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HomeMy WebLinkAbout0059 WHIDAH WAY - Health F(5, NVhidahR��y terville F/R A = 230 204 D it M n No. 42101/3 ORA a. a� 10% o m Lm C2 3 b - 070� w<�Z\ Commonwealth of Massachusetts �n p Title 5 Official Inspection Form11. , Ilk Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' r•�� 59 Whidah Way Fti7 L Property Address Francis Fermino 0 Owner Owner's Name K information is Centerville Ma 02632 4-4-19 required for every 71 page. City/Town State Zip Code Date of Inspection r' M Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information �' 3 on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Gy Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails oi�N agmeeren Hrcxq Brett Hickey ,:�a �z�:�;m-��®�a� ..�.��s 4-4-19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doc a rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth of Massachusetts P �m Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts �tl Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments l; 59 Whidah Way C'% tip Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way v Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a 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: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ O 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 59 Whidah Way u Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? El a 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) ❑ El Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? R ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ O 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ O Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I c Commonwealth of Massachusetts �m Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way L Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms(design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 353/GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes Q No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes El No information in this report.) Laundry system inspected? ❑ Yes El No Seasonal use? ❑ Yes Q No Water meter readings, if available (last 2 years usage(gpd)): See below Detail: 2017- 39,000gallons 2018- 41,000gallons Sump pump? ❑ Yes 0 No current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 v Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 59 Whidah Way u Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 44-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): I 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes M No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 59 Whidah Way Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron H 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I' c Commonwealth of Massachusetts �n ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 59 Whidah Way V Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. 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 1000gallons Dimensions: lit Sludge depth: 29" Distance from top of sludge to bottom of outlet tee or baffle 5" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 59 Whidah Way Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts �- Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): 0" 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... 59 Whidah Way V� Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2)500 gallon chambers 0 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �a ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way V Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Chambers were 1/2 full when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way Property Address Francis Fermino Owner Owners Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately Assessing As-Built Cards_, . TOWN OF BARNSTABLE '42A "Jy a r ocnriON 4 r✓y;cf ✓.,;, c VI LAt'i8' -vrY%>9 t/N��i= ASSESSOWS-MAP dt L x . t ? INS 7At I EFt'5 N:ir; PH ONE No. scr' °1>t Ls�.»rv5o _yao �5 x SEPTIC TANK CAPACCI`Y __lefla LEACIM40 FACIL.rry;(type) NO.OF BEDROOMS . PUELD vR oR OWIr'ER Xa;,�ru Hi i 7 t�l K r PERMITDATE: i ? i COMPLIANCE DATE Saperbtion:riistance BetwCen dw: Maximum Adjusted proundwater Table to the;8onom of ixaching'Facility, Feet. Private Water Supply Well and'Leactung Faeili y (if'aiiy wplla'enist'j j .-..+ gn 3itanr,tlhilun 2UQ�fut oPlaac}ung facility) , �ext v Edge of Witland and Leyching Fai lriy(If aky wCtlantls zx3at vttJum300'feet of ileac fig faLiLtyt, Fttrtushei by izy�x ro � l t s t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts �a w Title 5 Official Inspection Form I�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑N Check Slope ❑■ Surface water ■❑ Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @ 120"feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record Nov-1-02 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts , p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Whidah Way V Property Address Francis Fermino Owner Owner's Name information is Centerville Ma 02632 4-4-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: F■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ■❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 cick3� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN _I cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name VSLA P.O. BOX 145 Company Address CENTERVILLE MA 02632 few Cityrrown State Zip Code 508-420-4534 S14297 ':Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pdirsuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally'.Passes ❑ Fails ❑ Needs'Further Evaluation by the Local Approving Authority 3-20-14 Ins ector idnature 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 appitlpiriate regional office of the DEP. The original should be sent to the system owner and copies sent to ft buyer, if applicable, and the approving authority. ****This report-matytdestAbes conditions at the time of inspection and under the conditions of use at that time.This inspects not address how the system will perform in the future under the same or different conditions terse. t5ins-3/13 Title 5 officjIns m:Subsurface Sewage Disposal System Page 1 of 17 i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: AT TIME OF INSPECTION HOUSE HAD BEEN VACANT FOR SEVERAL YEARS AND HAS NOT SEEN ANY WATER USAGE 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F& Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a brokers;-settled or uneven distribution box. System will pass inspection if(with approval of Board of Health)` ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: El Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspecti : Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 5 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments M 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND 2 500 GALLON DRYWELLS Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): MIN Detail: HOUSE HAS BEEN VACANT FOR SEVERAL YEARS Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2003 S.A.S AS PER AS-BUILT, TANK ORIGINAL Were sewage odors detected when arriving at the site? ❑ Yes ® No ytfiuilding Sewer(locate on site plan): Depth below grade: feet 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): Depth below grade: 1.5 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: 1000 GALLON Sludge depth: SEE BELOW t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y< 59 WH I DAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness SEE BELOW 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? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): FROM BEING VACANT FOR SEVERAL YEARS TANK HAD NO SCUM LAYER AND HAD A LIGHT SLUDGE BUILD UP IN THE BOTTOM Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM , 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,-evidence of leakage, etc.): a Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert O" 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.): BOX LEVEL NO LEAKAGE AT TIME OF INSPECTION Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspectionorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•''� 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CHAMBERS WERE DRY AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspectiorr Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forte Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5 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: AUGUST OF 2013 Date El Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: f ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 59 WHIDAH WAY Property Address HASKELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-20-14 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 2 of 2 htip://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=230204&seq=1 3/25/2014 Assessing As-Built Cards Page 1 of 2 //TOWN OF BARNSTABLE �Cl LOCATION 572 ZIZL, /a SEWAGE,# VILLAGE ASSESSOR'S MAP&LOT a! INSTALLER'S NAME&PHONE NO. 12,9 YrvS SOS-520-9738 SEPTIC TANK CAPACITY -__laao LEACHING FACILITY:(type) -0 o /o/Urte cal=IIS (size) 13 X NO.OF BEDROOMS 3 BUILDER OR OWNER d?I�l,!^T//its r PERMITDATE: / 1 -30-CZ COMPLIANCE DATE: /-3_05 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 leas "g facility Feet Furnished byy�r7�cc� I http://www.townof bamstable.us/Assessing/HMdisplay.asp?mappar=230204&seq=1 3/25/2014 _ X cam°. Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: f l forms on the computer,use 59 WHIDAH WAY only the tab key Property Address to move your RICHARD HASSE17 cursor-do not Owner's Name use the return key. P.O. Box 75 r" -3 a- a.-y Owner's ddress VQIs C e2 MA 02638 Citylrown State Zip Code (I Date of Inspection: 9-1-07 Date 2. Inspector: MR. ROBERT A. DRAKE Name of Inspector KCJ ENGINEERING Company Name 66 GREENVILLE DRIVE Company Address FORESTDALE MA 02644 Citylrown State Zip Code 508-477-5048 Telephone Number a., 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 ofon site sewage disposal systems. I am a DEP approved system inspector pursuant to 15.340 oy; Title 5(310 CMR 15.000).The system: o M,gss - ® Passes ❑ Conditionally Passes o BE TA q°��� r1 i DR A E ❑ eeC�s Further Evaluation by the Local Approving Authority o CIVIL // ' No.41642�Q G�,�` Inspector's Signature Date FFSS,'ON\, The system inspector shall submit a copy of this inspection report to the Approv g 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. 59 WHIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND WORKING PROPERLY. 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: 59 W HIDDAH WAY-T51NSP.DOC.doc.11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ 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: 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 59 WHIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 59 WHIDAH WAY. Property Address CENTERVILLE MA 02632 City/rown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont): 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria 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: 59 W HIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 City/Town State ZipCode RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection 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 Y2 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 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.] 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. 59 W HIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 City/rown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. 59 WHIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5.Official Inspection Form:Subsurface Sewage Disposal System Page 6of16 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form B. Checklist 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 City/rown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: YES NO ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 59 W HIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form b C. System Information 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? - I o t Zo a t'a ❑ Yes ® No �1�6 - ►z-�occ •, ►3z�P`�Water meter readings, if available(last 2 years usage(gpd)) 138 gpd Jos- -i z l o r : ►an,p� Sump pump? ❑ Yes ® No Last date of occupancy: Presently Occupied Commercial/Industrial Flow Conditions: Type of Establishment: N/A 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): 59 WHIDDAH WAY-T51NSP.DOC.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: N/A 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: CONCRETE SEPTIC TANK IS.BELIEVED TO HAVE BEEN INSTALLED.WHEN.HOUSE WAS - .- BUILT IN 1985. D-BOX AND LEACHING FIELD WERE INSTALLLED IN DECEMBER 2002 . Were sewage odors detected when arriving at the site? ❑ Yes ® No 59 WHIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage:Disposal System Page 9 of 16 r Commonwealth of Massachusetts r Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): SEWER PIPE APPEARS TO BE IN GOOD CONDITION, NO SIGNS OF LEAKAGE. Septic Tank(locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) TANK AND ALL COMPONENTS APPEAR TO BE IN GOOD WORKING CONDITION. If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 1000 GALLON Sludge depth: APPROX. 5"+/- Distance from top of sludge to bottom of outlet tee or baffle APPROX. 26" Scum thickness APPROX. 6"+/- Distance from top of scum to top of outlet tee or baffle APPROX. 12'1+/- Distance from bottom of scum to bottom of outlet tee or baffle APPROX. 13"+/- How were dimensions determined? MEASURED IN FIELD 59 WHIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M ly`• C. System Information (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ALL COMPONENTS ARE IN GOOD WORKING CONDITION AND STRUCTURALLY SOUND Grease Trap(locate on site plan): Depth below grade: N/A 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: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 59 W HIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 11 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'M C. System Information (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 Cityfrown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: N/A Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes[I No Date of last pumping: Date 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 LIQUID AT INVERT OF OUT GOING PIPES 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.): D-BOX APPEARS TO BE IN GOOD WORKING CONDITION. Pump Chamber(locate on site plan): Pumps in working-order: El Yes El No Alarms in working order: ❑ Yes ❑ No 59 W HIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 J Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 Citylrown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection 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: ® leaching chambers number: 2-500 GALLON ❑ 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.): SAS FIELD APPEARS TO BE IN GOOD WORKING CONDITION. NO PONDING OBSERVED OR ODER DETECTED, VEGETATON IS NORMAL. S Arj�s y S o r(S e_ y.S it S17 C p CA d ,jAaPI M'Oy. )I t 'Z O Z. 59 WHIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 13 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration NIA 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: N/A Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 59 W HIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection 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. FKoN T # S-1 R RAc K g 1• deck i ►D 59 WHIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 59 WHIDAH WAY Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code RICHARD HASSETT 9-1-07 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: �] Obtained from system design plans on record 1 � Zooz If checked, date of design plan reviewed: Date Nov. ❑ 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: TOWN OF BARNSTABLE GIS MAPPING. You must describe how you established the high ground water elevation: BARNSTABLE 1992 HIGH GROUNDWATER GIS MAP INDICATE WATER AT APPDX. EL=30'. FROM BARNSTABLE GIS MAPS, GROUND ELEVATION IS AT APPROX. EL=46'. S(?t P(Ad — Yvo GCS io A dePih o F IZ0 10C 4p..S 59 WHIDDAH WAY-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 r No. Fee 1 1-1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppfication for 33igool *p!5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System <Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel `Z?00 Vj Installer's Name,Address,anA Tel.No. 1 (� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms_ 3 Lot Size 2 2- 0 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3 gallons. Plan Date 0 '2_- Number of sheets Revision Date Title Size of Septic Tank !D 60 Type of S.A.S. 6 4a—Le­-3 Description of Soil S-CA--Z?o /V C 40 C 2.- Nature of Repairs or Alterations(Answer when applicable) Ke;019.6e 41 4ot /epLe—K 4104 e✓� Z- S ��a A ULa~b—tn) (w tf e 7 S&,.p 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 thi§Boar of lth. Signed •G Date ° ti 3� L Z Application Approved by Date /Z 30 0-2— Application Disapproved for the following reasons Permit No. zoo Date Issued G oo _ Fee �7 v,# J THE COMMONWEALTH OP MASSACHUSETTS Entered in computer: V ' - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS.. _ Yes rication form ogaY stem �ongtructiot� ermit, p p Application for a Permit to Construct( )Repair( )Upgrade( : )Abandon( ) ❑Complete System Individual Coinponents_rf''� Location Address or Lot No. S Owner's Name,Address and Tel.No.� • Assessor's Map/Parcel 2^l o w y Installer's Name,Address,and Tel.No. Designer's Natnd,Address and and Tel.No. Type of Building: '. Dwelling No.of Bedrooms Lot Size 2 Z/ (11 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers,( ) Cafeteria( ) Other Fixtures ter. Design Flow 330 gallons per day. Calculated daily flow -? 3 gallons. Plan Date 0 Number of sheets Revision Date � Title Size of Septic Tank �R x /000 Type of S.A.S. /. f Description of Soil 4 06z,- 62. C C Z J ry i • Nature of Repairs or Alterations(Answer when applicable) K *04 a a�� 4-ol ,!1 1,/ 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 thi BAoa/roof lth. Signed Date Application Approved by Date /2 30 a•L- Application Disapproved for the following reasons Permit No. ZOO 2 L6F Date Issued ---------------------------------------- THECOMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 23v1i0� Certificate of Compliance - THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ((.I)graded( ) Abandoned( )by at G,/ti olw Pt Gv CP ill' 1 has been constructed inIccordance with the provisions of Title 5 and the or Disposal System Construction Permit No. 2�2-!007 dated1 LO Z- Installer b h s a e! 44 12- ZJi4etf e S Designer 6 ki=hA? ,�r.�s ex ryh The issuance of this permit shall not be construed as a guarantee that the sy-'em w� 1 function designed. Date Q t D hh 3 Inspector 1?c;:y' 'Ins Au Q S No. 2-DU 2g Fee , 1 THE,COMMONWEALTH OF MASSACHUSETTS - Z 3,7/" PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS .r W9po5al *potem Construction Permit Permission is hereby granted to Construct( // )Repair Grade( )Abandon( ) System located at Jv and as scribed in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply ith Title 5 and the following local provisions or special conditions. Provid\ :Constr ction 'Tust be completed within three years of the date of this p Date: Approved by Qi TOWN OF BARNSTABLE p `L'GCATION ,114,1 U/. Z SEWAGE # 2oo2—GD8 VILLAGE CrnT/;.�-y/!1= ASSESSOR'S MAP & LOT�30 20 INSTALLER'S NAME&PHONE NO. _cl�,s cG°`i �,� gwy--05 3DS SEPTIC TANK CAPACITY IOOD LEACHING FACILITY: (type) 2-SO0 6ol[/ref W15,11S (size) /3 X 2S— NO. OF BEDROOMS BUILDER OR OWNER I�I�Iff u/"Tcl�/Sr PERMTTDATE: 1 , 3D- 02 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leac 'ng f cility Feet Furnished by Ne, u�i (3�GlC � i �' �' '�c r{3. c_ ��� �� �� TOWN OF BARNSTABLE LOCATION SEWAGE # 2002-Gr 8 VILLAGE ASSESSOR'S MAP & LOT�� o INSTALLER'S NAME&PHONE NO. &1^Ho.5 e? -el O- SEPTIC TAN) CAPACITY 19o0 LEACHING FACILITY: (type) 2_-00 6ol dry r yl�r�S (size) /3 X ff NO. OF BEDROOMS BUILDER OR OWNER lil9rr9 / urTuhr_- PERMIT DATE: L 671 COMPLIANCE DATE: f —J 03 Separation.Dist.ance 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 'ng facility)) Feet Furnished by U�, 5/25/01 Notice: This Form-Is Tq Be-Used For-the Repair-Of Failed- Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM , E. X,-o-t' hereby-certify.that.the engineered plan signed by me dated lM-Z— concerning the property located at s� 1o" tii✓D*, A?,Vi `/ — meets all of-the following criteria: • This failed system is connected to a residential dwelling only. There-are no commercial or business uses associated-with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical-data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation 3© +adjustment for high G.W. = 3 DIFFERENCE BETWEEN A and B �D SIGNED : DATE: �!4zlza NOTICE Based upon the above information,&repair permit will be issued for 3 bedrooms maximum. No additional bedrooms are-authorized in the future without engineered septic system per• q:health folder.percexmp L,O CATION S EWAGE PERMIT NO. -Z W[A �a� VILLAGE r Cet Co 1-,4 INSTALLER'S NAME 6 ADDRESS B U I L D E R OR OWNER u� 1� �jDATE PERMIT ISSUED DATE:, = .COMPLIANCE ISSUED j . s. Lo i-' F 37' a all° qV 3� 5�° No.... . Fps....... ...........`- THE /1 , �COMMONWEALTH F c ETTS BOARD OF HEAT a ..............OF..... _...................3Pc Appliration for UhipuBal Workii C9vnotrurtiun Prrutit f�.Ii- Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal C` System r v . ....1.....e4z J..Id-V, ............ .............. .....rdF../.... -- I+ocation t..�._./..,� ....A e.� 1 o ....................... ..... . . ...._te't"N ................. Owner Address �j 5dn . - / �m..c........-•------•-•................................Installer Address Type of Building Size Lot Q41 A(el ....Sq. feet �-4 Dwelling—No. of Bedrooms.........3.............................Expansion Attic no) Garbage Grinder Other—Type T e of Building No. of persons............................ Showers � YP g ---•----•----•-------------- P ( ) — Cafeteria dOther ,fixtures ._-----•....... ---•-•------.....••--•---------------.•----------•---•...-------•-----------•-...------.......--•-••------..._..-----•--•--•-----•--- W Design Flow..........5 .......................gallons per person per day. Total daily flow...........3..3..0._...............gallons. WSeptic Tank—Liquid capacity 0..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. ft. Z Other Distribution box ( ) Dosin eta ( ) r a Percolation Test Results Performed by-_�.� �rP Al�_.L�Z..'ff7e_C p__ '' Date_.._..__s� i Test Pit No. 1_ ._.__minutes per inch Depth est Pit..... .. .....-- Deptt->'fo ground water.._-�. - /.--�. _ 44 Test Pit No. ..._... --minutes per inch Depth of Test Pit.`--•-......--•---_. Depth to ground water._.1-��. Oa ` Description of Soil Q/�.. � off{ ................................. x V C9 �s �'C�? -----------------•-•-•---------•-•----------•----------...-•-----••-•----••----••---------••-----.....----------- W VNature 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 TITLE 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 b2- ..................d of health. 01 Signed �1 Date Application Approved By.. - ----•-- ---------- --- -----•- ----•------•-`- ZS � � . ............................. Date Application Disapproved for the f oll ing reasons:.------•-------•----------------•---------------------•-------•-----------------•-•-------..Da.--............- -•------------------•------------•-------•--------••-----•----------......------............-•-•-•--•--•.------------------•----...•----••---•-----•-••-•-•---------•-•-----•--•----•---._...._......_.. Date PermitNo.................................................••...... Issued----.....-----•-----------•--••-•..._.......---•-...... Date _' No...- .�.��..- -j Fss........ .. . THE COMMONWEALTH OF MASSACHUSETTS BOARD F' H E A ' 'T c1. C'i..............OF......: '.. .:. ............................. , ppliration for Disposa orks (90hotrurtion rrruti# Application is hereby:made for a Permit to Construct ('') or Repair ( ) an Individual Sewage Disposal` System at �'�%d �r� �C. C. (�'�3 � �',� _____ __ L cation Ad ress o Lot No,� ................................... � •- ' ��,.�........--•.....--•---._..._ � .. "-f ...... .�� �: .........._..... Owner Address ......° . .r. .----•---•...............•- •-•-•....... .._.:� :- - --___.._...__--_- Installer Address d Type of Building Size Lot '4.v b ...Sq feet 14 Dwelling—No. of Bedrooms..........................................Expansion Attic 04 Garbage Grinder aOther—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) dOther,fixtu%s ............... ......•-•---•----•-.....__....-----••._...._..-------------••---•--------••-•-----...-------• ----.............••••-----•-•------- W Design Flow.......... ...: ......................gallons per person per day. Total daily flow........... .__.._ ............-----gallons. WSeptic Tank—Liquid"capacity_y46._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................. ft. Z ( ) Dosing, ( �)�r ,,. Percolation Distribution,T Test Results Performed by. Date............. Test Pit No. 1.. ,�3f.____mtnutes er inch Depth of' Pit.. Depth- o ground"water_.___ P P P, . GL, Test Pit No. ..__. minutes per inch Depth of Test Pit.....:.............. Depth.to ground water............__:....... ................... .....................•-•-••---_._.._...•--••--••••-.......-•-•-._......._... D Description of Soil �') .6..5.ey'z .....................................-...................... W .........• ---_.. ..•----------------•------ -•--...._._..._.._._..•••-•--......................_ -•-•-------------•-------------------------•------•---------------------------._.-•---------._...._•------------•---------•---:---...------••-•------..._............--•-----------........__........•-- U Nature 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 TITLs 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 bo d of health. igned...' � �r ".c�� Date Application Approved By.................... .^'....: ... ...... -t`-••- - Date Application Disapproved for the f oll 'ng reasons:-_.._....--•.........-•---••---••--•--•-----•-----•--------•---••-•----•-•------------------------------------ ............................••-----•--........__..........-------._...........--•----•--.......----•---.....---•-•--....---....--•---------------....._...-------•------...._.__......................... Date — PermitNo......................................................._ Issued........................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT ...... !` .............OF........ZI/ r t.01, ........................................................ (Inr�if iratr of (a auto haurr T S IS TO RTIFY q the Individual Sewage Disposal Syste constructed ( r Repaired by - ................ ( ).j T�}f System constructed rri .•a r:S f, ----....-• .... ...:.... . - -... - ........ - In 1 .. .•• --•- has been installed in"accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.............._....................._..... dated..............,_____..............._............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ..:_ ... - ... DATE. =.........�.�.. ..� ... - Inspector ............. THE COMMONWEALTH OF MASSACHUSETTS - BOARD F HEALT Fay...... ..... Disposal Works Tons#rudi an Vrrnti# Permission-is.hereby granted..................... to Construe ((o o epai r at) (Individual Sewage Disposal f ystem at No...•-•... �.... ............. • .....................................................................: ..... Street ' as shown on the application for Disposal Works Construction Permit No ` �" .... Dated. ._ ?. ..�.�............ ......•-••• ��-�- -----------------•-•---•----.........._ 6 Board of 'Health DATE....i........... . :_. . _.................................:............ Jf FORM 12S A. M. SULKIN, INC., BOSTON ' <f , y. i.. 71 _ .{ I t /�/ter } .. . � ��1•.l;V C/✓���r - ©` � 5.. .. .fir- _ % o,v'► �bu I� s F F t .. G I/ & O 4^ 4' cp 'IIOI�LIIT t'r ' 0 � �,I —,s ry mr i• .N� � ��_ �I� � � �� fdG. 99da7. `� . 51 e %. ,.. - z o N E� r�� £'i�` s r x; 2 S4``.. 'C'. � � ,.�.�./c•'. f z�� !ni/�T J—/ II ."a lX� L67,ple0 / A R7 T!J v/J✓ �S}�!q tv✓-S r ya J� rt yE" 0 Q' OI AI BEE 1 v v 4 ; !A. -i kr7 r 2 —r ( f o(I, y MORSE n Y u LEGEND ( E>tISTIN® - SPOT ELEVATION OAO 4 _.-_:. � _•" . sEX1ETINfa CONTOUR --- 0 - > , CERTIFIED PLOT P't"'AN ArINI HED SPOT ELEVATION—, f k 0 7 3 2 e'14 R T LC y , HED FINIS CONTOUR _,O -��--- C /i/7 ,'p/'/ �. _ 4 1pcation of any existing uT}i sewerage, wells' r or -ether ;utilities shown on 'this; plan Is approx- IN ateanly ,as" d.termined from;recoids' and/or verbal, #� a�nfoxmoip.n The contractor as :z�ospons�ble.= for. the " veriff cation-'of the e.xi.sting locations in,-,; field; SCALES ,`= ��0' DATE �►.�REDIPE`ENG/NEER/NQ Cf1t IN a Ch1.I:NT',,. .,_ I CERTIFY THAT THE PROPOSEQ . 7; ,� EQI$TERE RI a19TER p JOB,. NO; �3 BUILDING SHOWN ON THIS PLAN rl' ;4?CIVIL LAN Df'" � ''� �: CONFORMS ; TO ` THE. 20NIN0 LAWS r OR :QY ,,.�.,.,,,,. ,. 0 „ R RV r : OF. SARNSTABLE , MAs ¢/n M T12 MAI N STREET t �. CNI>eV �4AE H YA N N Is MAss �� z -9HEET..L- Of; REG. LAND SURVEYOR Ar I&xr • Wo CAfl.,VG Ply r Me 77 :.2,�," . I Ar COVER P/A�,041,F colvc-,004 4 10 _'Fr. low -T, SWAZ L &JF BROUGHT 06H r. To 'A C,pNCRCTE017CN Y .c DR/VIE WA)e �L>47_o co P1__jR5 A. co KA &A Cli 4 4f- A r< lq'PIA. I- Y_ OF . �18 U.0 0 CA 1- WA sHr D157 SEPTIC TANK V4 0 . WA SNFP-5774NE UFM f 'W r. -7 a 7 4o , too LPL Z VA 77 J-A 41- PIAM t z T,AT Fr 44, INLET --isMpr-1., I � .X, 1. 1 A . . ON SOX -4 SEWAGE. AOI%f~A.L SYSTEM -rXW"714101V INLET LEA CJV N42,PST Fr LEACHIMa IFCAI-E 4 DESIGNCRITERIA lot, 4- FAIAWS/0'N. DJ vv,,Of SER of 40z' SOIL : LOG - 0,1 SOIL 71-ST402 33 0 G,41.1,OAY SOIL Te57 I I—,-zaq. . LATE OF J01J_' T`E-S MUM&" 06= 4eACAUMG, P/73 / - - -79 AeA c OL A woN RA To / Less MIN /NCN IOT-ro^f 1.1074CHIAl Pill PIr- W, /1-, oA 7 TOTAL LEACHING AREA '—L L' So. 77 S194i'501-i 4?_=.SEokk1E ZE�CNIMS AREA 77 j -2 IV,7 E�f ALBERT' V/2 A. E.3 't L.7 7 tZ MA IN Sr AWANA yv ND ­Z7 jr L 10Af �RL 4-r7AW ,��Wv. 21 vral lip OIJKDER El-&V 0 MAID a SOIL EVALLIATION Design Ccacuictions 00 Date of Soil EVaI.: July 12, zooz M' Number of Bedrooms: 3 ° � WEQUAQUET FAKE �Cest Performed By: Glen E.E. Harrington, R.S. a. Lcavator. Joe's Septic Service Garbage Grinder: Not allowed With this design. Leaching Capacity Required: 330 Gal. /Day Test HI le Leaching Area Required: 330 Gal./(0.74 Gal./Sq.Ft.)=446 Sc,Ft. c� DEPTH SOILS ELEV, Proposed Leaching Structure: 1-25'L X 131V X 2'D Leachi-ig Trench 0 96.38' Leaching Area Provided: 471 Sq.Ft. �Johrbn l� D/A Proposed Leaching Capacity: 353 gpd > 330 gpd. req'd. a Nee Ln. sad loom l SITE Thread d g" 10Y5/4 95.71' j Little Zn 45" sios%< 92.63' 4, 5 4' arg 2" OF 1/8" TO 1/4,> C� ondyfloam _ PEASTONE (WASHED) -- reat M� ��11t11"1ey'S / 2.5Y7/6 67" 90.80' .� Road ar,,y � � _ E ane CZ Col 24" MIN- m-c 120" 86.38 t n 1 ' �\H �� L_ H-10 500 gal. chambers NO GROUNDWATER ENCOUNTERED (� ' V �O y, 05 �� \ 3/4" To 1 1/2�� WASHED -DRUSHED STONE ICI{- 2. �L) \ �`-�` _ _- -_ / 7_�8_2 TRENCH CROSS—SECTION L CUS 4 rn 0 / ����) 9' NO SCALE R/ GE '� ERAE NOTES Nfl SCALE g7 .J7 , / r e..�o, �� 7^ 0� II ` `�_ 1. ADDRESS: 59 WHIDAH WAY O�� \ Q \ l/✓�i C ~� 2. ASSESSORS NUMBER: MAP 230 PARCEL 204 ci 0 o ✓� o ( v �� �IVI�� ( / 3. DEM . C?PER'S LOT: LOT 32 4. TOPOGRAPHIC INFORMATION WAS COMPLIEV FORM AN Jt 7 9 2 ��2 ON THE GROUND INSTRUMENT SI RVEY. _1. TOWN WATER IS PROVIDED TO SITE AND 9 E A 2 6 �2 S . ' T. G/ / �, - Q F c �URROJNDIhJG FROPERZfES. S Q) / j 6. REFERENCE PLAN. PLAN"BOOK 395 PAGE 91 6�, G / 7. NO WETLANDS ARE LOCATED WITHIN 100 FEET OF SAS. CL 99 \ �C / 8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. \ / r, LLI C/ I CONSTRUCTION N07E,� 4,2 X S7, 2' X� slob �� 1. Contractor is responsible for Digsofe notification - and protection of all undergrobnd Vfilities and pipes. __J 2. The septic tank and distribution box shall be set level on 6" of 3/4"-11/2" stone. 3. Backfill should be clean sand or gravel with no stones oveF 3" in size. uti ties. �9L6 � - ea.C�__"- -� _ 4. This 'system is subject to inspection during installation X O r'h / o v. �5 __---__--_ �C✓! C�j C� �� �y' � ,� :_" _ __ _ _ . _- /_ _ by Gen E. Harrington..R.S. _ q� 5. The contracto- shall install this system in accordance with Title" V of the Massachusetts Environmental Code and the Regulations of the Town of Barnstable. O > 6. Provide an Acme Precast 5-Hole H-10 j92 U, / d-box with 2 H-10 500 gal, chambers or equal. N 7. No vehicle or heavy machinery shall drive over tie septic systern unless noted as H--20 septic components. 98 1 8. Instal gas baffle or equal on septic tank outlet tee end. I f� 9. All existing inverts and site conditions shall be verified by contractor. dPCB 10, Existing LEACH PIT to be pumped and backfilled. 7 �(, g' C� ( / 1 1. Five foot stripout required horizontally and down to C2 (E•7") around SAS. 0 9 e '�s i ear�i pit to (be 1 o 1 / p q LI pea 6 baakfi led F 99,b3 X 99,1 1_20"DRAM,ACCESS MANHOLE X 9 3 0 ��' / 8 5 H if 9 / % I= FEM I[= C 3 34" # 0 0 0 — 25' E X 13 W X 2 ,0' E) 24,. ° r STEEL REINFORCED PRECAST'CONCRE,E - 2 H-10 500 Gal. Chambers leaching trench using _� PLAN VIEW ENO—sEcl, chambers 21 H-�- 10 500 gal . Chambers with / � H-10 500 GALLON CHAMBER of stone on sidles & ends , � N07 To SCALE `— ,2,1 , USE ACME PRECAST OR ECIUAL � o / a 83 E }I` E PLAN /-�� �Ik ��qti��®FMq�s PROP0,SED SEPTIC SYSTEM UPGRADE V N/ f +--.- j r " `r ®+Z' PREPARED FOR �N SCA_E: "I =20 ER , MARY HURTUBISE 2 3020 Y BENCH MARK ON CORNER OF CONC, LEGEND � HA � ON � 2 APRON TO GARAGE ELEV.=100.00' (ASSUMED) ,1®70 AT C) j EXISTING, LEACH PIT TO BE �liq 5� WH DAH WAYPUMPED) & BACKFILLED FG(S'(rG�P�v *NOTE: ALL PIPES ARE TO BE 4" DtA. SCHEDULE 40 P.V.C. J- EXISTING 1,OOC GAL 4 'TA ` BARNSTABLE ICENTERVILLE), MA 10' in. from NOTE: INSTALL GAS BARPLE OR EQUAL ON SEPTIC TANK OUTLET TEE, © O H-10 SEPTIC TANK _ house to septic tank ° Septic tank covers md-st be Finished grade over system=z% slope away Existing House within 6" of finished grade 5 HOLE X 104,46 DENOTES EXISTING A-Box cover must be DIST. BOX one chamber cover must be SPOT GRADE S. within 6" of finished grade _ _ (�-{- r XlI ,;. ADE finished !sue m^9 CradB Etev;"Sg ., ,,,...rxQ srussss 95 EXISTING CONTOUR \ (I\�V I i�I V y R°\J within 6' of f n'she d _ GLEN E nt1 �/ U 1 Min, 2'-1/8"-1/2" 12'3vnn. .__._ J= 0.02' 9 LED ROSE LANE S wasl-ed stone 36" max. �,,�] S=.G1 Level for 2' L—' o.. 70, EXISTING 3=.01 Top Elev 96 5_ DEEP TEST HOLE �` - r \AA ^^ � 0(�} Cellar 1000 GAL 3 �--- MARJ1ON-� IY'1 LLSs VIA �1�� 8 SEPTIC 7ANK N o 12' nvert Elev.=95.78' -Y H10 ® ®® APPROX. LOCATICN GAsBAFFLE a m o m - ira ®o cs 24' MW. sotto" of Leach -' G--- G - - G EXISTING GAS SERVICE TEL: J.OS_428--3862 oR eouAL o µ n G5. _ Trench Elev.= 93,78 ' W FAX: 508-428-3862 d v > 7.4' (5' min. required ` W ------------W APPROX.ING LOCATION EACH TRENCH w -.- ' EXISTING WATER SERVICE -` 6" OF 3/4"-11/2" STONE -- a Bottom of T.H. #1 0 SYSTEM PROFILE c 1ev. 6,8 SCAL=: 1 "=20' DRAWN BY: GEH NOV. 1 , 202 6" of 3/4 11/z STONE DATUM: .ASSUME[ FILE: 'HURTUB.DWC SHEET 1 01` 1 Not to Scale - J .� tT�n.�er1 3 Cs(�