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HomeMy WebLinkAbout0336 WHITE OAK TRAIL - Health 336 WHITE OAK TRAIL,CENTERVILLE A= 192 247 �I�I �J��ECYC[Fp�om O 2 UPC 12543 � Now HASTINGS, MN No. .. L r` ��, � Fee d 7/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Migponl *pgtem Conotruction Permit Application for a Permit to Construct( ) Repair( Upgraadee( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. '3 3 'b Owner's Name, ess,and Tel.No. cy Assessor's Map/Parcel IN LS7 'Siq M Installer's Name,Address,and Tel.No. �►C 14,c*J Designer's Name,Address and T I.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size / sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.rejujtred) � gpd Design ow provided gpd Plan Date 1"Z A?W�Q 24at9ffiber of sheets Revision Date Title % Size of Septic Tank � � Type of S.A.S. t,, VA 1'j �,k Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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. Signed- 6 Date Application Approved by 'V'"> Date Application Disapproved by: Date for the following reasons Permit No. 2 ——— Date Issued 0 ----------- —��� Olt Y No. / ' !�_ t _ y; ' :r Fee THE COMMONWEALTH OF•MASSACHUSETTS Entered in computer PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes .'Application for Oigpogar *pgttm Con5tructiott .vertu Application for a Permit to Construct O Repair LAUpgrade O Abandon O ❑Complete System ®Individual Components Location Address or Lot No. 136 AWW —, `—Ok \`^ Owner's Name,r�4ress,and Tel.No. ehT� t Icy S��Qh ri� Assessor's Map/Parcel ? t Installer's Name,Address,and Tel.No. r f' o� Designer's Name,Address and Tel.No. P, c��,/ Gro�s� �br tev,e HAS 5Z e-.J $= 996 9— Type of Building: Dwelling No.of Bedrooms 3 Lot Size /�.:5:5 .:. sq.ft. Garbage Grinder , Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -? ?V gpd Design flow provided gpd Plan Date / G <<� umber of sheets Revision Date Title r d � Size of Septic Tank Px Ad� Type of S.A.S. S�� Gu 11 ko C 4, 0C/ Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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. Signed, !.. l_� •.1Jel_.a' - Date <- 13 Application Approved by � Date " �._ /;r r Application Disapproved by: Date / ! for the followig reasons t, 2 . Date Issued / dG i Permit o. �)�)�' --'----- ---_—I'---------------- '—��--------- --- �' THE COMMONWEALTH OF MASSACHUSETTS ( d' BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ) Upgraded ( ) Abandoned( )by 141c aliq l 4at (,1 � �( j° has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Gap- 19.1- dated (/ Installer «,e.�i �,Q'C°' Designer lz�l 4C �-�� #bedrooms oe Approved design flow -F gpd The issuance of this permit shall not be construed as a guarantee that the system ill function as,desi ned. Date —. /U y Ins ector IJ �� No.2oo -i+ 1� \' Fee /01� " THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS =tgpogal �&pgtem CottAtmCtion Vermtt l Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon System located at , : GA)h t-;2e_. DA L (1&-,, kf I/• and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. jl�/ Provided: Const ction7ust be completed within three years of the date of t1 is p t.Date � / {(� Approved byR i Town of Barnstable OFT ME r Regulatory Services - Thomas F. Geiler,Director • BARNSTABLE, MASS. g Public Health Division AIFD M a Thomas McKean, Director 200.Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: °y25 Sewage'Permit# sessor's MaP\Parce,19Ze ?_41 Designer: Installer: , 1 c.6-- 5 u C--Y i vC—, c P.-DC , Address: g z 5 > z. COAL Address: On �A was issued a permit to install a (date {in a r) septic system at 33 CO '� o*�- T*v,-� L_ based on a design drawn by (address) STc t s dated o (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Vi OF STEPHEN A� S �.., CIVIL v. nstaller's Signature) No.35461 '$ AFC/STtaEQ S lg (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH.THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Revised.doe TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE C��.` ��� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO.—k�e SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 2 (S'T Ati� (size) NO.OF BEDROOMS PERMIT DATE: 5 � 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 Leachin Facility(If any wetlands exist within 300 feet of leachi%a 'hty) Feet FURNISHED BY t � OZ7 � or lb r r7s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information ^� filling out forms ()l*` IgoC 9�f on the computer, Michael DiBuono use only the tab key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane Company Address Cotuit Ma 02635 City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ®Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11/21/19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is Centerville Ma 02632 11/19/19 required for every , page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains an existing 1,000 Gallon septic tank as well as a concrete distribution box and 2 500 gallon leaching chambers in stone. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): , t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explairr_below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is Centerville Ma 02632 11/19/19 required for every page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate Yes or No to each of the following for all inspections: _ Yes No ❑ ® 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 II Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is Centerville Ma 02632 11/19/19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] El ED The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system Is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �x Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 336 White Oak Trail L! Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage 119 Gpd 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 White Oak Trail `L Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: New leaching and distribution box 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 White Oak Trail v Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 3 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 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" 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.): Tee's inplace at time of inspection t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u% 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 White Oak Trail L- Property Address Daniel Saverino Owner Owner's Name information is Centerville Ma 02632 11/19/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 500 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Functioning as designed 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 11/21/2019 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION AJG ..rc ?1n y XNr SEWAGE# ^�— • VILLAGE I.L ASSESSOR'S MAP&PARCEL L92, e2`� INSTALLERS NAME&PHONE NO. IA,, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO.OF BEDROOMS _ OWNE PERMIT DATE: S t� COMPLIANCE DATE: ✓ C Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Fact Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi fa lity) Feet FURNISHED BY a76�" a—7 6 1 7s' https://www.townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=192247&seq=1 1/2 c Commonwealth of Massachusetts g Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 336 White Oak Trail Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. Cityfrown State Zip Code Date of Inspection. D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10 + feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: March 2008 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: Test hole data on plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 White Oak Trail u� Property Address Daniel Saverino Owner Owner's Name information is required for every Centerville Ma 02632 11/19/19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPAR`I`MENT OF EN iRoNMEN'rAL PROTEC 15, ONE WINTER STREET, BOSTON NiA 02108 (617) 292.5500 f r 4 1998 �WNOF S� �ALTHO WILLIAM F. WELD TRUD Governor t� ARGEO PAUL CELLUCCI 11; T RUNS Lt. Governor rom-'�issiener '� SUBSURFACE SEWAGE DISPOSAL SYSTEM LNSPECTION FORM 17 PART A I CERTIFICATION ` F � ,, Address of Owner: Property Address: 33t W�;�� oc- ^ Tci v— �k L �-vl f different) Date of Inspection: Name of Inspector: LL, zf 1eQ-A—L I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 Ci11R 15.000) Company Name: C )' --� L Mailing Address: Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of or.-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails LUL Inspector's Signature: Date: \ 1 The System Inspector shall submit a copy of this inspection report to the Approving Authority within L`.iny (30) d2ys of completing this inspection. If the system is a shared system or has a design (lou of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sea: to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SLTM3NIARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 5 'Sees,^ 1 SS 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If'not determined-, explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked. structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaccd with a conforming septic tank as approved by the Board of Health. (nwised 04/25/97) P2¢e 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM LNSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date'of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspect; or: if.(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl 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 the public health. safety and the environment. I SYSTEM WILL PASS LIN'LESS BOARD OF HEALTH DETER'i1ZtiRS THAT THE SYSTEM IS NOT FLICTIONTNG I\ A MAN N-ER NNIPCH ii"ILL PROTECT THE PUBLIC HEALTH A.-,'D SAFETY A_\-D THE E.N-VZRO`-.%IE.N-r: _ 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 ii'ILL FAIL LNLESS THE BOARD OF HEALTH (A:\R PUBLIC (WATER SUPPLIER, IF APPROPRL-kTE) DETER.NnNES T1LAT THE SYSTEM IS FUNCTIONING L\ A MA.N�`ER THAT PROTECTS THE PLBLIC HEALTH A\-D SAFETY AIND THE E`VVIRO\,'vfEN7: The system has a septic tank and soil absorption system (SAS) and the SAS is within I00 feet to a surface water supply or tributary to a surface water supply. i The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply we!I. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water, supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well; unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04125/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DI SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply- Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART B CIfECKLIST Property Address: 3g�Q cr sc Owner: . �j Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components. excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge. depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Pige 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM LNTOIRMATION Property Address: (J3� Uiy\'C- 5 _- OwTter: Date of Inspection: `(` `C, FLOW CONDITIONS RESIDENTIAL: Design flow: 6Q a.p d./bedroom for S.A.S. Number of bedrooms:y2 Number of current residents: 0-17- Garbage grinder (yes or no):_L) Laundry connected to system (yes or no): Seasonal use (yes or no):B:� `\ Water meter readings. if available (last two (2) year usage (gpd): _Cr •. Q�c•R-�►��x11 yj Sump Pump (yes or no):_ j Last date of occupancy: COIN VI-RCIAL/II`"DUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste _folding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL IN`FORNLATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)_ If yes, volume pumped: Gallons Reason for pumping: TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIi11ATE AGE of all components, date installed (if known) and source•of information:t `c1 b L- Sewage odors detected when arriving at the site: (yes or no) (revised 04!25197) pice 5 of 10 SUBSURFACE SEWAGE DISPOSAL. SYSTEM L\SPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 33G w Zi cic Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) t Depth below grade: a Material of construction: _cast iron -XZ PVC _other (explain) Distance from private water supply well or suction line Diameter L- Comments: (condition of joints, venting• evidence of leakage, etc.) SEPTIC TANK. (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list are _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: 3, Distance from top of sludr:e to bottom of outlet tee or baffle: Scum thickness: 3 u Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: t Comments: (recommendation for pumping. condition of inlet and outlet tees or baffles. depth of liquid level in relation to outlet inve structural jntegrity. evidence of leakage, etc.) V t N GREASE TRAP: L1D (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert. structural integrity. evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in workine order _ Yes: _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) tISTRIBUTION BOX:_��QS (locate on site plan) �r (� Depth of liquid level above outlet invert:• 4,—."D C>'�v`��'� Comments: (note if vel and distribution is equal, evidence of solids carryover, evidence of I ge into or out of box...;tc�. _ � x PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) f r SUBSURFACE SEWAGE DISPOSAL SYSTEM`INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: k C.co-k .: Owner: �Cll�2 t tiJ Date of Inspection: )I SOIL ABSORPTION SYSTEM (SAS): u , (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches. number.length: leaching fields. number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil. signs of hydraulic failure, level of ponding, condition of vegetation etc.) T• �. en �tsl CESSPOOLS: (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 (cesspool must be pumped as part of inspection) Comments: s (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) P2ge 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 33& Owner: ' gvc, Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Z 3 I JAI p,3 (revised 04125/97) Page 9 of 10 i f C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART C SYSTEM INFORMATION (continued) Property Address: b L"V: ' k-t Owner: `}ZV�(Li11iJ Date of Inspection: Depth to Groundwater .�ZJ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of h:alth Check FEMA Maps Check pumping records Check local excavators, installers AUse USGS Data Describe in your own words how you established the Hich Groundwater Elevation. Must be completed) U,s, `�-�°CiIG� Cc.�Sc%",1i•i L�G�t,t• �1 . '�• -- e.: i e3� i9a `~aW7 L0r•AT LION � , n L Nf-AG PERMIT N0. g k) V 1 GT INSTAL ER'S NAME i ADDRESS S U 1 DER OR ER OAT PERMIT ISSUED 2 DATE COMPLIANCE ISSUED - � �gZ�8� z2 TOWN OF BARNSTABLE LOrAnON �.� � �-( l�",� L SEWAGE # VIIJ-AGE &1�G LAJI ASSESSOR'S MAP & LOT 2ti INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1600 riO- 1 LEACHING FACILrf Y: (type) Or 1 (size) 10t 40-/ NO.OF BEDROOMS BUILDER OR OWNER v DATE: l COMPLIANCE DATE: Separation Distance Between the: 0 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) U" d Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N 0 t Feet Furnished by 0-4 tf�(� r i o , Z ° 3 � � m y p�, 41 3S No......... ........... .. ............... THE COMMONWEALTH-OF MASSACHUSETTS ® J BOAR® OF HEALTH Pet. .. T........OF...... �33� Appiiration for Uispniai Works C omitrn.rtinn Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: . ot_..6,9........ .. .. _- z� �....---.C� - .� y Locati or Lot Q. -.... ---- ------. � ..... �Owner Address S a - -•............. Type of Building Size Lot�, ......... .....•.._................ ............ Installer Address (, �(� tl_....L.V--l..Z....Sq. f e U Dwelling—No. of Bedrooms........:..................................Expansion Attic (�/� Garbage Grinder Mo a4 Other—T e of Buildin yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ......................... ............................................... W Design Flow......... �.....................gallons per person Der daft. Total daily flow.....' ----I ..........................gallons. WSeptic Tank—Liquid capacity/ allons Lengt ..... Width... ........ Diameter................ Depth...9......... x Disposal Trench—Nq.._..._._ Width _...� ....... Total Length.............#......Total leaching area....................sq. ft. Seepage Pit No........ ............ Diameter..... ......... Depth Pelow inlet..... _.......... Total leaching area. ......sq. ft. Z Other Distribution box (� ) Dosing tank Percolation Test Results Performed by...... !__ _.. �_.?C'€�. ............................... Date_-: �l - . W � . . Test Pit No. 1.....CZ..._minutes per inch Depth of Test Pi�,6..o...... Depth to ground water..M. ....6...� 4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--------------- .--------- 9 ---•----••----- ----•----------------•---------•--•---...._.....-----....•--••-....._................................................................ O Description of Soil --� l ... . :........ V ---------------•--------------..------------------ 4_-__ ... ....................... .....---- - .... ............------.....------••------.... . W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------•----------...-----------••-------------•--•--------------------......-----------•----------------------------------------------...----------...-----------•--------••-•......--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issued by of health. Signe -•-- --•s- --------------•----. Application Approved B ........ Y-t�s PP PP Y -- ... ..._.. _... ... Date Application Disap ved forlhe following reasons:.............................................--••---•----•--------••--------------------•-•--•------•----.....•. - ---------••------------------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date No.-_.... ......------ F�$.. ..v..� ...... 8/ 3 3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH : le oF..... a`:. .�s ....... ........................ f Appliration for Disposal tVjark�C�onstrlrtion rruti# Application is hereby made for a Permit to Construct (e) or Repair ( ) an Individual Sewage Disposal System at: �` �- -........_.---_..... •................ .........•-•••---•----------•...... ---- --•••--•- -••-• ..... - •-- Locati dd ss r Lot o use- �cr � as .� �s a� QVs r s- ----_. h...................................•--_---=----•------•--a -----...__ ___.�...._..... ._.�-:--:-.---•-----------...---�.- , Owner t l Y�JL4' Address / a --•••-••_. = ----------------------------------------- ------------- ---- -:..... A................................................... �Installer Address ��. �/�� S Q7i Type of Building ize Lot:._......v....... ........ q. ex U Dwelling—No. of Bedrooms............... ___________________..........Expansion Attic �40�: Garbage Grinder )w aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfi turas -----------------------------------------------------.----•-•--•-•----•---••-•••-••-•._...-•------ � �...------•-----.... W Design Flow......_.. ��_______........._______gallons per personer�a�. Total d ily flow_._.____.___________._.................... Ins. WSeptic Tank—Liquid capacity.l��gallons Lengtbd_o_.q.__.. Width.__ ......... Diameter________________ Depth__ .______. W Disposal Trench—N .________ Width ....... Total Total Length.............#_____ Total leaching area...... .........sq. ft. Seepage Pit No________ ____________ Diameter..... Depth elow inlet...... Total leaching area� _d�....sq. ft. Z Other Distribution box J Dosing tank �� '-' Percolation Test Results Performed b .. Date__ /,,Cj� Test Pit No. 1...... ___._minutes per inch Depth of Test P- _____.11�_________. Depth to ground water_! ___0.......... r, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --•••--• ---__ - - •--------------•----------------•----------•---------••-•-------------•------•--- 0 Description of Soil________________ W VNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ------------------------------------------------------------------------------------•--.........--•------------------------....----------------"--..-----------------------------------..._----•-•-•••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'ITI 4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance Ahasb issued by the;b of health. -------------------Date Application Approved BY - .................................... --•_ =Z =` �--..._._._ Date Application Disapproved for the following reasons-------------------------------------------------------------•------------------•----------------------••-•--••-- ! i ,- / Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF........ .......... ...: .................................... (Irdifirate of Toutpliattrr L.-I THIS IS TO CERT Y;;That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY-------------- -----------------1 --------•--•----____--------------------------------;______---------------------------------_____-_------________-----------____-------- Instal at...................:,r ....• _ -!:�� _._________- ----- 4 has been installed in accordance with'the provisions of T `` of The State Sanitary Code as described in the application for Disposal Works Construction Permit �'o__S'�___�72.............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............................................ZOO..._...•-_--•-- Inspector-----------CZAR THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH v ........ .............OF...... ^^ ��'� ...._._..._.__._..._.._.._......._._.. NO. J7 �� 8/__:39:3. FEE......... ........•--- DisposttWorks Tonstrttrtion Vprrmit Permissio • "hereby granted-------- -••-••...... - -`- ..-.-------------------------------------------------------------------------•----•--.....-•------- to Construct r Repair ( an Ildividual Sew,4ge D�oW System ✓ at No 5c --------------------------------•----------...._...---------...--•-••---•--. _-------------------------6.•1•-•-••-- � �...... .�.... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... �� oard of Health DATE---------------•--;;4------- /� =........................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS , w _ ACCESS COVERS MUST BE WITHIN - 6 OF FINISH GRADE 9 M(N(MUM, INVERT- EL E VA T I ONS DES I GN CR I. TER l A : GENERAL NOTES : 3' MAXIMUM COVER FIRST 2' TO ;INVERT OUT SEPTIC TANK: 102.75 DES I CiN FL OW: - r. BE LEVEL MIN 2' OF PEASTONE INVERT INDIST. BOX: ' 102.37 3 BEDROOMS AT //0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION -0R FILTER 'FABRIC INVERT OUT DIST.: BOX 102 2 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4' !AM PIP 3/4 - 1 (/2` D I A INVERT I N L EACH CHAMBER 101.7 1,102. 75 0 2 $ o DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER: . 99.7 NO GARBAGE GRINDER 2. VERTICAL DATUM 1S ASSUMED. FOR BENCH MARKS . * CA 1!Z SET, SEE S/TE PLAN. BAFFLE 102.37 3% 99.7 'ADJUSTED GROUND WATER: N/A OBSERVED GROUND WATER: N/A SEPTIC TANK REDUIRED: 3 OUTLET 330:G.P.D. X 200x - `660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND 2-SOD GAL LEACHING CHAMBERS EXISTING D-BOX W/4 STONE AROUND. 12.8 'x x 25 1 x_2 d BOTTOM OF TEST HOLE +�l 93.3 MAINTENANCE OF THE SEPTIC SYSTEM SHALL - SEPTIC TANK PROVIDED: (000 GAL. EXISTING 1000 GAL CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6' CRUSHED STONE OR , COMPACTED BASE ., *•' SOIL ABSORPTION SYSTEM REDO/RED: BOARD OF HEALTH-REGULATIONS. DESIGN PERC RATE C°;5 MIN/I NCH PROF I L E NOT TO SCALE SOIL TEXTURAL' CLASS 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0.74 GPD/SF - 446 S.F. REDUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS, PROVIDED 2-500 GAL LEACHING 'CHAMBERS W/4 ' STONE AROUND, A-471 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR } 471 S.F. z 0. 74 - 348 G.P.D. APPROVED EQUAL. Y 6. PRECAST T CONCRETE AND SEPTIC XSHALL BE REINFORCED y �! WATERTIGHT. D-BOX SHALL 1 BE WATER TESTED TO CHECK FOR LEVEL WHEN THERE too.a IS MORE THAN ONE OUTLET. N ; 31 l.46' P/ FE r 104.3 o '{3 �� 'LAfS t04.Ct �. TP+f 7. BEFORE CONSTRUCTION CAL L 'DIG-SAFE'. 104. a-PiN ? a 8'PAK -. 1-886-DIG-SAFE AND THE LOCAL WATER DEPT. ►_.� 167.50' 6 OA 4 ' OUND `UTILITIES. NH/TEL/TV PEDS -' 1^"OAK 4'P(Nr TP+? FOR LOCATION OF UNDERGROUND ® kA /0'OAK e yl, 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE , D-BOX :•. ^'a P1kE 2-500 GALLON LEACHING CHAMBERS DESIGN ENGINEER TWO DAYS PRIOR TO CONS TRUCT I DN " K W/4' STONE AROUND OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE J i J`;• Ex1srlNc , lo4.s CONSTRUCTION INSPECTIONS. TANK BM•CORNER f TEP EL-106.3 1 SOIL TEST P / T DA TA � --- 9. EXISTING LEACH PIT TO BE PUMPED DRY AND l BACKFILLED. I ND I CA TES �_ I ND I CA TES PERCOLATION = OBSERVED 105.4 TEST = GROUNDWATER TP +�1 TP �►2 le OAK f e Q GARAGE EXISTING DWELL lNG 1 L� HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR o 14.OAK` 0" 104.3 0' 104.5 _ _ ti Q LOAMY IOYR LOAMY IOYR o SAND 4/3 SAND 4/3 0 4• ..... .....................•...... .. 104.0 8' . ,. .. ........ l 03.8 � LOAMY IOYR LOAMY IOYR " DECK 1 C# B SAND 5/6 B SAND 5/6 � PNEN \ 24' .......................................... 102.3 26• ........................................ 102.3 MED-COARSE IOYR MED-COARSE IOYR C / C / No.35481 SAND AND 7/3 SAND AND 7/3 48' GRA VEL GRA VEL LOT69 18, 598+ S.F. 108, ....... 95.3 /08' ............... ........... ... 95.S C2 MEDIUM IOYR CZ MEDIUM IOYR i J SAND 7/2 SAND 7/2 11397 ' N ,88°40'I9'W R NO WA TER N0 WATER 132 1 93.3 132' 93.5 DATE. FEBRUARY 13. 2008 TEST BY: STEPHEN HAAS 5' P T C S YS TEM D E ,; / WITNESSED BY: DONNA MIORANDI FERC RATE: z MIN/INCH 336 WH 1 TE. � K -RA t.L MA P 1 92 . PAR C'EL �•4 E`EN TER V / L L'E • RARIVS TA ., . . , PREPAREIN FOR WE'QUAQUET LAKE , L EGf ND . • .• ;, ,, N G3 CONCRETE::BOUND SCAI4 E / MA RCH .20 . 2008 . _...}y WA TERLINE `REV M ,.. . x ,.HYDRANT _ . GAS LINE _ _ ; .. V ....._ . E L_ F Y 1 N1 NC •:-; ,. � ,, .. � 0 ER HEAD.. WIRES ' , . . . GHT 'POST 9 z 3 F c { # LI P u 6 , , - UNDERGROUNQELECTRICL INE> •;:<� �,., h o t fv1A . G12675 , .�' .- -''y' -11 �--T UNDERGROUND T PHON ,. .--.;• `•,. ,S C�Ei � �6 2 8 '9 ' _ .. ELF W E LINE ,�' 1 . 3 �. � .0 _� �2: .; . ..- - /' a / ,.. _ .: CTV UNDERGROUIVO CABLEVISIONLINE .. _ 1 . . , . : 508 43� 53�3 . , . ;. 0. SPOT - 4 T L VAT 0 - ., 1XISTING C NTO ,. fl .PROPOSED ON U �. 0 �: �, �. , L C S APLJ.08NLa 0 N 08009 : ,D. WIEEK CALC SAH/CFW C tC FAY ,N if C ._ .DRN SAH y r , - -..-..... , , . • , a .. . e. , ,..a..4. ,.. .. ,. ..^. .ate'.. z. .. ..... 7• "."'"`.""'. , ,.: ,., .. "Y'"== :=' -,'gme v w I •"f, y ACCESS COVERS MUST BE WITHIN INSPECTION 9' MINIMUM. INVERT- ELEVAT IONS . DES IGN- CRI TER/ A : GENERAL NOTES 6` OF FINISH GRADE PORT 3' MAXIMUM COVER FIRST 2 ' TO INVERT OUT SEPTIC TANK: 102. 75 DESIGN FLOW: BE LEVEL MIN 2' OF PEASTONE INVERT, IN DIST. BOX: ,102.37 3 BEDROOMS AT 1/0 G.P.D. PER 1. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION R INVERT OUT DI ST. BOX: 102.2 BEDROOM EOUALS 330 G.P.D. SYSTEM ONLY. INVERT IN LEACH CHAMBER: 10l.83 o' D AM PIPE OF THE SEWAGE DISPOSAL 3/4' - I I/2' DlA. l02.75 S� 1p• $o DOUBLE WASHED STONE BOTTOM:OF LEACH CHAMBER: /0/ O NO GARBAGE GRINDER 2. VER T I CAL DATUM I S ASSUMED. FOR BENCH MARKS a GAS T102.37 •� s 10I.0 ADJUSTED GROUND WATER: N/A SET. SEE SITE PLAN. BAFFLE SEPTIC 5 HIGH CAPACITY INFILTRATOR OBSERVED GROUND WATER: N/A 5EPT l C TANK REOUI RED: 3 OUTLET 330 G.P.D. X 20OX - 660 GAL. 3. ALL CONSTRUCTION METHODS AND MATERIALS AND EXISTING CHAMBERS W/3.5`t STONE AROUND BOTTOM OF TEST HOLE �►l: 93.3 D-BOX MAINTENANCE OF THE SEPTIC SYSTEM SHALL SEPTIC TANK PROVIDED: IOOO .GAL. EXISTING l 000 GAL l O'• x 38 ,1 x I O'd CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6' CRUSHED STONE OR ( SOIL ABSORPTION SYSTEM REOU/RED: BOARD OF HEAL TH REGULATIONS. COMPACTED BASE C�G�yd" CV��", DES l GN PERC.RATE ( 5 M l N/1 NCH PROF / L E : NOT TO SCALE �, � �,,� C�� , se SOIL TEXTURAL CLASS 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER a� EFFLUENT LOADING RATE - 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3,' 1N DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: 5 HIGH CAPACITY INFILTRATOR CHAMBERS W/3.5't STONE AROUND, A-460 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR s 460 S.F. x 0. 74 340 GPD APPROVED EOUAL. 6. SEPTIC•TANK AND D-BOX SHALL BE REINFORCED PRECAST CONCRETE AND WATERTIGHT. D-BOX SHALL } oo L BE WATER TESTED TO CHECK FOR LEVEL WHEN THERE ul f 4 P/ F 1r,4.3 o + { 3/1•46 ' ua•r. IS MORE THAN ONE OUTLET. } © '?'pJhr 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE lI RMG,'3 Rr+JC '� nr - -' % 5 H/GH CAPACITY ' 4`F�P'za ';a�Y c m A ,. 04.3 INFILTRATOR CHAMBERS ��z ��' - �r e oA.� l-888-D/G-SAFE AND THE LOCAL WATER DEPT. /67.50 ' HH/TEL/ry PEDs W13.5's STONE AROUND y ;�A FOR LOCATION OF UNDERGROUND UTILITIES. Tp*p + 1 !2`OAK 4'P I dNE>itiae ti t N 88°40 '12'W ® 7ro`OAx Y' � � r 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE D-eox o v 4'PIME PRIOR TO CONSTRUCTION `O"K OF THE ENGINEER T THE SYSTEMTOA� Y LOWFORSCHEDULING OF THE �r EXISTING ~` 26 j iu4.9 CONSTRUCTION INSPECTIONS. TANK 8M.CORNER STEP c, N `= _ 9. EXISTING LEACH PIT TO BE PUMPED DRY AND SOIL TEST P I T DA TA ® E BACK FILLED. INDICATES INDICATES PERCOLATION = OBSERVED 3 TEST GROUNDWATER TPi TP #2 £x/srING DWELLING 'o GARAGE N _ OR HORIZON TEXTURE COLOR �. OR TEXTURE COL l04.3 0' 104.5 o _ y A LOAMY IOYR A LOAMY IOYR o SAND 4/3 SAND 4/3 4• .................. ....................... 104.0 8- 103.8 Z B LOAMY IOYR p LOAMY IOYR DECK SAND 5/6 C7 SAND 5/6 P4- ......................................:... 102.3 26' .......... ............................... 102.3 C MED-COARSE IOYR C / MED-COARSE IOYR _f tt� SAND AND 7/3 SAND AND 7/3 ` wadf 48' GRA VEL GRA VEL �'oP ` + LOT 69A. A 95.5 /8. 598+ S. F. cnriL No.35461 108' ...............:... ........ 95.3 108- ........................... .r .� �r�l C2 MED I UM IOYR C2 MED/UM IOYR SAND 7/2 SAND 712 ` N 88°40 fr G � NO WATER NO WA TER ri rj 132" 93.3 /32" 93.5 -, DATE: FEBRUARY 13. 2008 ...: TEST BY: STEPHEN HAAS WITNESSED BY: DONNA M14RANDl C S Y S / E-M D E S f (a V PERC RATE: ( 2 M1 N/I NCH 336 W" TE- OAK TRA / L MA / 92 . PARCEL 24 ,7 < CE/VTERV / LLE > W£OuaouEr ►` P R EPA R E-D F OR LAKE cn x s L EGEA D CB CONCRETE, BOUND; =, BAN SEVER / /VO Z -W K A TER L I ENE x O klYDRANT SC4L E / .. - 2O MARCH 2O . 2008 A -G casLINE EACI:_.. EUR �/ Y 1 NG I NCB - �o s OHW_ (VER HEAD WIRES 5, o ' -0 LIGHT POST 923 'Rout e 6 A .`. -E-~ UNDERGROUND ELECTRIC L l NE =~ Y o r mo u t h p o r t , MA . 02675 ` --T- UNDERGROUND TELEPHONE L I NE Sri i�~ I 4 \�� 5 0 8 3 6 2=8 1 3 2 ' -CTV- UNDERGROUND CABLEVISION LINE ��`t/ 1 ( 506 ) 432-5333 +40.4 SPOT ELEVATION 40 EXISTING CONTOUR. PROPOSED CONTOUR L O C U S MAP 20 40 .JOB WO: 08-009LFIELD CFW/EEK' LCAL C: SAH/CFW CHECK: CFW ORN: SAN Ar . / + yy a 0 jut 77. ,"2"a""} .G'�.'. C.�. . •�6:ai. 7 All - r ley 72 )77 p t ���,i� � L� Y�'���,"`F' . . f� ti.l,�e'.ti"4� e^`• fir^rr�.m t.��"". lot TI dt 7o 1 — a OF I CONERY V32ik PLAH LAND r p MASS. ir'V7 G € rR �' C ,' Y 5 'ARE+f ST. � s`C'.mms. 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