------------•-----------•------•a------------------ ---
U Na lure of Repairs or Alt tons—Answgr when plicable...... .. �✓s.2..___ __ .. _...._._...
Agreement: i
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued by t e boaSigni r he Ith
e•----- ...... Date.
Application Approved BY..........�---�L---------------------------------------------------------------------------= ....................Date ;
Date-----------•--
Application Disapproved for the following reasons--------------------•------------••-----•-----------------------•------------------•------------•----------------
-----------------------••-------------------------------- ----------•--------------------------------------------••--------------------------------•------•-•-------------------------------------------
_ Date
Permit No. '------------------------------------ Issued............. 3 l7�.................
Date
F:
+.
pm
No.....19.1 ...... F>�a..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF UEALTH
�-L� ---- ---OF.... C / ...... ............------
Appliration -for Dhipoottl Worko Tonotr rtion Vamit
A 'lication is hereby made for a Permit to Construct or Repair an Individual Sewage Rp,•. y ( ) p ( } Se ge Disposal
Sys , ' at
---------- ----
�" Lee on.Address V or Lot No.
----- --- •--• ......•---•------•---•--•--•--
ner Address
Installer Address
UType of Building Size Lot_________________________-Sq. feet
., Dwelling—No. of Bedrooms___--__--;�---------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther
—Type of Building ______________________--_-- No. of persons-----------.---------....... Showers ( ) — Cafeteria ( )
a4 Other fixtures ----- ---•------•-•---------•-----•-------------•-------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow__..--------------------------------------..gallons.
WSeptic Tank—Liquid capacity_-_---_-____gallons Length-------........ Width................ Diameter---------------- Depth----------------
Disposal Trench—No. .................... Width..:............_.__. Total'Length._,_-__--_----__-_.- Total leaching area.__._._.--...--__-_-sq. ft.
x K,
Seepage Pit No..................... Diameter..........._--------- Depth below inlet.................... Total leaching area------------------sq. ft''.
Z Other Distribution box ( ) - Dosing talk.
Percolation Test Results Performed by --------- ------ ------------------------------------------ Date---------------------------------------
,� Test Pit No. 1................minutes per inch'fu Depth of 'Test ,Pit--------- .......... Depth to ground water-..--..___-_-.-__--....
�Tq Test Pit No. 2................minutes per inch ?el#,gf, Test Pit.................... Depth to ground water...--_-____:_...__-_-. -
---
------------------------------- -----------------------------•-------------•-------------------------------------
DDescription of Soil................................................. -w -------------------------•----- ........ --------------------- -----------------------------
x
x --------------------- ------------------------------------------------------------------------------------------ ----,----•fir
V N ure of Repairs or It s—A nswer when plicable...... ...........
.lQl? ..../J --------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b ssued by t e board of he It
Signedx� ; •_. '•� ' `
Date
ApplicationApproved BY------- ------------------------------------------------------------------------------
Date
Application Disapproved for the following reasons:...............................................................................................................
--•---......_••................•--_.....---••--•--------------•-..........--------•----•-•-•--•--------....-••-•----•------------_----•---------••••---••-•-•---------...............................................
/ ✓ / Gl✓ Date
PermitNo- - ..............................................:•: '�,. =$.. Issued::-= ........................................
Date
, T t
/660 J ' THE COMMONWEALTH OF�MASSACHUSETTS
x BOARD OF HEALTH
Gti
rs
Trrtifiratr of IT'omplianrr ` y 4 r
THIS AS CER 1 Tha/7 fa e Individual Sewage Disposal System constructed ( )`tor Repaired ( )
byc.. - -- -----------•---•------•---- .......-- --- �G ,lam-A..... .._..
O
at
leas-been installed in accopdance;_with the provisions,,of Atttc of The State Sanitary Code as described in the
application for Disposal Works Construction Permit I�7o____ __________________________________ dated....._...._._______....... •..._.._.._..__
r Yt"`° THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--- `'{ � ��� = ...-••--•---• Inspect
�. yv K �l .•1'K)yxJv..;
n.� f k'.'n•r..� TW S .�v 5,., 1 S ff
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF yHEALTH
.................7...�u-
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Permission is herebyranted----.----__-'.!_:'__'� '
to Construct ( Xor Repair ( ) an Ind3,vic al Sewage Disposal System
atNo. L.P h 4h F �-•-•••-•----••-------+------•-----......----'Street---•--•--- r �
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as shown on the application for disposal Wo`rksmGonsruction r) rmit No............... d..........................................
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` -_-•---•--_-• Board of H alth
DATE----- f,.3' 7
FORM 1255 HOBBS & WARREN. INC.. PUBLIS'HERB .
;;OVA, t.. +,., �K Va f s+ :1 t f':, ��1; i. ♦..� .+ s
i
NOTE •`
\• / / / �' _ — ` = ' L Water Supply ForThis Lot is Municipal Willer.
s , • r , -
/ _ _ ly 2 Location of Utilities Shown on This Plan Ark Apptft
At Vast 72 Hours Prior to Any Excavation FbrThis
/ _� RD�Q Project The Contig Safe(1-1 Make 22 Required
/
/% __ _ /00. \ qG Notification toDipSafe(1-800-322-4844) 0 Vg
p / / / i ^E Ths Coniraetor is Required to Secure A"rIa% •o
/ / i �0 Permits From Town Agencies For Constructroll
N
9e
1 Defined by This Plan
Install Risers as squi R dleaf �• -+o re to Within -
�- I Finished ••�.+► �/ � / � \ `y.�� f � Grade. � -
`I9 GONC•S�6 ? / � / 5.All Structures Buried Flow Feet or More orSubject'
f r 0 L to Vehicular Traffic tobe H-20 Loading. ❖. Cr8 •• n
S /
�' —• ' EACHING �(/t(
HAM gea \ 40 6 Septic System to be Installed in Accordance With •� :_.,��
310 CMR 15.00 Latest Revision And The Town of
Barnstable Board of Health Regulations ..••�:s G �` r.
.• ::. .. rat
All Piping to be SeR 40 PVC.
x' D-go coo I bE$IG DATA
z `\ e
x \ i I hnum Design
W
Mutth no Garbage Grinder ` LOCUS PLAN
/ I Daily Flow=I IO GPD x 3=330 G Pb
Septic Tonic=330 GPD x 2009•m 860 OPO Scale: I = 2000
Use 1500 Gallon Septic Tank Assessors Map 226
LEACHING AREA Parcel 001
t�y�•Vf ��� �' `��� \ / I I �I Sldewalll a 2(2'.25!)2 F148 Required
p►pP 00 O'.. __ 'A 0 '� I f 8ottomArea=IZXV'= 300 &F: Zoning RC
v 'A s I I I I I 448 SF.Total Provided Setbacks
i 'Q AIL I I I LEACHING CHAMBER DESIGN Front 20'
All Pipes to be Schedule 40..Use '
2-500 Gal.Leaching Chambers Ina Side 10
�kr1r9,p*rC q I N I I I 12*x25�Washed Stone Field as Shown Rear 10,
N c'I 1 _
o � I I � Ground Water Protection
J` Zone: AP
N I N - __r_Ruhr
T I III A /ayr(r lbegaehs Rill s '
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l i -1, :
6
mill sl.0
Q�� F• / / / .N cam s 1Daumil�•
LOT AR EH .0• V rri� � l / I � Sronr
o�►�` 5� / CROSS SECTION.OF CHAMBER OF
PETER
l AN
W.29733 -+
PITS
% CIVIL
�XST.L.QAGb1
To OIL AtSAWDt�N6D � ��V
W
PLAN VIEW
Scale• I = 30' �F 2.o' __.___
F.G.24.9
21.9 SITE PLAN
Connect to Exist 1500.Gallon Top El. 22.9 PROPOSED SEPTIC UPGRADE
House Sewer 24.0 Septic Tank 23.8 ATInv.24.7- Bot.El. 19.9 -
C
23.0 22.8 68 WATERMAN FARM ROAD
Bedding as 14.9 -
Ground Water o E1.Less Than 5.0 CENTERV ILLE , MASS.
Per Title 5 as Per T.O.B Ground Water Map FOR
DAVID B. EPSTEIN
DELVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM_ SCALE, AS SHOWN DATE: JULY 7, 2000
/ REVISED Size ANp LOCATION �• Not to Scale SULLIVAN
SS.ENGINE
MA INC.
REVISION 9 is/ T r•
Oo 'OFr sapIC 5VSTM 7 c>
99029