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0086 WHIDAH WAY - Health
$6 WHIDAH WAY ,Centerville ` f� A= 230. 197 i a M E A D KEEPING YOU ORGANIZED No. 12534 2-153LOR WRES A" MIN.RECYCLED INITIATIVE CONTENTIO°!o® CorGfiad Fla' Sourcing POST�CONSUMER www.sfigrogram.org af9-01270 MADE IN USA GET ORGANIZED AT SMEAD.COM V U Barnstable Town of Barnstable Regulatory Services Department AMmt>icaf j BARNSTABL- 1639. ASa , ' Public Health Division m F0Mr�°i 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-M-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 1512 May 2, 2017 GIGLIOTTI, LISA & GEORGE G 6167 BLUE DAWN TRAIL SAN DIEGO, CA 92130 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 86 Whidah Way, Centerville,MA was inspected on 04/19/2017 by Michael DiBuono, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 C MR 15.00) due to the following: • Backup of sewage into the house due to an overloaded or clogged SAS or cesspool. J .,��'" You are ordered.to repair or replace the septic system within six s from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH G T omas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\86 Whidah Way Centerville.doc I,. Postal CERTIFIED MAIL0 RECEIPT' JU .. • ra OFFICIAL - USE [r Certified Mail Fee Cr $ Extra Services&Fees(check box,add lee as appropriate) t• [�Return Receipt(hardeopy) $ 5 t� O ❑Return Receipt(electronic) $ k O ❑Certified Mail Restricted Delivery $ []Adult Signature Required $ `,tr^• ❑Adult Signature Restricted Delivery$ ��rt O Postage (C7:Here m $ �� Total Postage and Fees a sentTo '`,GIGLIOT.TI, LISA & GEORGE G r- o s«eetard. `".t6I67rBLUE DAWN TRAIL City State,4+ SAN'DIEGO, CA 92130 :.. r r r rrr••. - - --- Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipients retail associate. signature)that is retained by the Postal Service'" Restricted delivery service,which provides _ for a specified period. delivery to the addressee specified by name,of Important Reminders: to the addressee's authorized agent s lm p Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®;First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age International mail. and provides delivery to the addressee specified.t ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent'. with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is "1 insurance coverage automatically included with accepted as legal proof of mailing,it should bear a- certain Priority Mail items. USPS postmark.If you would like a postmark on I rr ■For an additional fee,and with a proper this Certified Mail receipt,please present your .r• endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for the following services: postmarking.If you don't need a postmark on this—' -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion] of delivery(including the recipient's signature). of this label,affix R to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. Ps Form 38OO,April 2015(Reverse)PSN 7530-02-000.9047 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3. A. Signature �j�,, ■ Print your name and address on the reverse X�G`��� r'l ❑Agent so that we can return the card to you. 0 Addressee 4 `"' B. eceived by(Printed Name) C..Date of Delivery ■ Attach this card to the back-af the mailpiece, � L1C or on the front if space permits. (� �'C'C/N� 2-9Mllij /+ 1..Artiole Addressed.m _ ,, — _i D. Is delivery address different from item 1? ❑Yes If YES;enter delivery address below: 0 No GLGI.In"TTL LISA'&-GEORGE G'¢ ';6 i 6,7 BLUE DAWN TRAIL r SIN DIEGO,:CA 92130 . i � L II I IIIIII IIII III I III I II I II I I I I IIII I II I I IIII III 3. Service Type Priority Mail Express® ❑Adult Signature ❑Registered M61ITM i 990 duIt Signature Restricted Delivery ElRegistered Mail Restricted rtified MaiUe Delivery ..l 9590 9402 2480 6306 7766 05 ❑Certified Mail Restricted Delivery etum Receipt for 0 Collect on Delivery Merchandise �. Article Number ffraneso�f "-lelivery Restricted Delivery 0 Signature CohfirmationTm ❑Signature Confirmation �� ?015l 317 3 0.(,0 0 01; 4 9 9 0 k t1512 f t t+�Restricted Delivery Restricted Delivery (over$500) _ PS Form 3811,July2015 PSN 7530-02-000-9053 Domestic Return Receipt USPS TRACKING# First-Class Mail Postage&Fees Paid USPSJu Permit No,G-10 9590 9402 2480 6306 7766 05 United States •Sender.Please print your name,address,and ZIP+4®in this box* Postal Service Town of Barnstable Health Division I 200 Main Street Hyannis, MA 02601 Ifi Town of Barnstable a�xxsr�acE: . 6 ,�� Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA•02601 Office: 508-8624644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES T.O•REPAIR FAILED SYSTEMS (To -44 and Title V: 310 CMR 15.000) _ An"x"m, e e ❑ is the fa' criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or pondin o o the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ackup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Single Cesspool ❑Any."conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway,due to H-10 components, etc) ❑Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc No. 1� ! v Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pprication for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair(upgrade( ) Abandon( ) ❑Complete System .PlIndividual Components Location Address or Lot No.&,LZv I(NA Owner's Name,Address,and Tel.No. F_ i � Assessor's Map/Parcel 5 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size ;�Q 04;?— sq.ft. Garbage Grinder( ) Other Type of Building d t-,s tcy;*Ira No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided '�i'�C'�, Lj gpd Plan Date C 1-1`] Number of sheets �_ Revision Date Title Size of Septic Tank Type of S.A.S. tiC Aojrlgu4t��� Description of Soil Nature of Repairs or Alterations(Answer when applicable) i,,jr-,,krlj c.L_,,i 3 eW c3 1Dc2,r Ck,a30 C�0,&.1 t'rS Uv tl—►� N ' �•fir.; cc� ��rr��ti ep^) 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 Certificate of Compliance has been issued by this Board of Health. Signe - Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2t] " (J U Date Issued '—�Z "�7 IF ,..m..-n` -- -... T .r r" n ,. „ r... ,. .�v.G, ,. •a n .. `rrr... .. ..�-...: �; �.•.�.;,.r,.. .t•,. � „ r ,:�-dr ;A' 1� Y� � .. 1 No. � v,7 l D i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION 'TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for v4osai 6pstem Construction Fermat Application for a Permit to Construct Repair(VT Abandon( ) ❑Complete System „®'Individual Components � Location Address or Lot No9G Wtil ��,� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 27 Installer's Name,Address,and Tel.No. Designer's Name,Address,andTel.No. + Type of Building: Dwelling No.of Bedrooms Lot Size O,p'e; sq.ft. Garbage Grinder( ) Other Type of Building rs tcj�r Ce No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow(min.required) ? gpd Design flow provided L.) gpd 5 Plan Date G -1-17 Number of sheets D Revision Date Title Size of Septic Tank (-y<I Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 K)�,,}rj ra,✓-��t,� ;Vjc �� - 9%Q 11C1A l 1AL'llMlD`P�s9 Wl} Lt L� �[)IVZ' Gtg �1 Wna en& 1{lli i Date last inspected: Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date Application Approved by Date / /-7 Application Disapproved by Date for the following reasons Permit No. 2 U/-7 - / o Date Issued ' !L `j 7 - . _ . -_ - - _ _ - - - ------ ---- - - - ---- ------------- ----------------- ------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS t, Certificate of Compliance I THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Upgraded( ) Abandoned( )by ,.�c�o A !�x j rJ T N c— at t;JJ,i� it `fw�c. . �� /v t,1 P has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No p f 7 9 0 dated Ij Installer A Designer #bedrooms Approved design flow gpd f The issuance of this pVaishall no/lf be construed as a guarantee that the syste will f nic'on desi ed. Date �s/ Inspector ��.....,.�/ r No. ) O ( 7 ` 00 Fee !THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Nsposal 6pstripAronstruction Verm t Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at g o try k 1 CMG"1 ep and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. i Provided:Construction must be completed within three years of the date of this permit 1 Dated 1 Approved by TOWN OF BARNSTABLE �;OCATION SC `` Nn W4N SEWAGE# RO 7 &(J VILLAGE Le i� ,ef ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.J .ac),_% &� L1,T=rQC SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 96411(��Otyg�lq''�(size) Z NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Y �y _8 c IC D - r ser Town of Barnstable .° IK*E °o Regulatory Services Richard V. Scali,,lnterim Director tantuvsrnBtE. w.. 'Tublit Health :Division v� 1639. �0 ,offo39,ta Thomas McKean, Director F 200 Main Stred,Hyannis,MA 02601 Office: 508-S62-4644 Fax: 508-790-6304 Installer&Designer Certification Form 20(7 0 Date: Jyrte ��� Sewage Permit# Q0 (7�Assessor's Flap\Pareel 23 (17 Designer: Dvy;A Covfrl aodt"r Installer: Address: I55 66:1 &(je/ ?A h Address: C� tkH , w,� E On was issued a permit to install a (date) (installer) septic system at , W k' ci k Wk�� based on a design drawn by p J(address) -� D44 D. (ovf4qh0Vr, t� S dated vne 1, Z01 7 /� (designer) V I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution boa and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State c'' Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(ifrequired) was inspected and the soils were found satisfactory. 1 certify that the system referenced above was constructed 11 a with the terms of the IkA approval letters (if applicable) �pti�' o�/t�$sge DAVID yGM D. COUGHANOWR N (installer's Signahtrc) No. 1093 (Designer's Signature) (Affix Desity s S amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH H DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL 130"I'H THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:NScpticllaesigner Certification Vann Rev 9-14-13.doc. Eversource E-Bill 4 Page`2 of 2 https-/Hsecure8.i-doxs.net/NSTAR/Secure/PayAdd.aspx 6/15/2017 i Town of Barnstable P 6 7-S De artinent of. ,•I1'' � p Regulatory Services �• a�a,var�ers4 F Public Health Division Date �.� 1�3A 200 Main Street,Hyannis MA 02601 r ! 1 1-1 ' f Date Scheduled` Time Fee Pd._ d dt4 ;) Soil Suitability Assessment for Sew age Disposal Performed-By: <b VCCkq 110d✓r , �—j Witnessed By: LOCATION&.GENERAL INFORMATION Location Address '• '�Y1 r d qI ,p tn�u Owner's Name y �e �P V l ) 4l _ Address Assessor's Map/Parcel. ` 23 `/IU /—7 Bngincer's Name 1),-4 /� (/1 �G1lgUw✓. NEW CONSTRUCTION REPAIR �� D x / Telephone# � p Land Use (�A ' Slopes(%) 0 L Surface Stones Yt'"h o Distancos fbm: Open Water Body It possible Wet Area L-1 R DrinkingWater Wall 1 �0 ft • r y� i Dralhage Way t ft Property Llnc D tt Other {t SICEbTCHC(Street name,dimensions of lot,exact Iocallons of test holes&Pero tests,locate watlands?a proximity to holes) -41 �-2- :w e �3 .2 Parent material(geologic) ®n n Depth to Bedrock V1 0 M q r Depth to Oroundwatcc Standing Water In Halo: ` _ Weeping from Pit Ron C Bsdtnated Seasonal High Oroundwatcr wore ���n 13Z ttg 'Croon 5vv'�9C� I DETFINIINATION FOR SEASONAL'HIGr�I WAT]�R TABIr� Method Used: VV10. �n� I De th Observed standing in oba.hole: _ _— In, Depth to soil mottles. Do�th to weeping from side of obs.bola; In, Groundwater Adjustment ft. Index Well-di Roading Dato:• Index Well lmvol Adj hotor ArQ.Clrtaun'dwater•inVal,._ PERCOLATION TEST bate 3i t Irime Observation + Hole# (� Time at 4" `q Depth of Para l !!11 Time at 6" Start Pro-soak Time @ _b V Time(9"•6") Vt` End Pro sack ! `0 Rate Min.Anoh Site Suitability Assessment: Slte Passcd Sup Failed: _ Additidnal Testing Neoded(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on back • I I ***If percolation test is to be conducted within 100' of wetland,you must first.notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISBPTIM13RCFORM.DOC j • I Vo . O DEEP.OBSERVATION HOLE LOG Hole#—�— Depth from Soli Horizon Sall Texture Sdil Color Sall. Other Surface(In.) (USDA) (Munsell) Mottling (Stnueture,Stoned;Boulders. • rsistoncy.96'Oravall • - l2 Q Sad b1m CD` P-3 lZ �30 W Fr 1.,r*b le t 2 3`f- B w Lo4o 3q#W Fri a b l P' lsq- 112, to DEEP OBSERVATION HOLE LOG Hole# Depth from Sall Horizon Sall Texture Sall Color Sall Other Surface(In.) (USDA) (Munsell) Mottling (Structuro,Stones,Boulders. 0. t2 4 P . • Sind �G� W •P-312 No�e, � q • C2•-3Z q w Locimy S'iad eo`�P SlG I' �fl4bl -------------- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Hodzon Soil Texture Sall Color Soil Othe r Surface(in.) ..�; (USDA) (Munsell) Mottling (Structure,Stones,Boulders, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Solt Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Slopes;Boulders, Flood Insurance Rate Map: Above 500 year Pood boundary No_�. Yes Within 500 year boundary No/1 Yes ' Within 100 year flood boundary N04- Yes Depth of Naturally Occurring Peryigus Material Does at least four feet of naturally occurring pervious material exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what Is the depth of naturally occurring pervious matorlalfi _�__�.. Certi--- tion �DJ �qj I certify that on (date)I have passed the soil evaluator examination.approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required ning,Wortlsoanp experience described In?10 CMR•15.017. Signature I ��l' Datts �Ita. 3 2l7 Q;%SB1-T1C%PE11CPORM.DOC <� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Whidah Wa Property Address hN;7 George ig Owner liotti_ - G -------- ----------...-------------------- Owner's Name ' --- information is L required for every Centerville Ma . 02632 4/19/17' - - -- _ -------------- ---- — page. City/Town - State Zip Code Date of Inspectior'> .: 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return -- ------- -- --------- -- ----- — key. Name of Inspector DiBuono Sewer and Drain Company Name 8 Johns path -_ ...._ Company Address E«r� S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 —_ _ — S113522, _ _ — 't -Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function.and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of - Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails Needs Further Evaluation by the Local Approving Authority 4/19/17 "Inspector's Signature Date I The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perfornrl the future under the same or different conditions of use. 15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17 ®cja . Commonwealth of Massachusetts -- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Whidah Wa Property Address — — — — George Gigliotti� Owner Owner's Name information is required for every Centerville_' _ Ma 02632 4/19/17 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: ❑ I have not found any information which indicates that any of.the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments:- B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Whidah Wa- Property Address George Gi liotti - --g-----9 - ._. Owner - __..._... . . .... - ---- --- Owners Name . - information is required for every Centerville _ _Ma_ 02632 4119M 7. • ' page. . City/Town State Zip Code Date of Inspection B. Certification (Cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑__Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): r broken pipe(s) are replaced ❑ Y ElN ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ------------ ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ .ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and.the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3113 _ Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -1V0 86 Whidah Wad---- - Property Address- George Gigliotti__ Owner ----------------------------------------..---------------- ----___---------- == Owner's Name information is required for every Centerville Ma 02632 4/19/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within . 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if-the.well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm„ provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: ; 1 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 El due to an overloaded or clogged SAS or cess ool ® 1 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow l5ins^3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forrh — _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ 86 Whidah Way Property Address George Gigliotti f. . Owner - - ------.._.-----___--------------------------------- Owner's Name - _. information is •, required for every Centerville. _ - Ma 02632 4/19/17 page. Cd State Z yfiown ip Lode - Date o --==----- _- _ _ . _ 1p Code 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, for4ecal 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 failurecriteria 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. ® El 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 F-lealth 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 god to 15,000 god. 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'Se'ction 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. 15ins•3113 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 86 Whidah Way Property Address George G ig I iotti_.— --—-------------- ------- Owner Owner's Name information is required for every Centerville Ma 02632 4/19/17 page. City/Town State Zip Code Date of Inspection C. Checklist - — ------------------- ------ Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the `previous two weeks? + ❑ ® 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 In-Formation 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): 3302 !Sins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I _ Commonwealth of Massachusetts —..� Title g Official Inspection Form I? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -- Y a 86 Whidah Way Property Address ----- - — ---- George Gigliotti Owner's — —— -- — - -- ---- ----- ------ == wner's Name _ _— information is t required for every Centerville - _ Ma 02632 4/19/17•__ City/Town/Town _..___..._.. ------------page. Y State Zip Code Date of Inspection D. System Information Description: System contains a 1,000 Gallon septic tank, a Distribution box and a 1,000 gallon leach pit. Both the septic tank and leach pit have scum under cover. As well as over top of pipes. System has been in hydraulic failure. Number of current residents: 2 K Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) _ ❑ Yes ® No Laundry system inspected? Yes ❑ No 1'. Seasonal use? Lr ® Yes ❑ No Water meter readings, if available last 2 ears usage d 214 GPD . 9 ( Y 9 (gp ))� Detail: Sump pump? Y ❑ 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 Title Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Whidah Way Property Address - -- --------- -----— --- Gedrge Gigliotti Owner Owner's Name information is required for every Centerville _ — Ma 02632 _ 4/19/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date 'Other(describe below): General Information Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? -----T------ --- - --- Reason for pumping: -- -------- - Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system es or no if es attach rev'❑ lolls inspection records if an Y (Y ) ( Y p p Y) ❑ 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 86 Whidah Way Property Address - George Gigliotti Owner Owner's Name —---- -- — ----- -- —--- ---- e----- — information is required for every Centerville .. ._ _ __.._ -.-_: Ma 02632 4/19/17 City/Town' - page. Y/Town State Zip Code Date of Inspection D. System Information (cont.) -------------------------------- . -- Approximate age of all components, date installed (if known) and source of information: 28 Years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): ----------- — Distance from private water supply well or suction line: feel ---- — — Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 15__ _ feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) 1,000 If tank is metal, list age: '' . r `.. --------------- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: l5ins•3/13 Title 5 Official Inspection Form'Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts _ F Title 5 Official Inspection Forte Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 W h ida h_W_a_y"- -------- ——-=----—--— ---------------- — Property Address George Gigliotti _-- ---------- _-- Owner' Owner's Name information is required for every Centerville - _Ma 02632 4119/;17 page. City/Town 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 24" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick,-- _-- How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Should be pumped before new install 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 -- 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System,Form - Not for Voluntary Assessments ,» 86 Whidah Way— ---- - -- ------------ - Property Address George GigIiotti O _ _ t Owner _ Owner's Name , information is Centerville Ma 02632 4/19/17.required for every --------------- ----------------------------- ------- -------------� ----- . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: ------------- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions.- Capacity: — ----- — — gallons Design Flow: gallons per day -------- -- Alarm present: ❑ Yes ❑ No Alarm level: --------------- Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts — W Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 VVh ida h Wad -- ---------- ----------- ------------ ----- Property Address George Gigliotti Owner Owner's Name - — -------- — ---- ---- -information isis Centerville Ma 02632" 4/19/17 required for every page. Cityjown 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 Not found. Pipe to Dbox crushed _ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber (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 F Title 5 Official Inspection Fran Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Whidah Way ------- ---_.------------- --- - Property Address George Gigliotti Owner --- --- ---. ----- ---- --- Owner's Name -- -- require tion is Centerville Ma 02632 4/19/17 required for every _ _ L page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ Type. 1 ® leaching pits number ----" ❑, leaching chambers t number: } — L ❑ 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.): 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 15ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 86WhidahWay _—_-_- Property Address -------------------------- — George Gigllottl Owner Owner's Name --- - — ----- ----- ----- - - ---- information is required for every Centerville _ Ma 02632 4/19/.17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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 i Commonwealth of Massachusetts -- :; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A . 86 Whidah Way Property Address George Gigliotti O Owner --- •;. wner's Name information is Centerville __ , Ma_ 02_632_ 4/19_/17 _required for every _ _ _ _ page. City/Town 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 15ins•3/13 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title fflcialIns ion Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Whidah Way Property Address George Giiqliotti _ Owner Owner's Name _ _ _ information is required for every Centerville Ma_ 02632 4/19/17 — -- — ------ — --------------- ---- _ 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: TBD at time_o_ferc testfeet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: . Date — ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: TBD at time of�erc test Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 t �... _. _ _. _ _. _ _ l _ � _ :. _ `. . ,. W :.r, ,y` °' . � `� l � d ' 1 _ � , d I�, _ .. .. � ail `. .. .tt.. lr.J. ,' .. .- Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Whidah Way Property Address George Gigliotti Owner Owner's Name --- ----- - — _— information is Centve required for every —_--er--...--ill Ma 02632 4/19/17_---------------------_..__.______------------- -- — ------ ---- ------------- page. City/Town_ State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information - Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file T (Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 17 of 17 r / v� LOCATION vuse � SEWAGE_P [7 11V NQ. 9- LLAGE INSTALLER'S NAME a ADDRESS /t-b B U I L D E�ryR rON OWNER DATE PERMIT +ISSUED DAT E _..COMPLIANCE ISSUED i THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEA T �CX!..... ..............OF.. .. ..... l...0....... .. ., f............................ Appliration for Biopo,sal Works Tonotrurtion rumit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal syst ate / !'..a..`1..Gf >�-�.-- - --------6.1Z / ram'/ / -.................................... Location-2. ress or No. Owner Address F ----- --c--!-�-c-®11---------------------------- ... t............................................................. Installer Address d Type of Building Size Lot-?jqf*_ ....Sq. feet U Dwelling—No. of Bedrooms......... ..............................Expansion Attic (kd) Garbage Grinder (p 4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria a Other fixtures ________________________________ W Design Flow_._...--- ...................gallons per person per day. Total daily flow........3.1.0_______________________gallons. WSeptic Tank—Liquid*capacitylpQ0...gallons Length................ Width................ Diameter................ Depth................ 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 tack �61 Percolation Test Results Performed by.__ lr .............. Date__.__ �_.. Test Pit No. 1)�.4:5 5_._._minutes per inch Depth of Testit..._``_ _ /...... Depth to ground water_-/_��j Test Pit No. � .Xminutes per inch Depth of Test Pit_/O.._..__.._ Depth to ground water°`..� �__._ Description of Soil.._._; v •-•--•-•....----•-•• •---..._/_. s _..-. .:_ v ........ ?.► ,'.. _. .__....-•------------------------------------------ ................ ----------- `ff -------1. -----------� �' ----------------------------------------------...--------------------:•.•-._...----------------._._._...--------- 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 T I T U 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in P P Y health. Si ned_._ , I� operation until a Certificate o Compliance has been issue the - o ea A. • Date ApplicationApproved BY--- --.._._... -.......................................................... ---•. .......... Date Application Disapproved for the following reasons:-----•---------•-------------------------•--•---------...------------------------------------------•--•--•••••- --•-•-----••-----•••--•-.....•-••-----•-------•-•-•-••-•-•-•-•....-•-•••--••----•-•-••------••-•-•--•--•-I-•...--•-----•-------••--•----•-•--••---•-•-••-••••••--•••--•-•--••••--•-•---•--•-----....-•--- Date PermitNo....... " (©`7 .................. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS . BOARD F HEALT ...........OF... � .°" .... ........................... Appliratinn for Disposal Works Tnnstrurnurt Prrmi# Application is hereby made for a Permit to Construct ( or,Repair ( ) an Individual Sewage Disposal ......................................... Location- ress or 11 ..... �c: o_........ - - •--.... ..--. 0...K = .-----Er::ads . . ,... Owner Address fifi a� v .............................................................. Installer Address Type of Building Size Lot�' t .. : ►4`.__.Sq. feet U Dwelling—No. of Bedrooms.........= ------------------------------Expansion.Attic (ki,c Garbage Grinder (ol y P4 Other—Type of Building .-.-_--.-- No. of persons............................ Showers — Cafeteria G4 Other fixtures ----------------------------•••- ..........gallons per person per da Total daily flow........z - - `.......................gallons. W Design Flow g P P P Y Y WSeptic Tank—Liquid capacity ". ...gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..•------------- --- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tauk a Percolation Test Results Performed by. ! ft�.:`: ............. Date.....77 `*? ,` Test Pit No. 1, _5��.....minutes per inch Depth bf Test' it _.-_.•- Depth to ground water.._ (i Test Pit No. '� ' ---.�txe:!l.sminutes per inch Depth of Test Pit.r.".. .:........... Depth to ground water........._.._.._..___._. R+ r^ /�r� / ----..... ------------------ ••............ .......-------...... O Description of Soil......0 !` C>Grs�i :,eJ Jf� ------------------------•-- /. .... - ._ -t. i' - Y ,iI U ---.. ................................ ....... ......................... f r' - ,:.._.:..... 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 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 theb of health 7w.4- Signed.._ :x w...... Date Application Approved By... .. �...- :................. Date .......... Application Disapproved for the following reasons:.........:.:................................................................................................_.. .....-•--•-•.............•---...•-----....---•••....••••......•--••-.......---••-------...........----•-•.--•..............-••-•---••-••••....•••....................--••-•••---.....-•-•••----•-•------- Permit No..... /�'tT� ....... Issued.......................•••-•---•-........__Date...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALT f (9rdifirate of faumplittnrr TH S IS TO C�TIFY Th t the Individual Sewage Disposal System constructed ( or Repaired ( ) s by...... . - = . : .0 a. - a._.... --------- at --------------------------------- ---------------------------------_ j .. ,1 Installer p .....�!. ..... .:.:: ' .'.t,, ! _f:i..... .. '` ..... r" Z- ' ...... �`�- has been installed in accordance with the provisions TI F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... ...............Ot...7 dated......(.f12-P 0 ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE <SYSTEIVI WILL FUNC ION SATISFACTORY. DATE... .),I......... -�-�.................................... Inspector ...-----....---•----.......---------.........-•---• THE COMMONWEALTH OF MASSACHUSETTS BOARD''OF HEALTH ......70-W.-.f... ...........oF...... �- � . ........ ��-- Fzz...,..�. �i��ru� 1 murk �un��r irrn hermit Permission ted:. ...:�..- ------••.............................................•-.................... reby gran to Construct or .__.. Repair ( p) a Individual Sewage isposal SiSy' at No. y / Street as shown on the application for Disposal Works Construction Permit ............................. _+ C :=<: Yu .--•------•-----........._ Board of Health DATE...... " =,327_ ' FORM 1255 A. M. SULK,IN, INC.. BOSTON j'� /n T S GG a r' 3. G ® �� j .. 58 T OJ O 72-5 2v b 5 _ T rr Gp , vj97 A. P Vj S i ` • - .��� ��. , �iY /�Y" 'l/fl `rl 'Yid -�. f LEGEND f<,. 1� :EXISTING SPOT ELEVATION OAO CERTIFIED PLOT PLAN 00-STING CONTOUR --- O /'IM►SMEO SPOT ELEVATION ' Lod Z� l�✓/ //L ,1i// W.4 � # tM1p.E0. CONTOUR 0 ' L"/✓ E. �/� z J iocation of any existing"u_nd_rg:•ou_d sewerage, IN J ' woils -.9r .other utilities shown on this plan is approx- imat�e nlx as determined from.records and/or verbal ;;gy Alt p on, :.The contractor is. responsible for the r �ioxf, caton of the existing locations in the field. SCALE "- O DATES �/,/91�s E DREDGE ENO /NEER/NQ CCJI ING� 6izE�-n/aV ' CLIENT. .,_ I CERTIFY THAT THE PROPOSED REGISTEREQ JOB NO. f3 �9 BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS r E R DR.QYi '�,.A:. ...._ OF SARNSTABL'EMASS. .7 •, ' 712 MAIN STREET. -7 Lce57 CH. BY /MYANNIS� MABS. 9NEET—L OF �� T REG. LAND SURVEYOR 77777777 .y Sr • s :5 ,-'~= ._.�• -_NOTE /F E/7iY=I!RTNf SF C�TANK lDR cHlar+rG�`�ir.,4J�rE JrJORL= {TNAt✓`./2 QEtOn/ :MIiV ' rsRi'1 DEJ�. ?4:�//17yFT..ER CONCRFT.E fONE.+r r� R St1ALl dF.. B1P uGH.T TG G/qA DF.��Jv :EXTRA PYC P1PE t CovcoCCTE i /YE.4Yy C!�ST°IRON GDI�ER SiV.41L.BE USES M AN- PITCH !F/N DR/VEWA Y, fit-:s9:O COVERS pZ,p FT j ' u=, dJl.4GE CO YER CL EA V SAND 1 � L 941140 LEVEL 2'LAYFR t:a /P�•Il N.PlTC!/ ': e• •t • . • . • • r s •• WA S tiED 57 'r C t '= Vi•Pe�e rrr. SEPTIC TANK D/sT. • _ • . . . • . t r 80X • • • •� 8 • r • .• • r . • . a � { fir• .,'�' � r •Et'fECT!✓E ' � : 3/ '- I /z` �: • • r • • DEPT// • • • • . WASNEO STah'E i.o / /3 ► s.. . r • • . • • • •• • � ••r PREGSTS. 1946E Piz" OA / A 0 G.at DAy P/T DR L�pUJv. lNi�P�t T L`L ENAT/DNS c.r+ y / s ,. . • • . . . . • • i • - t � • s � L-L �8 0 INVERT AT Ol/JLD/1VG S 3,v 3 r L Fl: D/�ll?• i ,SEE 7W.,W LAT10N� /IVLE7 .Siapr.IC T.4/VK Sz-�FT, l z f7 O//aM. C oU7,LET SEPTIC 7ANK 5Z (--FT, //VLET Ol3TR1AVT/D/V BOX SZ 9- FT SEG7"/ON OF GROu/VD..It�ITE� TitaLE N/TLFTO/3TR/BdTION BQX SZ? FT IJFLE r LCACYI VCr AV T s z o FT SEl�AGE O/SPOSA L .SYSTEM W "TIOM L EACH/NG P/TvjH .6JCALE FT. DES/S/V CRITERIA O/tfE�++rslo N S—�—FT• FT.. /''r I N . NU�ldER OF 4EAROOMS 3 tRQ.tGED/spossl UNIT Non/ SO/L. LOG TOTAL EST/MA'T•ED FLOW 3 3 O (;.A D,4Y SOl L TEST 11E/ SOIL Tl�ST�2 Sa/L TEST t N G / �r�_`� EL AT OF 80/L TEST YUM"R 4r LEAC !N P/T� �^F[EY. l�Y. D E � � IS//TNESSED dr ��• Cv��a'v RPSt/1TS �- AAL�:SS INCH At0 rrOM LEs4CN/%VG PER PJT l SQ it; .� ,� ,yj PEACOL/•►TIOX TQ� TOTAL LE4CH/NG AREA Zh4 -s4 cT S�.>� r: '= PE1rCo4LA "ON RATE 2 -r, /� n/MI�•�/>vc ?ESEMVE LEA N/NS AREA �4 SC. r T �:^ _ 4 � � •t, ,.- .sort _� B. e� ElD "DGE`✓ \� 'lj I PFO /yA/N Sr, H)eA A( MA S. \ - T JYO GROUND WATL`R EJti/COUNTE�eEO tL/ENT ���c�GIdTE•(p / r 8 �] Cs�OU/YO L✓slTER �1T FLEt/. Ft3 09l �MGI�Ts� Y roe a A'-,NAY NOT A' TO SCALE sT19 LEGEND N,�N��s 3 y/l`90q�9'9J SEPTIC COMPONENTS P am Z EXISTING n a AT 1000 GAL `` 3 S 2 po V (C pV IrMM SEPTIC TANK m LOCUS o Eco= T.ECW°VS EXISTING 2 OLEACH PIT- PUMP & FILL CENTERVILLE. MA DISTRIBUTION BOX I] L O C U S uW A P TEST PIT /GARB G R OT A OWED /55 55 -— 133.65 ft \ IJ l E _ � • ` N GRADI MINIMAL G � 1 55 EXISTING CONTOUR TTyp/ PROPOSED , G GE 56 c. 55 th® f� © vi Il _ �p• � JIy R QQ s 56 57 BREEZE 12 in 10 ft PINE WAY + PROPOSED SOIL --- . All" ABSORPTION my GARAGE SYSTEM w v, / PA V •., ® 57 -SEE DETAIL a °' DRIVEWAY ` A CK ED SLAB �/ 1 ON 8 iN.3kr2s c*w`"'ft+.�."wy`+'.v° ',� �/ � �=awy:..C ^.ur;esr,'`?"� �`.�-"twty r.Fs� - _ _ _..__ .+r.+-w�-• - _ 4: __�k _ -,...-...,.r.. 4 / 58 59 \ �_ \58 j rt �;.,e,"F 60 59 �6 0 1 / \61 —61 �62 i 62 I LOT 25 ' 1 AREA = 20092 sf+— PLAN BOOK 395 PAGE 91 � L Q NI 21 ft ASSR MAP 23O PCL 197 G �. SCALE: 1 in = 20 ft d O 20 40 1 O 10 20 1 PRINT ON 11 x 17 in VT§L VES PAPER FOR PROPER SCALE WATER LINE �•- — GAS LINES � LE GI � �8 S SA D n 5 - u A O N T TEL/CABLE TV—M--SPRINeELEVATION HEADKLEFOUND ���i/1. 58.73 THIS IS A Sp°TOnI BLILKNEP°c COLOR PLAN USE COLOR PLAN ONLY FOR ION OF R4 0 0 -- FULL DETAIL I�TBEST �DAVIDSs9CGJ, �P��DAVIDSS9�GJ ��OoT��� SEWAGE DISPOSAL VIEWEDD. y� SYSTEM PLAN FULL COLOR c� COUGHANOWR n COUG 460WR N -TO SERVE EXISTING DWELLING No. 1093 i LISA & GEORGE '�FCIsrE��° s gpPROVEo G I G L I O T T 1995 SgNR 0/� E O C� OWNER(S) OF RECORD F�ES2� 86 --WHIDAH WAY r 155 Geo Ryder Rd S ' CENTERVILLE, MA PROPERTY ADDRESS Chatham, MA 02633 -- -- Dovidcou®Hotmoii.com IDATE. JUNE 1, 2017 508 364-0894 [P i2 JOB# ETE-4181 �B�oE SOL TEST ,4LOOO PERC# X DEGIO I CAL CULL U ION DATE MAY 30 2017 SOIL EVALUATOR: DAVID D. COUGHANOWR. ASE *461 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT. SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS NO GROUNDWATER ENCOUNTERED TEST PIT PERC AT 64 in - 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOUND STRUCTURAL CONDITION. IF NOT. INSTALL NEW 1500 GALLON SEPTIC TANK. .... INCHES HORIZON TEXTURE fMUNSELU MOTTLES 58.00 0-12 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. 55.17 12-34 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE SOIL ABSORBTION SYSTEM: 34-132 C MEDIUM SAND 10-YR 5/4 NONE LOOSE THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 47.00 SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES NO GROUNDWATER ENCOUNTERED PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. TEST PIT PERC AT 64 in - 2 MIN/INCH IN C SOILS THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY III ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DEPICTED BELOW CAN LEACH: INCHES HORIZON TEXTURE fMUNSELL) MOTTLES BOTTOM AREA = (24 x 12.5) = 300 sq. ft. ! 57.85 0-12 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE SIDEWALL AREA = (24+24+12.5+12.5)x2 =146 sq. ft. 55.17 12-32 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE TOTAL AREA = 446 sq. ft. 32-132 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 44 = /FLOW CAPACITY 0.74 x b 330.04 al do 46.85 9 y - —- — INSTALL A 24 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED BELOW. FLOW CAPACITY = 330.04 goI/cloy WHICH EXCEEDS 1000 GALLON SEP= §C TANK THE 330 goI/cloy REQUIRED FOR A THREE BEDROOM DESIGN. DIMENSIONSi OREY TANK TO BE PUMPED DRY AT TIME OF INSTALLATION D 1 S T R 1 = U T 1 O N = O X DB H2 AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL DIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. AND DETAIL FOR 2 FEET BEFORE DOWN REPLACE WITH A NEW 1500 GALLON TANK I In IF CRACKED, ROTTED - 12 In TAPER OR OTHERWISE C MIN -►� COMPROMISED. —► Lo FROM S TANK TO O o ^ SAS 0 00 O NOT �o°b� aCP 4- 6 in STONE BASE. Ln TO 21 CROSS SECTION VIEW f ^ SCALE NO 8 ft-6 ;n ABSORPTION SYSTEM CONSTRUCTION ► • INLET OUTLET 4 CO VER CO VER DRYWELL 24.0 ft 3 IN DROP UNIT -► /l FLOW LINE FROM = °' 10 in = _ BUILDING 14 TO '^ D-BOXco 48 in Ln ® '� I CV � N LIQUID GAS ` LEVEL BAFFLE V-)z STONE-' 3.5 ft 8.5 ft 8.5 ft 3.5 ft i 6 in STONE BASE IF NEW SEPARATION BETWEEN INLET & OUTLET 500 GALLON DRYWELL TEES NO LESS THAN LIQUID DEPTH DIMENSIONS & DETAIL INSTALL ONE INSPECTION CROSS SECTION VIEW USE RISER TO WITHIN THREE INCHES OF FINAL GRADE H-10 & INDICATE LOCATION ON AS-BUILT UNI T 0 in o� - 0;0 000o Dt0 a.\� -INSTALLER TO OBTAIN DISPOSAL WORKS Ip 5 NPERMIT BEFORE STARTING WORK. 2 'n -ALL COMPONENTS INSTALLED SHALL MEET CROSS SECTION VIEW THE MINIMUM REQUIREMENTS OF INSTALL AN APPROVED GEOTEXTILE MASSACHUSETTS TITLE 5 SEPTIC FABRIC OVER STONE O CODE (310 CMR 15). -INSTALLER TO VERIFY LOCATIONS OF ALL T EXCAVATING FOR SYSTEM. 28 UNDERGROUND UTILITIES BEFORE 9/4 in TO 24 a 3/4 in TO In in GRAVEL ® DE inPTH -ECO-TECH ENVIRONMENTAL RECOMMENDS IVE: 1-1/2 in GRAVEL THE INSTALLATION OF LOW FLOW ( FIXTURES & APPLIANCES, AND PERIODIC 46 in 58 in 46 in PUMPING OF THE SEPTIC TANK. 150 in S --:SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. L O V V p O F L TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE 4 in SCH. 40 PVC EL = 59.60 +— 6 in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MINv 57.5 I i � D-BOA 3' I' USE H-20 � .. M A X [�}n{DSTM 54.75 s�o�oa O;0" o EXISTING o i 10 000o GALLON o , o PRECAST i 55.85o, �° DRYWELL o°°�a��oo° SEPM TAN in 54.13 0 .��3�°aado EXISTING REFER TO DETAIL BOX STONE L A° BSORPT�ON + 54.30 BASE 54.00 4- 6 in STONE BASE IF NEw ����[ � -REFER TO EXISTING 30 ft 5-12 ft DETAIL BOX 0 52.00 NO GROUNDWATER BELOW MOTTLING OBSERVED _ 46.85 SEWAGE- DISPOSAL SYSTEM PLAN 86 WHIDAH WAY CENTERVILLE MA IIJUNE 1. 2017 ETE-4181 PG 2/2;