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0038 WHITE OAK TRAIL - Health
38 WHITE OAK TRAIL, CENTERVILLE A= �IIII A JN�R6C�CsFp A UPC 12534 No.2153LOR HASTINQS, MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / L-- h✓1 CO r,S-r 10 Ow ner Ow ner's Name Information is / Pam. �vl Ile /4 ao1&-Z /-1 � required for every page Ckyfrown State Zip Code Date o 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:Men A. General Information filling out forms �� y► �O on the computer, use only the tab 1. Inspector: key to move yourTl/)cursor-do not G�� p S P� A use the return Name of Inspector key. �--- �' Company Name /C) Company Address // nun j S 7-l/h A✓"! Ckylrown State Zip Code SID eo--2,M) Telephone Nu n1ber 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 16,340 of Title 5(310 R 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1)11)4�'-k �U- �c Inspect 's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system.or has a design flow of 10,000 god 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 aescribes 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. tEne 3113 Title 50fficiallropeesonForraSuosulace Sewage Dlsposal system•Page Iof17 LIV �Iz� Ii I Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 (As4e oG4- Property Address COO,f i vt 0 Ow ner ON ner's Name information is Ce0 er-/1`le required for every page. City rrown State Zip Code Date of I spection B. Certification (cont.) Inspection Summary: Check A,B,C,O or E I always complete all of Section 0 A) 71ehave m asses: 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, NO) 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 ❑ NO (Explain below): t5ns,3/13 Title 5Offlcial Inspection Form Subsurface Sewagefalsposd System•Page 2ofV Commonwealth of Massachusetts Amm Title 5 Official Inspection Form V Subsurface Sewage Disposal System //Form -Not for Voluntary Assessments Property Address Co✓Sr✓�� O.v ner ON ner's Name // ,�j r� information Is cell, 4rG V- /!t //� Q� li o /,Z h required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Cl 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): ❑ 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: ❑ 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 t5ns-W 3 Tllte 5 01flGai Ins pactlon F arm: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 Property Address ON ner Ow ner's Name information is Ce H rV� � /�A �a 6�� �� l� required for 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 an 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 ❑ CTI" Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins•V13 Title 5 otflcial Inspection Form Subsurrace Sewage Disposal System-P ge 4 of 11 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System /Form -Not for Voluntary Assessments r . Property Address Co✓S o ON ner Ovv ner's Name information is CAN ���� /� Q�( �p� _ required for every State Zip Gods Date o Inspec ion page. cityffown _— B. Certification (cont.) Yes No ❑ 21-1-- Required pumping more than 4 times in the last year NOT due to clogged or - obstructed pipe(s). Number of times pumped: . ❑ 03Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 2/1*" Any portion of cesspool or privy is within 100 feet of a surface water supply or / tributary to a surface water supply. ❑ (B Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L� 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- ❑ / he systete The T system&1jo. 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. One Y13 Me5Offlc4d InspectlmForm Subsurface Sewage Disposd System•Pepe 5of17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for voluntary Assessments Property Address Co rsr✓J o Cw ner Owner's Name / II Information Is / P�4e&7 A 3� required for every (•� // — page. City Rown State Zip Code Date of nspec ion C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes ❑ mping information was provided by the owner, occupant, or Board of Health ❑ e any of the system components pumped out in the previous two weeks? ❑ as 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 NIA) — /❑ Was the facility or dwelling inspected for signs of sewage back up? LH' ❑ Was the site inspected for signs of break out? LAY ❑ Were all system components, excluding the SAS, located on site? Ly' LJ 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: l� ❑ Existing information. For example, a plan at the Board of Health. u 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: N Number of bedrooms (actual): Number of bedrooms (design): 3�0 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•Y13 Title 50MIN inspection Form Subsurface Sewage0fsposO System-Page®of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address orSl ✓�o ON ner Our ner's Name �9-, $ /� information is � �`7 ` vo�6�oZ required for every StatA Zip Code Dateofl speCtlon page. Cky/Tow n D. System Information Description: G-,, µ 11 c,f�i�b�rT�o✓� '�5�� Number of current residents: 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 Qx0 Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ `es No Last date of occupancy: Date v Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ra-3/13 Title 80fAclal inspection Form Subsurface Sewage Disposal System•Paga 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 3? ©e.41 l�a Property Address orS►n 0 ,( owner ON ner's Name CeW�'Vt /�information is required for every State Zip Code Date of I spect n page. CitylTown 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 S m: 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) ❑ InnovativelAltemative 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (desch be): TiO50111ciai inspecton Form Subsu we SewapeDlepceal System.Pape 0oM We•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '?52 "/-/d DAB- Property Address Co'-ft 4 o Cw ner Owner's Name / information Is 6t.-kVy6 G e �� required for every page. CitylTown State Zip Code Date of nspection D. System Information (cont.) Approximate age of all components, date installed (if kn` oyyn/ d source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 4o 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): /C Depth below grade: feet ` Material onstruction: 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: f ' Sludge depth: t5im-3113 TIUe50fficial ins pec bon Form Subsurface Sewage Disposal System-Page 9of 17 C\' Commonwealth of Massachusetts lipTitle 5 Official Inspection Form Subsurface Sewage Disposal System ForT -Not for Voluntary Assessments Property Address COr�rr/!O Ow ner Owner's Name / _N ✓ < / l'_ 0o)6 7p V1p � ��information is ��/ yrequired for everypage. City/Town State Zip Code Date oftfon D. System Information (cont) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 /I 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.): )ee c4j tj Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass Q 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 t61ns•W 3 Tito 5 Weld Ins poe6on Form Subsurf ace Sawepe Diepa981 system•Pepe 10 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ✓`� �Sf ✓l 0 �iJ ON nerrni 0+r ner's Name information is required for every -- page. City own State Zip Code Date of nspection 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 Ons•3113 Tile50fflclal Inspection Form Subsurface SewegeDlspasel system-Page 11 of 17 i Commonwealth of Massachusetts Title 5 official Inspection Form lug Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address O✓'CQ N V Cw ner Oyu ner's Name I- information is CQH`f�vtl� required for every State Zip Code Date of Ins action page. City/Town D. System Information (cont.) C Distribution Box (if present must be opened)(locate on site plan): �v� �J C Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any (7 J evidence of leakage into or out of box, etc.): 11 C]2� so/� LQG�I 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: Tidesomial impoe ban Form Subs,1=9 Sewageo1sposal System•Pape 12 of 17 t51ns•W3 Commonwealth of Massachusetts Title 5 official Inspection Form 's Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Co V,5 1`0 0 t Ow ner Owner's Name / fJ (�d r la information is C2,r �fi! ! -e ,/ required for every State Zip Code Date Inspection page. Cityffown D. System Information (cont.) ��ll Type; U-a, S40o-e4eS5 ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative 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 Tide 6 Official ins pectionForm Subsurrace Sewage olsposei system Page 13of 17 thins•Y13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sy��ste/mr Form -Not forVoluntary Assessments Property Address co'-ft .10 ON ner Ov ner's Name - information is Ce -k ��14 �j¢ 00)6,4 -g 1. / required for every page. C tyRown State Zip Code Date o!Xnspecthn 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.): t5 ns,3f1 3 TItIe 501ficlai Inspection Form Subsurface Sewage Disposal System•Page 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments Property Address orSr N v Ory nor O,n ner's Nana / / 4 Information Is required for every State Zip Code Oat® f Inspection page. GtyRown D. System Information (cont.) Sketch Of Sewage Disposal System; Provide a view of the sewage disposal system, including ties to at lea t two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate whe public water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately A`=� yy., f� I `+r ', 9 41 31 . 3 2 qt,a 16'z 3`7.a l� 3 q7.5 3S �':3 (t� 3-7, Y iA 5' tire.0 http-.//issgl2/intranet/propdata/prebuilt.aspOrnappar=191046&seq=1 8/5/201 Title 50fAolai Inspection Form SUbaurtece Sevrege01sposd System-page 15 d 17 Or*•WS n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System / 1 Form Not for Voluntary Assessments ?? Property Address CL 1-i'r ki 0 Ono ner Oav ner's Name information is /� required for every �oW n State Zip Code Date of Inspection page. City D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells /0 Estimated depth to high ground water: feet l 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: pate ❑_/ Observed site(abutting property/observation hole within 150 feet of SAS) L7 Checked with ocal Board of Health-explain: ��� s t 7 Z-".s7' ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: S� s (.s 114elo I LI 011ndL;1� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins,W3 TWe5officid IropecticnForm Subsurface SewageDieposel System-Page 16d V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -?-6 (./Lk 7ia, , Property Address 6101:�-I V1-0 Ow ner Owner's Name c� inform /ation is CQH ✓✓t ` /� required for every page. City/Town State Zip Code Date of spection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed I system Information—Estimated depth to high groundwater L7 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 9 po Y P 9 P r' t5ns-3113 Title 50ffldal Inspectlon F am Subu rface Sewage Disposal System Page 17 of 17 Town of Barnstable P# ?u W THE> pl Department of Regulatory Services 11 MRN"ABLe, : Public Health bivision Date d �J MA89 1 200 Main Street,Hyannis MA 02601 Date Scheduled Time �(/ Pee Pd. od Soil Suitability Assessment for Sewage D sposal Performed By: i'(LanQi, ;CIY�Qf1F�� �L) L.S� i Witnessed By: �1 �- t✓] ✓ i LOCATION&°GENERAL INFORMATION. �/�p� Location Address` ((�� n Owner's Name L q,17/1 CV erS(r r(J ` .Sy W Yll+e t�(,t R �r�jl! I rwlt� Address f o 6_DI)( g 0*7kNI1,r / Assessor's Map/Parcel I I 0 N to Engineer's Name J G' NEW CONSTRUCTION REPAIR/Y' V Telephone tl Land Use St'(15iC &GaYttl AlA.fl�t' Slopes(%) 'L'^.� Surface Stones Distances from: Open Water Body Ail R Possible Wet Aren N�R Drinking Water Well Pill R Drainage Way MA R Property Line .,t O Il Other R i SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) PLOA rP( TP Z V K BA5 Parent material(geologic) Oukuwtl Depth to Bedrock u Depth to Groundwater. Standing Water in Hole: 7 420 bSS Weeping from Pit Face 7 1 Zt'a bs S Estimated Seasonal High Groundwater (ZQ 5 DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Dtfe_C_ 1pS t Ja -- Depth Observed standing in obs,hole: t 2Q in. Depth to soli moules: Depth to weeping frbm side of obs.hole: _'; 120 in. Groundwater Adjustment r ft. Index Well H "' Reading Date: — Index Well level Adj.factor Adj.Groundwater Level PERCOLATION:TEST Date.8-II/C Time IO FF I f Observation Hole N — — 3 r. 8 Time at 9" _ Depth of Pere o Time at G" Stan Pre-soak Time rB IC•C yAn a Time(9"-6") End Pre-soak /e:0 9.4!9 Rate Min./Inch Site Suitability Assessment: Site Passed ZS Site Failed: Additional Testing Needed(Y/N) ✓V —_a.. Original Publie I-lealth Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. QASEPT'IC\PERCFO RM.DOC DEEP O$SERVATIQN HOLE LOG t Hole# n Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. C t isles % r I G y L�Ik.r LS /V ir'3/1 LS ivYrS/6 - - 30-00 C. 11-05 2,ayb�6 Sfa"e-( i DEEFORSERVATION HOLE LOG Hole 4- Depth from Soil Horizon Soil Texture Sod Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders, Consistency,%Graven e- A/C L-5 /Cir311 - -3 0 L.5 - 16-12d r H-GS' 2 3Y% _ 5%6 °Ste DEEP OBSERVATION HOLE L6.G Hole it Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. i i i DEEP:OBSERVATION HOLE;LOG' Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. v Flood Insurance Rate Mao: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes _ Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? I e-5 If not,what is the depth of naturally occurring pervious material? Certification I certify that on ��"L9"9 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature s g Date Q:\SEP"rl C\PERCFORM.DOC i i I I NO. 3—OTHE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH T(3t�P1 OF 9CLClSVaG atC- APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade (t/�'Abandon ( ) - P<omplete System ❑Individual Components '3 Oak< Tcoit CeAe.ruitle Cocgt,no Location Owner's Name r(aR 19 t PO UY, 23b Cen$reryilie N A Map/Parcel# Address t# 'Telephone# ,Install�is Nam r Designer's Name �� °`2�j CconVXcr HI'A41Wp✓ E. wore4>avtn faA o2s3ft Address Address 5-6e--(A-q-z 508,Z73-b 377 Telephone# Telephone# Type of Building: 5ZA4e. Awek`ihs Lot Size 2-0, e97 r Sq.feet Dwelling—No.of Bedrooms Fine a e_ (3) Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) 330,p gpd Calculated design flow 330.0 gpd Design flow provided 35'(.,3 gpd Plan: Date Av�VsF- i 1�20I o Number of sheets pAt (t) Revision Date Title Acts 05c!A SzP n eS k.�n y P�c4d e_ Description of Soil(s) sce- o M SICCA QAa^ Soil Evaluator Form No. Name of Soil Evaluator Ncc6-k een,-4,-k Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS fw.orA lesoo 5aF. szeFtc Gn(sy g- oc NSF d1sk:citoukton most Fo�cn1 12 RRO 36t�G t3tocFtEf cS (kcer�clneS') tng0ec�tal Do(k� The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 aifuerthe system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed e OL FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. _. THE COMMONWEALTH OF MASSACHUSETTS FEE 1�/ _••-�_ -9A9&WAAZC' BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: /]!Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: Ih�I _ j at (� ( A ll�1 �_ has been installed in accordance with the provisions of 3 0 CMR 11.00 (Title 5) and the approved design plans/as-built plans relating�to a plication N ..r�C�/6 ' .'7vdated ! I Approved Design Flow 3 (gpd) Installe A _ 1 �. l Designer: "Vl Insp ctor _ Date The issuance of this certificate shall norb-e construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 I � i THE COMMONWEALTH OF MASSACHUSETTS FEE ho f B4- -aw�, .BOARD OF HEALTH T- DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby, _ra'}te�)t Qonstruct ( ) Re i ( )j Upgrade ) A,b-a�nrdO1}l ) an individual sewage disposal system at �'+�fY L. . I .Y/Ll I as described in the application for Disposal System Construction Permit No. (/ dated l Provided: Constructs/On sh '1 be completed within three years of the date of this per 't.A kcal onditi.ri�-must be met. Date ! /( / Board of Health 77 FORM 2 - DSCP/ DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS- BOSTON N y fTHCOMM, WEALTH OF MASSACHUSETTS FEE o.--ya? I t`��'--'�' E CO M fi BD,D, OF HEALTH OF L k� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT I , Application for a Permit to Construct ( ) Repair ( ) Upgrade (V�Abandon ( ) - { .Complete System ❑Individual Components j ! 3 8 WhAc_ 0 i it en tC,cuil�e Lynn Co(stno Location Owner's Name r(o " l 01 1 QU t�oX 23�I Ceyi4rturl►e , HA Map/Parcel# Address Qarce, y�a Lot# Telephone# o.) C.lC TG ErlgineeCt',t15. Zric . (6 I Installer's Name Designer's Name y rjoa� ? `'� Go.� __ C� Z$3y Gronbucy N+cbu�oy, C-, wo(e9nc.,rv). NA o2538 V l�ddres`s� L C Address Z73-0377 Telephone# Telephone# _ Type of Building: 54 4e. k am'ky A W 01%, Lot Size 7-` , 69-7 r Sq.feet Dwelling—No.of Bedrooms 1Hc ee e_ Garbage Grinder ( ) I Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) 330•0 gpd Calculated design flow 3� gpd Design flow provided 3%.3 gpd Plan: Date Au�osE 11, Laic Number of sheets ane t 0 Revision Date Title tweo5eA Septic '5y0km U eS(.d e_. Description of Soils) Sce ©NC61--ck 00n ,•.> -Soil Evaluator Form No. Name of S&IkEvaluator M&wcl f.menVr� Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS seo{1 c Gn v a t vt�t i e( r N 4(sttkIdukton \oo>r Jok41 12 (Vc. Exohtf(C�t5 IceAc4115) _ L rn5Oe4'41 ewk5. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu er agrees not-to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed le -InspeIN cften� a r \ FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 71W Town of Barnstable Regulatory Services 4 Thomas F. Geller, Director ' Publie Health Division 1e39' �`� Thomas McKean,•Director 200 Main Street, Hyannis, MA 02601 0fticr:r 508.862.4644 Fav 508-NO f'):%;14 Date: , � � " Sewage Permit# 3 S-n Assessor's Map/Parcel ,_I� Installer& I)esipner Certification Form Designer; _Sc:_ L�rlci�e� ci���� v_IC Installer: Ca(�cwcete._Pnt �rise .� Address; 2 t 5`I c cm\oer-r t �� _ Address: y0 (3ox -7 ---__—— -X--- --- (2 �et` 273 0377 On LnJ-(- r1`sQ_ was issued a permit to install a (instal ler) septic system at 3��...�u�r�c t e (?OK _n Ali la —_ based on a design drawn by dated a.c ICU • _�,.� _ �-..fir�.....u,.,,........_.....—...__.... __...__-............—_.�...__.._.�.__..........' / (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the• distribution box and/or septic tank. Stripout (if required) was inspected and the soil', were found satisfactory, I certify that the septic system referenced above was installed with major Changes (k,'. greater than I lateral relocation ol'the SAS or any vertical relocation of any componem of the septic systerxt) but in accordance with State& Local Regulations, Plain revision or certified as-built by designer to follow. Stripout (if required) I acted and the soil., were found satisfactory. JOH � C L CMURUFiCNrLL ' -� (Ills is SignatUrc:) - - ML �reo Signers Signature -�(Affx lie gn Icre) - P ASE RETURN TO iARNSTABLE 1'U8Li ' LZ 1 I)IVISION. ERTIF1 '1 E OF COMPLIANCE WILL NOT BE IS5U1laD UNTIL B T)Eiiy ]H'ORM .ANI) AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC H�'ALTII D1V[SIQti. THANK YOU. q DMICK l'urma•.dr ergnE rcertific uripn 1l rm•dPc 10 'd 2_9£0 £LZ 809 9N I Z133N I 9N33r Wd Lb: b0 0 T 0Z-0£—nnu TOWN OF BARNSTABLE LOCATION 3 ���}e on,r .r rui 1. SEWAGE# ®I 0 3 Sn VILLAGE ASSESSOR'S MAP&PARCEL I q h (0 INSTALLER'S NAME&PHONE NO. 1�4pecv/c-L 67-7kr f?1!�eS It-Lc SEPTIC TANK CAPACITY /5-0® /a -10 LEACHING FACILITY:(type) 1'0,1 ddy %/e 1,C1, (size) (7-) A2 c 3(o i(. 3 NO.OF BEDROOMS l� y� 3 T#' + cs 5%at GacZ OWNER �✓1 y� l)a S-C PERMIT DATE: l(a s 2Ao i o COMPLIANCE DATE: Z(o • 2,0 Separation Distance Between the: 2 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 10 Feet Private Water Supply Well and Leaching Facility Of 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 G•A1r IL •�� ,�� a' Lh kl 6 'SA t �l �. L o-"- RR TOWN OFE§ARNSTABLE LOCATION' r\I l -i�— I C-.�I SEWAGE # V& AGE (' ®�1�� ASSESSOR'S MAP & LOT _ INSTALLER'S NAME&PHONE NO. O�a� SEPTIC TANK CAPACITY LEACHING FACIL=: (type) (size) NO. OF BEDROOMS 1 � BUILDER OR OWNER PERMITDATE: 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 A act �N PA D ce� �5 N � �g TOWN OF BARNSTABLE LOCATION �� _S� l'.1/�/ ,rx Oe+4T .�ii�L SEWAGE # VIL. AGE C4—: .� iL/'' ASSESSOR'S MAP &LOT C INSTALLER'S NAME&PHONE NO. APO�S lit/Sc Pe-- ZZ r— SEPTIC TANK CAPACITY LEACHING FACELrrY: (type)T -Ir(i G� F (size) NO. OF BEDROOMS BAR OR OWNER �� /�� �e�s✓r PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lea ling facility) Feet Furnished by «/ �. 1-� � V S' ,� 1 �� �y ,� 1 � ' ;, , l � �� t �3 s � aµ=�x �. ��. �Yr ... ...LL�. __._ _. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION n N tl 4 ?1 V� i" TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ° 4 ., PART A CERTIFICATION Property Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner's Name: MUSHET Owner's Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 ' Date of Inspection: 11/6/00 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONSo, 6' Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 / CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.34'of Title 5(310 CMR 15.000). The system: X Passes 3 _ Conditionally.P ses _ Needs Fu her, aluation by the Local Approving Authority _ Fails F Inspector's Signature: �/ Date: 11/6700 � � i The system inspector shall subm' a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM NOW AND EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. ****This report only describes'cbnditions at the time of inspection and under the conditions of use at that time.'1 his inspection does not address how.,tfle system will perform in the future under the same or different conditions of use. e ti �1 Ps tt� Title 5 Inspection Form 6/1512000 ' Paoe 1 of 11 , .i s Pagr 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART A { CERTIFICATION(continued) Property Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner: MUSHET Date of Inspection: 11/6/00 Inspection Summary: Check A,B,C,D or E/All MAYS complete all of Section D A. System Passes: X 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 PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM NOW AND EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. 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. n/a 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: n/a 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: n/a 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: ; i . Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner: MUSHET Date of Inspection: 11/6/00 C. Further Evaluation is Required byIthe Board of Health: Conditions exist which require further-evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board^of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. ii _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has aseptic tank'ir and SAS and the SAS is less than 100 feet but 50 feet or more from a private water a �; . supply well".Method used to determine distance n/a "This system passes if the welAvater 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: n/a i t; 111- i 'I Pagg 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE',SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 38 WHITE OAK.TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner: MUSHET Date of Inspection: 11/6/00 D. System Failure Criteria applicable,to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Wa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspooll'o4,privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool;or privy is within a Zone 1 of a public well. _ X Any portion of a cesspoolor privy is within 50 feet of a private water supply well. X 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.] f (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 fi�i 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. 4! .I 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400..feet of a surface drinking water supply X the system is within 200 feet.of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well ,ly 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. a e,I IiF Page 6 pf 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner: MUSHET Date of Inspection: 11/6/00 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3. Number of bedrooms(actual): :_.'_ DESIGN flow based on 310 CMR,615.203.(for example: 110 gpd x#of bedrooms): 110 Number of current residents: 1 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no):.NO Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL ;4; Type of establishment: n/a ti" Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no):NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO Water meter readings, if available: n/a Last date of occupancy/use:n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information:n/a Was system pumped as part of thelh9pection(yes or no): NO If yes,volume pumped: n/agallons'L-"how was quantity pumped determined?n/a Reason for pumping:n/a 2 TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy i t _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): n/a Approximate age of all components,date installed(if known)and source of information: 1971 Were sewage odors detected when arriving at the site(yes or no):NO t i' Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner: MUSHET Date of Inspection: 11/6/00 BUILDING SEWER(locate on site plan) Depth below grade:36" Materials of construction:_cast iron =40 PVC Xother(explain): ORANGEBURG Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:8" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 6' X 6' BLOCK CESSPOOL" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 0" Scum thickness: 0" Distance from top of scum to top of out tee or baffle:8" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY ONE YEAR TO PROLONG`THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) t , Depth below grade: n/a ` Material of construction:_concrete—metal"'fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee-or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a I' 'i;t13 I c�tj? 1 rya Page 8 of 11 s' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner: MUSHET Date of Inspection: 11/6/00 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): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must-be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): n/a PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a x 4 � 1 f Page-9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner: MUSHET Date of Inspection: 11/6/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a 6' X 6' BLOCK CESSPOOL overflow cesspool, number: 1 n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE OVERFLOW CESSPOOL IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE OVERFLOW HAD 1' OF LEACHING LEFT AT THE TIME OF INSPECTION. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or rid): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a { 3 -Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner: MUSHET Date of Inspection: 11/6/00 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. IA t Ito I " � A PA 314 r . „ 1 Pages 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 WHITE OAK TRAIL CENTERVILLE,MA 02632 M191 P046 L019 Owner: MUSHET ' Date of Inspection: 11/6/00 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 10+FEET J \ .1 TOP OF FOUNDATION = 69.8'± ' GENERAL NOTES PROVIDE EXTENSION RISER INISH GRADE OVER D-Bo 67.5 ± 4"SCHEDULE 40 PVC FINISHED GRADE OVER BIODIFFUSERS = 67,0' - 67,5' WITH COVER OVER INLET& FINISH GRADE OVER TANK EL.= @ MIN. SLOPE 1% SLOPE 2% MIN. REMOVABLE WATER-TIGHT COVER OVER @ 1• UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISHED GRADE OUTLET TO WITHIN 6"OF F.G. RISER TO WITHIN 6"OF FINISHED GRADE INSPECTION PORT WITH ACCESS METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL 68.0 '� BOX TO WITHIN 3"OF F.G. @ FOUNDATION = 68.5�± 5" DIA. OUTLET(S) CODE AND ANY APPLICABLE LOCAL RULES. -- (ONE PER TRENCH) 20"MIN.ACCESS t9" 6"MAX. } 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE COVER(3 TYP.) "MIN. I f DESIGN ENGINEER. PROP. PVC 9"MIN. I SEWER PIPE P:� ROP. PVC 36 MAX. 9"MIN. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SEWER PIPE 36"MAX. TOP OF SAS/ B.O. = 64.550' SYSTEM UNLESS OTHERWISE NOTED. EXIST SEVVIEk f'1PE` MIN.SLOPE76" 3" 2" DROP MIN. PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN 3" DROP MAX. MIN.SLOPE ,% L = 11�± JOINTS (TYP.) 1. ELEVATION =64.50' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A 74" PVC IN FROM CLEAN SAND 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF *6 '' 65.75' SEPTIC TANK O 4" PVC OUT TOd' d' 1.33' nY; 6"TYP THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. ' LEACHING FACILITY 0.90' EEEi (TYP.) 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. 67.2 ± 66.00 12^ 6^ � 11E 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. 48" OUTLET TEE 65.00' MIN. 64,83' 64.071j63.17 (LAID FLAT) 2.875 (34.5 ) 5.75, 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK GAS BAFFLE 6"CRUSHED STONE 5 0' (TYP.) FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS OVER MECHANICALLY (TYP.) NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH TO FND 31.3 ' COMPACTED BASE5'MIN. 11.50' AND DESIGN ENGINEER. 6"CRUSHED STONE 5 OUTLET DISTRIBUTION BOX 30.0'(TYP FOR BOTH TRENCHES) 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 69.00' ESTABLISHED OVER MECHANICALLY TO BE INSTALLED ON A LEVEL STABLE ON TOP OF EXISTING BULK-HEAD CORNER AS SHOWN ON PLAN. COMPACTED BASE BASE. FIRST TWO FEET OF OUTLET GROUND WATER ELEV= < 57,50' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION PROPOSED 1, PIPES TO BE LAID LEVEL. 500 GALLON CONCRETE SEPTIC TANK (H-10) THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT LENGTH 10' 6' WIDTH 5' 8" DEPTH 68" (Dimensions per Wiggin CROSS SECTION VIEW BIODIFFUSER (PROFILE) BIODIFFUSER (END VIEW) 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES Precast Corp., Pocasset, MA) _ TO THE DESIGN ENGINEER. `CONTRACTOR TO VERIFY THIS ELEVATION SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL 12 ARC 36HC (#361 6 B D) BIODIFFUSERS &REPORT TO ENGINEER IF DIFFERENT NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING ' ' , • TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM + + • 0 + PERC NO. 13028 APPROPRIATE AUTHORITY. ♦ # • �� . R . ° + INSPECTOR: David W. Stanton, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS " �• : "' ' ! + EVALUATOR: Michael Pimentel, E.I.T. LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE v THEY SHALL WITHSTAND H-20 LOADING. � " • • ' C.S.E. APPROVAL DATE: Oct. 1999 ' • + '� ' DATE: August 11, 2010 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. • �� ` " TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE • • ; MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. : " • + , ,, . `,,�y ELEV TOP = 67.50' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, . FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255 3 MAP 191 �r "�. • " � ' s ELEV WATER= < 57.50' ( ) w PARCEL 47 + ' . '. `! + • a+ + • PERC RATE - < 2 min./inch 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN e _ CV) �. + • + ++ + SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. N f '� ' LOCUS DEPTH OF PERC= 30"-48" 16. PROPOSED PROJECT IS LOCATED WITHIN: Q '" ' * ' „ TEXTURAL CLASS: 1 ASSESSOR'S MAP 191 PARCEL 46 a / + ' * • OWNER OF RECORD: LYNN D. CORSINO -i Benchmark . + • .,. * , . * ADDRESS: PO BOX 236 To B.H. Corner ! Litter , + + • • • L � � . � * � ! • � 0 67.50 CENTERVILLE, MA 02632 S83021'00"E 1 Elev. =69.00' ` ' • • • 4" Loamy Sand 67.17 rn 182 70' a EXISTING CESSPOOL & LEACHING PIT TO BE PUMPED LL1 �/ * R m A rox. M.S.L. ` AND FILLED WITH CLEAN, COARSE SAND & ABANDONED / Z !I : . ' • ; . • / A/E / O . • 0 • 8„ 10Yr 3/1 66.83' 01 � N 4 * + ,• • '�* `" . FEMA FLOOD ZONE C �`�� ► + • B Loamy Sand COMMUNITY PANEL# 250001 0015 C < / ! • a 17. DEED REFERENCE: LAND COURT CERTIFICATTE 160403 m -- - - - - - ( /66 I MAP 191 ` . , - . * • 301, a- MAP 65.00' 18. PLAN REFERENCE: LAND COURT PLAN 32373-E z / PARCEL 142 rrw� + ! ; ' + Cl Perc 191 ' • . » . Cr8 d ` 48" 63.50' 19• ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. ' PARCEL 46 B.H r� ++ ++•!!• • ,•+ • �! *r 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY I + ♦* + + + • " FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY 20,697 S.F. ± / -PROPOSED 1,500 GALLON H-10 SEPTIC TANK � If Medium -Coarse Sand fJ ++• •• • FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. f M � #381f • '• +•* : : C 2.5Y 6/6 EXISTING �/ 65x0' PROPOSED DISTRIBUTION BOX (5-10%gravel) r� 3-BEDROOM 31.3' O \ DWELLING O TOF = 69.8'± o DECK LOCUS PLAN � - m I n \ / oC. Pi SCALE: 1"= 1000' rn o o \ \ I / CONTRACTOR TO REMOVE EXISTING TREES AS NECESSARY TO 120" 57.50' - -W�� W - �P 7 INSTALL LEACHING SYSTEM & REPORT TO ENGINEER LOCATION / No Mottling, Standing or Weeping Observed 0 AND NUMBER OF TREES PRIOR TO COMMENCING WORK o - - - - --- ----------- -- ---- ---_ _. v ` -- GSRAB) 12 M DESIGN DATA TEST PIT DATA LEGEND 7.5 / MAP 191 PERC NO. 13028 co BIT. DRIVE _ I OI�I� 35.2' 65x0' PARCEL 141 NUMBER OF BEDROOMS (DESIGN) 3 INSPECTOR: David W.Stanton, R.S. 11 EVALUATOR: Michael Pimentel, E.I.T. 50xO EXISTING SPOT GRADE S GAS GAS �' DESIGN FLOW 110 GAUDAY/BEDROOM C.S.E.APPROVAL DATE: - 50 - - EXISTING CONTOUR - GAS - -- G -� .2f PROP. TOTAL 12 ARC 36HC BIODIFFUSERS� G�� 25 Oct. 1999 - 1 Off _68_ ��� (6 BIODIFFUSERS EACH TRENCH) TOTAL DESIGN FLOW 330 GAL/DAY DATE: August 11, 2010 � I / � � DESIGN FLOW X 200 % = 660 GAUDAY --E50 PROPOSED CONTOUR TEST PIT#: 2 I U.P.#: aI� 65x3 PROPOSED INSPECTION PORT WITH �_ USE PROPOSED 1,500 GALLON SEPTIC TANK ELEV TOP= 67.50' ❑/H/W - EXISTING OVERHEAD UTILITIES ,. \ \ S780 31 '30-E ACCESS BOX TO GRADE (TYP OF 2) ELEV WATER= <57.50' GAS - EXISTING GAS LINE _141.32• / PERC RATE _ �-66_ `O� INSTALL 12 - ARC 36HC #3616BD BIODIIFFUSERS W W EXISTING WATER LINE / SWING-TIES ( DEPTH OF PERC=ic__h_X_X_X_X_X _ FENCE (TYP) DESCRIPTION BH HC SYSTEM CAPACITY TEXTURAL CLASS: 1 % TEST PIT LOCATION \ 65x5' SEPTIC COVER IN (1) 33.1' 48.7' - (TOTAL L.F.OF BIODIFFUSERS)(7.8 SF/LF)(0.74 GPD/SQ.FT.)= GPD 0 0 PROPOSED 1,500 GALLON SEPTIC TANK MAP 191 SEPTIC COVER OUT(2) 37.8' 43.5' (60.0')(7.8 SF/LF)(0.74 GAUSQ.FT.)= 346.3 GAL. LEACHING/DAY 0" 67.50' PARCEL 45 BIODIFFUSER CORNER(3) 47.2' 45.3' 4 Litter Loamy Sand 67.17' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE MAP 191 BIODIFFUSER CORNER(4) 57.4' 54.7' TOTALS: A/8E„ 10Yr 3/1 66.83' I O PROPOSED DISTRIBUTION BOX PARCEL 140 BIODIFFUSER CORNER(5) 74.9' 46.7' B Loamy Sand 0 PROPOSED ARC 36HC (#3616BD) BIODIFFUSER TOTAL NUMBER OF BIODIFFUSERS: 12 10Yr 5/6 BIODIFFUSER CORNER(6) 67.4' 35.2' TOTAL NUMBER OF COUPLINGS: 0 - TOTAL LEACHING AREA: 468.0 SQ.FT. 30" 65.00' TOTAL LEACHING CAPACITY: 346.3 GAL./DAY REV. DATE BY APP'D. DESCRIPTION PROPOSED SEPTIC SYSTEM UPGRADE t3'H PREPARED FOR: � BH NOTE: `- Medium-Coarse Sand LYNN D. CORSINO o #38 EFFECTIVE LEACHING AREA OF 7.80 SF/LF OBTAINED FROM THE C 2.5Y 6/6 EXISTING (1 DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER (5-10%gravel) C.) a 3-BEDROOM "MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO LOCATED AT DWELLING O ADVANCED DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003(LAST Cn TOF = 69.8'± (2 MODIFIED FEBRUARY 18, 2010). TRANSMITTAL NUMBER=W000052. 38 WHITE OAK TRAIL v r n i NOTES: DECK (3 ENT RVILLE, MA 02632 4) _ 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF 120" 57.50' SCALE: 1 INCH = 20 FT. DATE: AUGUST 11,2010 Vi>J►� 0 10 20 40 80 FEET EACH SEPTIC SYSTEM COMPONENT. - _ No Mottling, Standing or Weeping Observed (! GARAGE JOHN �J L. PREPARED BY: 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF (SLAB) M RESERVED FOR BOARD OF HEALTH USE CHURCHI .1R. JC ENGINEERING, INC. THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST c1 2854 CRANBERRY HIGHWAY PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL O '\ EAST WAREHAM, MA 02538 N BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. (6 115 �/, ��,� c SITE PLAN 5) 508.273.0377 �3. PROPERTY IS LOCATED WITHIN THE ESTUARINE ZONE WATERSHED. SCALE: 1"=20' Drawn By: MCP Designed By:MCP i Checked By:JLC JOB No.1850