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Home My WebLink About0047 WILD GOOSE WAY - Health 47 Wild Goose Way Centerville A= 167-039 0 S M E A D No.2.153LOR UPC 12534 amaad.com • Made In USA Y ROUSmMISM UCI N jF1 �M��SR 1MMMSFWFADGRAµQW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out 314 forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name raa P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number �N License Num I B. Certification AUG 3 1 REN I certify that I have personally inspected the sewage disposal sy m at this address a at the information reported below is true, accurate and complete as of a Inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furker Evaluation by the Local Approving Authority 8/19/2010 I p c o' Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ( �1 I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Di osal System•Page 1 of 1.7 A Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is Centerville Ma. 02632 8/19/2010 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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 septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. - -- *A metal septic tank will pass inspection if it is structurally sound, not leaking and.if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name 'information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town - State _Zip Code Date of Inspection B. Certification (cont.) 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 L15in. 9/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is Centerville Ma. 02632 8/19/2010 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. " ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. v ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems:— You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5147 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is Centerville Ma. 02632 8/19/2010 required for every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® . Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 0 ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El Have large volumes of water been introduced to the system recently or as part of �o® this inspection? _ ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑. Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue. approximation of distance is unacceptable) [310 CMR 15.302(5)] D.'System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 47 Wild Goose Wa`, M J Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No ,000:132 I Water meter readings, if available (last 2 years usage (gpd)): 2002008:132,000 Detail: 2008:361gpd 2009:397gpd Sump pump? ❑ Yes ® No Last date of occupancy: 88//19/2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form . . m p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Wild Goose Way w a Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information III Pumping Records: Capewide Enterprises,LLC. Source of information: Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy F ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) }. I ❑ '" Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 21 ., Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 3" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10tt �M 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010" every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" 811 Scum thickness Distance from top of scum to top of outlet tee or baffle 2" 4" Distance from bottom of scum to bottom of outlet tee or baffle 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.): Pump tank every two years.inlet and outlet tees are in place.No evidence of Ieakage.Tank appears structura!!y Sound. w Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness -- Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): P 1_• Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet Iateral.No evidence4 of solids carryover.No evidence of leakage. 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.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches "- number, lengtfi: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Leaching pit.Pit had 2' of water on bottom at time of inspection.Stain line observed 16" below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is*required for Centerville Ma. 02632 8/19/2010 t every page. City/Town State Zip Code Date of Inspection D.-System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, " etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page'14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to - at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately #47 � 25�op i Septic Tank .-' -� "D" Box 4 OJ fo SAS t5ins•09/08 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is Centerville Ma. 02632 8/19/2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 25' 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts = to Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 47 Wild Goose Way Property Address Laurie Gardella Owner Owner's Name information is required for Centerville Ma. 02632 8/19/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Septic System Inspection Report ' 47 Wild Goose Lane Centerville, Massachusetts - RECEIVED AUG 14 2001 July 20, 2001 TOWN OF BARNSTABLE HEALTH DEPT. Prepared For: ' Deborah B. Lovequist 47 Wild Goose Lane ' Centerville, Massachusetts 02632 ' Prepared by: William E. Robinson, Jr. Septic Inspections 43 Tomahawk Drive Centerville, Massachusetts 02632 1 I COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS M DEPARTMENT OF ENVIRONMENTAL PROTECTION 5� ' TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ' PART A CERTIFICATION ' Property Address: 47 Wild Goose Lane,Centerville Owner's Name:Deborah B.Lovequist Owner's Address: Same as above ' Date of Inspection: July 20,2001 Name of Inspector:(please print) William E.Robinson,Jr. ' Company Name: William E.Robinson,Jr.Septic Inspections Mailing Address: 43 Tomahawk Drive Centerville,MA. 2632 tTelephone Number: (508)775-7986 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported ' below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ' X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ' Fails Inspector's Signature: Date: 7"ay'dl The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 ' gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ' Notes and Comments The septic system appeared to be in good functioning condition on the day of inspection. ****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. III Page 2 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist ' Date of Inspection: July 20,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS 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 septic system was found to be in good working condition on the day of inspection. ' B. System Conditionally Passes: N/A ' One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. ' Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. ' The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with ' approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ' ND explain: ' The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ' obstruction is removed ND explain: i Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) ' Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist Date of Inspection: July 20,2001 ' C. Further Evaluation is Required by the Board of Health: N/A 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 E Supplier,if lier and Public Water Su an determines that the Y) system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ' The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ' failure criteria are triggered.A copy of the analysis must be attached to this form. ' 3. Other: Page 4 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist ' Date of Inspection: July 20,2001 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: 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 X Any portion of the SAS,cesspool or privy is below high ground water elevation. ' _ X Any portion of cesspool or 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 cesspool or 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.] ' No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A ' To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: ' (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered ' "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ' Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist Date of Inspection: July 20,2001 ' Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X — Pumping information was provided by the owner,occupant,or Board of Health(Sewage Treatment Plant) ' — X Were any of the system components pumped out in the previous two weeks? X — Has the system received normal flows in the previous two week period? ' — X Have large volumes of water been introduced to the system recently or as part of this inspection ? X — Were as built plans of the system obtained and examined?(If they were not available note as N/A) ' X — Was the facility or dwelling inspected for signs of sewage back up? X — Was the site inspected for signs of break out? I ' X Were all system components,excluding the SAS located on site? — — Y� P g , ' X _ 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? X — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? tThe size and location of the Soil Absorption System(SAS)on the site has been determined based on: ' Yes no X Existing information.For example,a plan at the Board of Health. X — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance ' is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 ' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION ' Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist Date of Inspection: July 20,2001 ' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 ' DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd(assumed) Number of current residents:2 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): N/A Seasonal use:(yes or no): Yes Water meter readings,if available(last 2 years usage(gpd):1999—104K eats.(285 eaWdav).2000—63K gals.(172.6 ealsJdav) Sump pump(yes or no): No Last date of occupancy: Currently occupied. ' COMMERCIALANDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq ft,etc.): ' Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: ' Last date of occupancy/use: OTHER(describe): I ' GENERAL INFORMATION Pumping Records Source of information: Septic Inspector witnessed pumping on July 23,2001(1K gals.) Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped:1000 gallons--How was quantity pumped determined?By meter on truck Reason for pumping: Amount of sludge and scum. ' TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be ' obtained from system owner) _Tight tank _Attach a copy of the DEP approval ' _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist Date of Inspection: July 20,2001 ' BUILDING SEWER(locate on site plan) ' Depth below grade: 116" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): ' No evidence of leakage,all Joints appear to be in good condition on the day of inspection. SEPTIC TANK: X (locate on site plan) ' Depth below grade: 2' Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) ' If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8.5'x 5'x 4' ' Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 2110" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 3" ' Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Direct measurement Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels ' as related to outlet invert,evidence of leakage,etc.): Tees in goad condition. No signs of leakage,liquid level at outlet invert. Recommend pumping(pumping com lete). ' GREASE TRAP: N/A (locate on site plan) Depth below grade: ' Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: ' Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: ' Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 1 Page I of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist Date of Inspection: July 20,2001 ' TIGHT or HOLDING TANK: N/A tank must be pumped at time of ins ection locate on site plan) ( P P p )( P ) ' Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): ' Dimensions: Capacity: gallons Design Flow: aallons/day Alarm present(yes or no): ' Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): ' DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): "D"box leve4 no evidence of solids carryover,no evidence of leakage. PUMP CHAMBER: N/A (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.): � I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist Date of Inspection: July 20,2001 ' SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) tIf SAS not located explain why: ' Type X leaching pits,number: 1 leaching pit(with 2 of stone all around) leaching chambers,number: ' leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ' overflow cesspool,number: innovativetalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Soil dry,no signs of hydraulic failure,no youding,no lush vegetation. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: ' Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: ' Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ' PRIVY: N/A (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.): 1 Page 10 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist 1 Date of Inspection: July 20,2001 SKETCH OF SEWAGE DISPOSAL SYSTEM 1 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. 1 i Please see attached sketch i 1 1 1 1 1 1 i 1 Page 11 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) 1 Property Address: 47 Wild Goose Lane,Centerville Owner:Deborah B.Lovequist Date of Inspection: July 20,2001 ' SITE EXAM Slope: Mostly flat in SAS area Surface water: Scudder Bay is approximately 250'to the east ' Check cellar: No water Shallow wells: None in area ' Estimated depth to ground water 44 feet(below the around surface at the SAS) Please indicate(check)all methods used to determine the high ground water elevation: ' Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: ' Checked with local excavators,installers-(attach documentation) X Accessed USGS database-explain: ' You must describe how you established the high ground water elevation: Seasonal high groundwater was determined by comparing USGS/Cape Cod Commission groundwater data and Town of Barnstable GIS data to field measurements and installation as-built information.. The surface of the ground at the SAS was estimated from the Barnstable GIS map (June 1992) to be at elevation 51, The bottom of the SAS was measured to be approximately 9' below the surface; therefore,the ' bottom of the SAS is at elevation 42. The groundwater elevation beneath the site was estimated from the Barnstable Ground Water Contour and ' Road Index Map (June 1992) and found to be at elevation 7. Using the Cape Cod Commission method to estimate the seasonal high groundwater elevation, the site was found to be within the area of groundwater indicator well MIW-29(Zone Q. According to the data available from the Ca C Commission the June 1992,the adjustment for that well is 3.6' upward. Therefore,the adjusted gr dwat r is at elevation 10.6. When subtracted from the SAS bottom(elevation 42)the resultant separatio s 31.4' etween seasonal high groundwater and the SAS bottom. LOCUS MAP & SEPTIC SYSTEM SKETCH i ' ' y , �• , oJ9 ' 7 Stoney tl ubae! 34 ' u ` _ i n " • , III `` � �:.• �• ,0 ��'j "' �•' , • . �• .off' j Hayes V Pt '1 ' ' " • •�• • •• 11 rest c� I , �.,• Pt +^ �' I �• Cry a(r.. .,/� �* Ij U on -\` .)`- \` ,��-a fps, t ,, a� •..�• ,/ l •� "\. \ ��!-w t� • • � � I. vO ,•• yam•. y 1k •J t r• !ate Cranberry V, 46, ��rp-w.� - 0 1.� ` �• _ _ _ /. try - i I ��. -�'- ( • , •l.`(•///� •�+ aeYor�k i•,�' �Y 1 �• O � �„• � �u••• .f 'w• o i''A.`.1 —,V r� �'-r^ itRoa \ 1� 79 6 ell ' I', ;. !/ \ � •p (�O • : 7.7 , •�• � • di• is 01 Pond • o �G � =. ♦ w Got�eabn _ ��" Public ulr Sa»e .7 Landing +�o' Pond11 i!s do. X i �f .. Poredd Xi /' .vet Cr7, :.�� :.� •••• �►';��i� .�t1� i� '•S l � 5 - ) I 47 r } •1 � � / l0 I A. c * ', ' o• • � .o 0 CENTERVILLE \ \_ East Ball a t i / t2o 1 " • .• t � 11 + � I %' ,),� 1, s \ 8• l 11 • n zpowsei►-� 1 i. - - • %` li.�r�Z Beach \\�,a` ! IIII 1 /4 \ 16°W VIL ' Name: HYANNIS Location: 041'38'48.4" N 070°21'56.0" W Date:8/9/2001 Caption: Locus Map Scale: 1 inch equals 2000 feet 47 Wild Goose Lane ' Centerville, MA. Copyright(C)1997,Maptech,Inc. Septic System Sketch ' Cross Section Ground Surface 24" 33" 36" El Foundation Septic Tank "D" Box SAS ' Wild Goose Lane 1 #47 25„t0.. Septic Tank "D" Box so ' SAS ' William E. Robinson, Jr. Figure 2 Location: 47 Wild Goose Lane Septic Inspections Centerville, Massachusetts 43 Tomahawk Drive Not to Scale ' Centerville, MA. 02632 Date: duly 20, 2001 Based on Visual observations 1 Inspectors Certificate 1 1 1 1 1 1 1 1 1 1 1 1 1 w t Ln rfl Sbllf ��l~ THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT William E. Robinson, . Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR ' as provided in 310 CMR 15.340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection: April 20, 1995 Acting Director of the. ' ton of Water Pollution Control F9, F '. A- LOT NO..: 014NERS NAME: (y G ot� 'r SEWAGE PERMIT NO. REPAIR: DATE I,SSUED DATE INSTALLED:' �� INSTALLERS" NAME: �� G�IL CAL - INSTALLATION OF: ) &JOL vvc, WATER TABLE: FINAL INSPECTION BY: DRAWING OF INSTALLATION ON REVERSE SIDE: 03 b;z , TOWN OF BARNSTABLE ,y LOCATION = SEWAGE # VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) (size) NO.OF BEDROOMS 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 No.._1... �°.. Fx$....� �....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tle4-`00...-.. ......OF.... �4 ot'r�"y...*--------- ---- Appliratiun for M-4g uttl arks Tonstrurtiun Frrutit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: ._ _ &*' : -Address ----------- --------•---•--.�•orLot------ -- ----------------------------------- 3014,•• �� ._ ......... �.}........... Owner a = '' G�G�L ..---••-- ................................................ _V✓�.YILn 4,/e7v� a{.-0 ................................ �' ' Installer Address U Type of Building Size Lot__ -g�� .....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q . Other fixtures ------------------------•------______----------•--•--------------••---•-------------•- ---•---------••---•-•--_---- W Design Flow.......... ___._______________-_gallons per person per day. Total dail� flow-_ X.1�®.=_:______._.___gallons. WSeptic Tank—Liquid capacity/�'�gallons Length___' Width.....YMU Diameter__-___"'""_. Depth___—.$_6__. x Disposal Trench—No_ ____________________ Width-------------------- Total Length..............`.... Total leaching area__-______...........sq. ft. Seepage Pit No._______--/_-_____. Diameter..._./ V-___... Depth below inlet____-_�_____.___. Total leaching area0.7.____sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by--•-�o_-�..___�:_�______ 6��/9.x - Date ,aa Test Pit No. 1....A?_.minutes per inch Depth of Test Pit.�z'.S_.�__. Depth to ground water_..__!? -�J_____-_ Li, Test Pit No. 2._._/-Z-.minutes per inch Depth of Test Pit---- ____ Depth to ground water_______ ...... a �dE L .O Description of Soil-•---------•...d.'"_.Z:�......._?�'_..�Sv.....g�G �_�� V .............. :5_"_.l. t_sI... °e" -! � ` 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 TITLE 5 of the State Environmental Cod The undersigned further agrees not to place the system in operation until a Certificate of Compliance a sued by the board of health. -....... �.. .................... ....--...... - --.....- -- ...--- -.-..............-----------. Application Approved By ------------�4S�igned ....................... `.-...... �' Dare Application Disapproved for the following reasons- ------------------------------------- ---------------------------------------------------p.-...--..-...-------- --- --= - -- -- -....... - -- -.....- -- - -................-...........- - .....-.... ----------------...................... Permit No. --..:7. .. '`.-�'�� --------- Issued ------dam--/7 Date No.•• ...e-- .... Fins............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......row ................OF.........!..?'�,'��................................/9 " Appliratiou for Di-spoottl Workii Tonitrnrtion rprmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: A0i 4- � --------------- ---------------------- -------------------- .......... ----••--. ---- .. oca`ion-Address t No. r4......-......-------------------------------•-•-- •�- ......... ��. Owner Add p� Instal ler Address U Type of Building Size Lot_.ZQ A5?5;?.....Sq. feet I--. Dwelling—No. of Bedrooms............................................Expansion Attic ( 3) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) .< Other fixture d ----------- ••-----•................... W Design Flow............................................gallons per person er day. Total daily flow..�X_l/U.!_�-4�..G_.......gallons. WSeptic Tank—Liquid capacity/gallons Length__-_�___ Width..... Diameter_."'":_. Depth... r x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------..1........ Diameter-----,!d_.____. Depth below inlet......4........_._. Total leaching area.- !!..?.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results. Performed by-_.. __�_- ._ .. Date..._ ... . I-. H E—i—� _ _____________________________________i_.....__._...__-.. .. Test Pit No. 1.....'.... :_.minutes per inch Depth of Test Pit./Z-.:;` ...... Depth to ground water.__._9L'..�!_....__ Test Pit No. 2....!!�: __minutes per inch Depth of Test Pit....,f!?__c_._.. Depth to ground water........... ............ 04 .4f I------------------- .......................................�_Z................. D Description of Soil....... ��'-- Z--s ...... _.... V--,,!;SC77 L ---0------ W •-•-••-----•----------------•---------------------------------••----•••-----•----------•-------•--•------------•-----•----•------•-•---•-----•--------•---•••-•----•--------•••--•----•................. VNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Coded The undersigned further agrees not to place the ,, iX. system in operation until a Certificate of Complianc/e� as-been=issued by the board of health. Signed ........../-��.:. ..... i ��.... .........................------..-------..................... .............--Dare.--.............. \ Application Approved By—"',....... .........C............. f '---'-:'-------------------------------------------- �..w Dare Application Disapproved for the following reasons: .....................................r................................................................................................. ........................ ........ ..... ..... .. ................................................................................................ . .... .. .. ........................................ CIO, f, - ,,..��„rt � �- Dme Permit No. .... ..... ....''` '..' - Issued ...... '............................................................../ Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �T -- ---------------------------------------------------------- Erttftrate of Tantylianre THIS IS TO CERTIFY, That the "agisposal System constructed ( ) or Repaired ( ) by............... . ...................................................... ........................ .....------...... ....................... ....---.............. ---.--------..... _ Installer at ........................... ......................................................� .... . ............ ................ has been installed in accordance with the provisions of TITLE,5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No' ' ..-. ' :-"'%.._._---- dated .. `.. ....,......------ --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SA�T+ISFACTORY. DATE..........� '. l ................................. Inspect r - , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. 4 -?...............oF. .�!�"1 .L .-•----...._............_. No..%.. ......v. FEE... : .'....... �io�oottl-, ork,� �un��nr#iori �prmi� ' ► r Permissionis hereby granted.......... -=-------------------l--r------------------------•---.._......---------------•-•---------------...---.....---............. to Construct ( or Repair ( ) an Individual Sewage Disposal System Gc1/1_Zh 400s� at No... [c.? - •---•---•-•------------------------•------•--•--•-..._....---.------------------------------------------••---------------...-------•--------------................ $Yreet f/ r1-7 as shown on the application for Disposal Works Construction Per Dated.... ........ .. ....... . 1 Board of Health DATE. /// / '� /// f � Form 1255 H&W HOBBS&WARREN TM Publishers GENERAL NOTES : DESIGN CRITERIA : INVERT ELEVATIONS I . THIS PLAN IS FOR THE DESIGN AND DESIGN FLOW: INVERT AT BUILDING 100. 80 ACCESS COVERS MUST BE WITHIN 3 BEDROOMS A T-LLQ G. P. D. PER INVERT IN SEPTIC TANK: 100. 50 CONSTRUCTION OF THE SEWAGE DISPOSAL 103.0 12' of FINISH GRADE BEDROOM EQUALS 330 G. P. D. INVERT OUT SEPTIC TANK: 100. 25 SYSTEM oNL Y. FIRST 2• To BE LEVEL INVERT IN DIST. BOX: 100. 00 NO GARBAGE GRINDER 2: ALL CONSTRUCTION METHODS AND 4' Pvc INVERT OUT DI ST. BOX: 99. 80 2' OF MA TER I AL S FOR THE SEPTIC SYSTEM SCHEDULE 40 PEAsroNE INVERT IN LEACH PIT: 99. 70 SHALL CONFORM TOE MASS. D. E. P. 100.80 100.25 SEPTIC TANK REQUIRED: 99.8 BOTTOM OF LEACH PIT: 93. 70 TI TLE 5 AND LOCAL BOARD OF HEALTH 1oo.so 100.0 99.7 6 3/4' 1 1/2' DIA. , 3o G. P. D. X 150x - 495 GAL 3 OUTLET WASHED STONE SEPTIC TANK PROVIDED: 1000 GAL . ADJUSTED GROUND WA TER: REGULA T I ONS. 93.z /0' MIN. 1000 GAL D-Box OBSERVED GROUND WATER: 3. ALL SEPTIC SYSTE SEPTIC TANK 2 s 2 M COMPONENTS LOCATED LEACH PIT SIZE OF LEACHING FACILITY REQUIRED: BOTTOM OF TEST HOLE: 89. 70 ' 330 G. P. D. UNDER AREAS SUBJECT TO VEHICULAR TRAFFIC PROFILE : NOT TO SCALE pES I GN PERC RATE MIN/INCH OR GREATER THAN 3 IN DEPTH SHALL BE N CAPABLE OF WITHSTANDING H-20 WHEEL LOADS. PROVIDED:.-I . 6 •PIT(S) W/ 2 'STN. 4. ALL SEWER PIPE SHALL BE SCHEDULE 40 SIDEWALL : 188.5 S.F. X 2. 5 - 471 GPD OR APPROVED EQUAL . BOTTOM: 78. 5 S.F.X I. 0 - 78. 5 GPD TO TAL : 267 S. F. 549. 5 GPD 5. BEFORE CONSTRUCTION CALL 'DIG-SAFE'. a 1 -800-322-4844 FOR LOCATION OF M SOIL TEST PIT DA TA M UNDERGROUND UTILITIES. m I ND I CA TES _�_ I ND I CA TES a � TEST CATION = GROUNDWATER OBSERVED 6. VERTICAL DATUM IS: ASSUMED ZONE RD - I P-6237 Tp# 1 Tp# 2 7. FOR BENCH MARKS SET. SEE SITE PLAN. \�\\ SETBACKS: FRONT - 30 ' GRND EL 102.2 GRND EL. 101.5 SIDE - 10 ' G.W.EL. N/A 6.W.EL. N/A M. N.W. CORNER CB/DK �\\ \ REAR l 0 ' EL. - l 0I.8/ \\ 99.02 TOP TOP 6 N 85'28'22'E 143.90 \\\\\\ ��CATCH BASIN SUBSOIL 2 0 SUBSOIL 99. 5 2. 5 99. 7 \ 0 LOT l /000 \ A MED l UM MED l UM 20. 000t S. F. SEPTIC TANK 102. +102.2 �i \\\ \\ \\\�o� SAND SAND GARAGE � fi ' P 1 T �i� � / \ \ '�• a W/2' STONE D-BOX x TP NO WATER NO WA TER �? o o /� �1Ji.3 �� -� ® 12. 5 89. 7 /2. 0 89. 5 o o 4j02 1 HOLLY+ i� �\ \� .to 1 DATE: JUNE 2. 1994 +102.4 i \ N AP 1 t/� +lo .e �\\ \\ y�< STEPHEN HAAS TEST BY. 21 rzy 0 WITNESSED BY: ED BARRY +lo2.s , RESERVE ,� ��' TP #2 i PERC RATE: 2 M1N/INCH to 42•_ �/ O 1 a ' 102.1 / � CATER SERF/C .}J¢ .2 /JTK%TACK FND 1 +l0 6 E ,� SE S YS TEM DES / GN � 1 1 �+/02.o � t 100.99 RA N S 7"A i9l. jF , < CE/V TER V I L L E' +102� N.`e'. CORNER CB/DH 49•/y -,� PREP.4 RED FOR /-s9 1 101.7 EL. - 101.93 /ILIA RKWOOO CORP . � p I ti O ^� SCALE : / - 20 JUNE .2 / .99-4 ` HAND/TEL/51 1 E'�4 G L L' S IJR YL�'Y I NG 6'i E'NG I NEE'R I NG I NC' 1 I ® S eat ® arm L. czne 1 r• 02.4 1 _ - 4422 e (" 67 4 .32 - 5"3 .3 .3 0 /0 20 40 JOB NO 94-275 FIELD:CFW/RVB CALC: SAH CHECK: CFW IDRN: SAH