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HomeMy WebLinkAbout0131 YACHT CLUB ROAD - Health 131 Yacht Club Road ,. Centerville A=211 - 029 UPC 12534 ' No.2153LOR HASTINGS, MN • u GYl #� sue, I �i _ _ _ __ 'c Commonwealth of Massachusetts o2 0 r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name _ / information is Centerville V Ma 02632 7/15/2020 required for 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:When filling out forms A. Inspector Information on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. P.O.Box 151 tab Company Address Forestdale Ma 02644 City/Town State Zip Code +ten 774 274 2581 12866 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 7/15/2020 I spector's Sign re Date The system inspector sh4su a cop of this inspection report to the Approving Authority(Board of Health or DEP)withinf cpleting this inspection. If the system has a design flow of 10,000 gpd or greater, thr and the system owner shall submit the report to the appropriate regional office of the DEginal form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. L 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass. ov 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 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 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 (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Botard 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 �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: i **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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. CityFrown 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 '/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.] ❑ ® 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �d (:p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts - - Title 5 Official Inspection Form I.� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 5 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. City/Town 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: pumped during inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Reason for pumping: maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 18 c� Commonwealth of Massachusetts 9.- l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 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: 2016 upgrade Were sewage odors detected when arriving at the site? ❑ Yes E No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 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.): none t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): ' Depth below grade: 1 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 gal Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle 22,E Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? tape and sludge judge 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 place no major decay. pump tank every 2 years t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 C Commonwealth of Massachusetts ,w Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. City/Town 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 c Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 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 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.): in new condition -camera inspected -at working level t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts 91 ,itp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System SAS locate on site Ian excavation not required): P Y ( ) ( p If SAS not located, explain why: probed area of SAS dry no soil saturation Type: ❑ leaching pits number: ® leaching chambers number: 2) 500 gal LC ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 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.): probed area of SAS no soil saturation Dbox shows no signs of over loading 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts 1 ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �8'0 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. Cityrrown 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 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 J� S' C33 _ 0 Al ?S_ J C� U t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma 02632 7/15/2020 page. City(rown 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: 2016Date ❑ 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: SAS installed and signed off from health dept. with min. of 4 feet seperation from G/W to bottom of SAS Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 131 Yacht Club Road Property Address Eric and Jillian Devoe Owner Owner's Name information is required for every Centerville Ma, 02632 7/15/2020 page. Cityrrown 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION )(A.CA+f GL.uO BD SEWAGE# VILLAGE C�sNTE��Iti��.� ASSESSOR'S MAP&LOT 2.11 CZ-9 INSTALLER'S NAME& PHONE NO. / ��nif e r/ �'='�- 7"y SEPTIC TANK CAPACITY WuJ c LEACHING FACILITY:(type) GAL. t.��w (size) 23 X /1-03 k z ' NO.OF BEDROOMS BUILDER OR OWNER fe Ira PERMIT DATE: V//��l COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) t1���1 Feet Furnished by �fi� d 10 V v �.� 0 v � u mot' V l 4 m No. ` FEE Board of Health, /, MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(�Upgrade( ) Abandon( ) ❑Complete System &ndividual Components /3/ c! 11 Location Owner's Name , Map/Parcel# // Address dp Lot# �70 Telephone# Installer's Name ` e7 CC ,� Designer's Name 3�� Address Addresseat 7-7 Telephone#.5��„ Tom-_ 8Z� Telephone# off Type of Building Lot Size sq.ft. Dwelling-No.of Bedrooms �✓ Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) 3 3d gpd Calculated design flow Design flow provided gpd Plan: Date /� ��/�J� Number of sheets IL, Revision Date Title Description of Soil(s) Iftyc—'�F(f �06 Soil Evaluator Form No. Name of Soil Evaluator C fC,4, Date of Evaluation /1ZA2liS— DESCRIPTION OF REPAIRS OR ALTERATIONS✓ The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed �c --� Date :i1Z�/6 Inspections day-•,--[:�.rv'. '4,-.+"1.k s.i. Ir 1-k:.�^.i• „� k. >tl:..' . " ` w a6� l F� No FEE COMMONWEALTH Of. MASSACHUSETTS nBoard o Health,' r� f�� MA. f s P APPLICATION FOP, DISPOSAL SYSTEM COATRUCTION PERMIT Application for Permit to Construct( Repa r(t111VpgradeO Abandon(M) ❑Complete System U4ndividual Components Location �3/ �f �' ,�6 Owner's Name Map/Parcel# // .y. (� AddresIAr Lot# ,?0 Telephone# Installer's NameA'Z/ Designer's Name Address Address 3J � _Air IN�r � Telephone#,,5"a,,57 7 i f-_ . Telephone# j; ,p 6- - Type of Building Lot Size sq.ft': Dwelling No.of Bedrooms 3 Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( Other Fixtures Design Flow (min.required) 3-3d gpd Calculated design flow Design flow provided -7 -gpd Plan:.Date Number of sheets / Revision Date Title // 1e Description of Soil(s) ®��SC f�,•rmr Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation j/,�3o DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees ttoo_not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ./ �^.�'- y Date Inspections No. FEE COMMONWEALTH OF MASSACHUS ETTS "~r Board of Health, Lj6�i>sr� 6�c� MA. CERTIFICATEF COMPLIANCE Description of Work: ndividual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired Upgraded ( ),Abandoned ( ) by: �� at has been installed in accor ce with the provisions o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application Noe261 b� !� dated ��`1 ^l . Approved Design Flow l 1 1 (gpd) Installer r-\)�1� � T'— I Designer: Inspector: /(,f'+/ t / � _ Date: / The issuance of this permit shall not be construed as a guarantee that the system will function as designed. / No. FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(G)�Upgrade( ) Abandon( ) an individual sewage disposal system at /3 / !4e'�4 7` ''1'!- -,-' 1'"g-,/- as described in the application for .Disposal System Construction Permit N61:26(6-1 11 dated Lj—/.2 -1 Provided: Construction shall be completed within three years of the date of this permit. All�,Jcnpdkildcns m st be met. r(� Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date ' Board of Health lr ,� � t ��D Q �rA� ��'A-e� �'�T P O �� �� 0 - _ s� � �\ � � � � a k �'����-% i UIL Of ry e f- Thomas F.Geller,Director sr�wsana , xuss. PublHe EleaLth DM&n: E�,s, 4 �'��cr��°` Thomas McKean,DirectOy Tain SteL-$,y�1.[paIM�,tIM `m Fax_ 508-79076304 Office. 508-962-4644 sofa �r& esr er_Certmcadou Form Date- � � I W Sewage T C-1mi"t I(D¢sii�n�.ere � �n�ta)lle>ro 6 Adl&r ess; Address: 0�i to r F tl t On was issued apermitto install a (date) (installer) r septic system.at qk P� �Led on a design.dravwn by dated l (d i,g) er) l ceztify that the septic system: efelenced above zrvas installed substantially according to the design, which play include minor approved changes such as lateral zelocat on of'l e- distribution box and/or septic tank. I certif� that the septic system refexenced above -was installed with major changes greater than 10''latezal relocation of the SAS or any vertical:relocation of any componPrEt of the septic system)but in accordance with State&Local Regdations. Plan.revision or certified as-built by designer to follow. LSH oF,u,��� 1�4 (Installer's Signature) A° DAI � OJAIA m CIVIL No:46502 STE (Designer's Signature) ( p Hero) l L�r sT F T9R1,T Tt� I31 W-_43T�RLE FOBLd Ad,`9'�t kD.O�l1 9QDP?. CE Ti IC TE OF iLWA CE , L t�T BE iSSOY D UME B01H ' S Fo ��� r�?S-Bt7�T CI AJ� JP.��L+DYEDr 71 + ��g��LEPUBU�CW!_A.CDR 1,910l�I. '�'I-�ANK—YO�J i TOWN OF BARNSTABLE LOCATION 4$I VmA+1" awls P C> SEWAGE# .2®/C—I/14' VILLAGE CiW7�Cyli-LG' ASSESSOR'S MAP&LOT 2.11 029 INSTALLER'S NAME&PHONE NO. S— SEPTIC TANK CAPACITY G LEACHING FACILITY:(type) 900 &N— LJ9bC&kX0 (size) NO.OF BEDROOMS BUILDER OR OWNERL�- PERMIT DATE: �j/ �js COMPLIANCE DATE: -f—�4 /6 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)— / .d�' Feet Furnished by Ac P-- c 13 ` 2� G e O � Deparfine=lnt of RegWatoq Services PubRe HealthINT181071 Date h1lelli Pgg � 200 Main Street,Hynnnls MA 02601 .Date Sahedulad 3 d f ' Trwe_ �� !�Q• Soil Suitability Assessment for Sew ' e sp�sal 1'erFornzed aY Witnessed Ey: tv, S�t'A 1,9 Location Address �3 I Yc,,G k .1 R Address Assessor's Map/k'aroel: 9 v Engineer"Namc (/„v 2 NEW CONSMUMON REPAIR Telaphona# oe) 34d ` i<f / - Land Use: t°�r�C� A E�� Slopes(9b) © ^�G� Surface Stones Dlskancesfrom: QpenWaterEody #t PnssiblPWet•Aren ,to(/ft Drialcing Water Well }�k Drainage Way ea. 01 .? • ft Property Line 1 ft Other ft. SIM9TCH.1(Street name,dimensions of tot,exact locations oi'test holes&.pert tests,'locate wetlands.1`n proxin*Y, to holes) 1 ' T Parent material(geologic) � � Depth tv)3edrgclt Depth•toGroundwater. StandingWaterinHole: /V Weeping from Pitlanae• Estimated Seasonal high Groundwater t ATIO T FOR SEASONAL GH WATER TABLE, Method Used: Depth Observed standing in obs.hole: lu. Depth Ta.sQll xotti�s,. ltt, Depth to weaping from side of obs.hole: lTl, (3ronndWaterAd]uelment X• Index Well RcadingDake: Index WelllaYei ArJJ,fhotdr,...,,,,,,,_..,_.�it�f 4rouildwaterl.eval_ ]PERCOLATI.ON TEST Data [VIP_-T1wa_LLA0 Observation Bole# Tltnp•at.�" . r._. A/ Depth of Pero. ` Tlme At V Start Pre-soak`l'lrna@ lc ��GO -- Time(91)41) -- -,----- End Frc-sank `of Rate Mindluch S1tr SultablIlt,AsaPssmcut: S1CP 1?aSSPd Site Failed: Additional Tastlu Ncedcd(Y[N) original: Public health Division Qbaerktion Hole,Data To Be Completed on Back----- (� ***1f pe�eolatiba test is ti o be cuA acted witbia 100' of Wetland,you must first aa0t1fY the Barnstable Consel�vntaon Dadslon at least one(1)'week prior to beginning. _11SM�'I ICIPIJ.RCF6RM.D O C )0 LOG Dcptli-rrom 5ailHorizon Sail.Texture SdItcolor Soil•. Ot'hcr Surfaeo(in.) , (U5D'A) (MunseIl) Mottling (Srncturc,Stones;Bouldrm. • _ �o i'tcn�y.9b'Cravcll ' G . 5L o ly16 - IMI {,T Depth from Sall Hatizaa Sail Texture Sall Color Sail Other Surface(in.) (USDA) (Munseil) Mottling (Stractare,Stones,Boulders, o sis en 'o Grave 3 7 DEEP OBSERVATION ROOF,L 0 G Role 9,. Depth*oni SoilHorizon Soil Texture Soil Color Soil Ofhcr' Surface(in.) (USDA) (Muns❑ll) Mottling (Structnz❑,Stancs,Houlderg. Co i tc ❑ Omni) Depth fiam Sail Hodzon SailTexturc Soil dolor Sail Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stotim',Souldars, ' Ca si tan b , �'Icod Ynslvraxtcaf�.alre I(��.�:. Abov6500_yearflondboundary No— Yes_ Within 500 yearbauudnry No,41 'Yes . Within 100year flood boundary No.K ' t' all amag obsfi'ved thrnu hour th6 [L I e1"Vi Us irrat�Clxl e7tlg >.n �; Does at least four feat of naturally oec rr ng p area proposed for the soil absorptibn system' V � If not,what is the depth of naturally occurring pervious matarlall 1 certify that on (date)x havepassed the soil evaluator examination approved by the Depa=Ont OfBnVIronmental Protection and tharthr, above analysis was performed by me consistent with . 'the requited training,expertise and experience described in�10 CUR 15.017. Signature ' Datb�' 4 • r 1.Cr0RM.nOC . p:ts,�i�T'tc� lx � -{, � - W-'-s' F"`-'`.*`4.,. Yy. « ' _ f ......'�„"�.`�,"'� r '0'' '7,.'.M.w-�:.�+sr`��'"��.�r«ic.`'�.��_ 'F,�`"`� �•_' '-�'{' T 'L`"ti=.J �g - 4 r r i • n r ALL TE SHALL SYSTEM PROFILE MARK ED WITHCMAGNETICTTAPE OR BE NOTES (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. NAVD 88 PROVIDE MIN. 20" DIAM. WATERTIGHT 1. DATUM IS F' ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE CONCRE7E COVERS TO WITHIN 3" GRADE 2. MUNICIPAL WATER IS EXISTING TOP FOUND. EL. 52.8' FILTER FABRIC OVER STONE 2% SLOPE REQUIRED OVER SYSTEM 49.0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 0 MINIMUM .75' OF COVER OVER PRECAST NOTE: 2" MIN. WALL 4. DESIGN LOADING FOR ALL PROPOSED PRECAST � boo PRECAST H-10 THICKNESS REQUIRED BLOCKS OR:3 UNITS TO BE AASHO H-10 yoke Ot RISERS (TYP.) PRECAST RISERS Wequaquet 2'0 49 0' 4"OSCH40 PVC MORTAR ALL H 10 PIPES LEVEL 1ST 2' COMPONENTS 5. PIPE JOINTS TO BE MADE WATERTIGHT. Lake 4' (n'P') sloEs 46.03' ENDS 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE loll **EXISTING 14" Po�o�oo� °o°oo TEE SEPTIC TANK TEE 000� O Elmmim SLED= �00m >0000000o WITH 310 CMR 15.000 (TITLE 5.) ' ° ° ° ° ° ° ° ° 7 THIS PLAN IS FOR PROPOSED WORK ONLY AND *47.6 °°°°°°°° 0000®�oaoo� aaaoo�000ao �°°°°°°°° �� Locus 0 0 0 0 0 0 ° ° ° o ° ° ° ° 20c -°°°o q '°°°°°°°° �����DDDO�f� �O�O�DO��O� °°°°°° NOT TO BE USED FOR LOT LINE STAKING OR ANY GAS BAFFLE::; ° ° ° ° ° ° ° ° ° ° o � 000000000 � 0000000 � oo ° ° ° ° ,0 0 0 0 0 0 o ° ° ° ° ° ° ° >°o°o°o°o a000aaaooal� aoa0000aaao °o°o°o°o 45.47' 45.3' °°°°°°0?0°° 43.2' OTHER PURPOSE. 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. e d ens `H-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL POP � Phan — — WASHED STONE 4' MIN. Q J 3 4" 1 1 2" DOUBLE Gr e / / a ALL AROUND PRECAST STRUCTURES (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR arsh Q 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' - CONCEALED WITHOUT INSPECTION BY BOARD OF N HEALTH AND PERMISSION OBTAINED FROM BOARD Route 28 COMPACTION. (15.221 [2]) Li OF HEALTH. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP VERIFYING THE LOCATION OF ALL UNDERGROUND & ( 6 % SLOPE) ( 1 % SLOPE) 38.0' BOTTOM TH-1 OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NO GROUNDWATER FOUND WORK. NOT TO SCALE FOUNDATION EXIST. SEPTIC TANK 35' D BOX 12 LEACHING 11. ANY UNSUITABLE MATERIAL ENCOUNTERED FACILITY SHALL BE REMOVED 5' BENEATH AND AROUND THE ASSESSORS MAP 211 PARCEL 29 PROPOSED LEACHING FACILITY. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS TANK SIZE AT 1000 GALLONS AND ITS 12. EXISTING LEACHING FACILITY SHALL BE PUMPED PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM SUITABILITY FOR RE-USE. REPLACE WITH 1500 AND REMOVED OR PUMPED AND FILLED WITH CLEAN C LEGEND- GALLON SEPTIC TANK APPROPRIATE TO SITE SAND. CONDITIONS IF NOT SUITABLE 99— EXISTING CONTOUR SYSTEM DESIGN. X 99.1EXIST. SPOT ELEV. � � I GARBAGE DISPOSER IS NOT ALLOWED —[99]— PROPOSED CONTOUR 110.9 DESIGN FLOW: 3 BEDROOMS © 110 GPD = 330 GPD 198.41 PROPOSED SPOT EL. WJ — N 79'27 " TH1 i 4, N� SNZ 48 USE A 330 GPD DESIGN FLOW TEST HOLE BENCH ARK: YY GARAG LAB .5219 p 21 .2' SEPTIC TANK: 330 GPD (2) = 660 2q" SLOPE OF GROUND = O. NAV —' **RE-USE EXISTING 1000 GAL. SEPTIC TANK UTILITY POLE o LEACHING: FIRE HYDRANT SICaFS:,4.,,_2.(25 + 12.8i 3))2 ,, .741 = 112 GPD _ NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING i � o h � 9 �t` BOTTOM 25 x 12.8.3 (.74) = 237 GPD SLAB OR �w o TOTAL: 472 S.F. 349 GPD TEST HOLE LOGS pEch. o 00 a ( > ( ) A USE 2 500 GAL. LEACHING CHAMBERS ACME OR EQUAL LOT 30 �, o WITH 4 STONE ALL AROUND CRAIG J. FERRARI, SE #13871 15,867 SF �� ,'--- L)c ENGINEER: 0.36 AC. �� WITNESS: DAVID W. STANTON RS r �z 55 pECK ; MA DATE: 1 1/30/2015 `-' APPROVED DATE BOARD OF HEALTH PERC. RATE _ < 2 MIN/INCH i EXI EI_l_ING 8 till) � pW 52 .) OF CLASS I SOILS P# 14905 0 T ELEV. ELEV. �,'� OttV"` 49' off4 49' QpJ�o w �J A A 47 LS LS o 10YR 3/2 10YR 3/2 39.5`3pO, 6 18" 16" L�66 B2 B B _ ° — TITLE 5 SITE PLAN 1� SL SL ` `� f� 50 OF� � o 36" 10YR 4/6 46' 33" 10YR 4/6 46.3' L=4 12' _ pj #131 YACHT CLUB ROAD =40. � C�� N 49 CENTERVILLE, MA PERC C C PREPARED FOR CS CS CAPE COD SEPTIC DATE: DEC. 8, 2015 1OYR 6/4 1OYR 6/4 � = IN of Mass off 508-362-4541 ,� r�pL�HOFf"gss� �cy �, fax 508-362-9880 •�� o �o f7AR!IEt ���: downcope.com 1p DAhILLA m t OJALA a , n' down cape en illeerin , 1/1c. '02 N .4Gvz f 132" 38' 120" 39' �' Q7 Q4 o C, ° ��S ! civil engineers NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 ss � �=..�-� " y „ °�F �• �., ''� land surve ors 939 Main Street ( R to 6A) LICE # > 5-348 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 15-348