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0124 ZENO CROCKER ROAD - Health (2)
124 ZENO CROCKER RD, CENTERVII A= 170132 ti llll � No. 52534 R HASTINGS,MN N I�wqNo. ®/ ® Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpficatiou for ]Disposal 6pstem Coustruttion Permit Application for a Permit to Construct( ) Repair( ) Upgrade(14/Abandon( ) ❑Complete System individual Components Location Address or Lot No. 2 l�h� '6/'r�Q tr Owner's Name,Address u, nd� "oTel�..No. Assessor's Map/Parcel �-'" ca Installer's Name,Address,and Tel.No. Desi er's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms _ Lot Size S sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) `530 gpd Design flow provided gpd Plan Date 101 1 L f i k Number of sheets Revision Date _ Title . Size of Septic Tank Type o S.A.S. 2 G C�'al Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,t w Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the.Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo to e h. s gne — Date 1/ Application Approved by Date / Application Disapproved by Date for the following reasons Permit No. Q Date Issued 1-...+.i H.., .r- .. '-x:,..r �!':. •_ - �,--..^ .'�, r :�,r..:� yr. 1.�.. ♦ r. �'..h. J,F, ,*,.:w.,T.. Y' ; ' , �' * ;{ No. i ✓Q/D Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -:T0,WN„SJF BARNSTABLE, MASSACHUSETTS Yes ftphratlon for -Misposal *pmrtu ConBtrUrtlon permit Application for a Permit to Construct( ) Repair( ) Upgrade(_,Abandon( ) ❑Complete System - Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. �a �� {A,� Assessor's Map/Parcel I�VZ ��` t• y� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. rylvAlh 7 � �In � r Type of Building: U 0 - Dwelling No.of Bedrooms q� Lot Size IS sq.ft. Garbage Grinder( Other Type of Building r� No.of Persons Showers( ) Cafeteria( ) Other Fixtures j , y y. rr Design Flow(min.required) gpd Design flow provided `'l X. gpd Plan Date 1J ID �JJ� Number of sheets Revision Date Titlel�. 41.b{{ /.yqW !� �� Ci� /I D _ A n �,�L1( to tf G C"�rV Size of Septic Tank 1i p�� Type o S.A.S. .. clai Description of Soil I'M hAAJ Ad W A , W l <4 rL II • j `a Nature of Repairs or Alterations(Answer when applicable) i <,k - firV" Date last inspected: Agreement: 7 ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of ' Compliance has been issued by this Bo 'd o�I ealth. Signed' . Date ~_Application Approved by.,, '.y; ay .. ��„ Date Application Disapproved by for the following reasons s ' 'r _ -- p/d Permit No. (._�y'�—y/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS CPrtifi ate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at - 7_� . ( �.W( -1 r F . L. .has been constructed in accordance with the provisions of Title 5 and tth�e'for�D•�isposal System Construction Permit No. /g dated Installer ��)LLktx � .tlt/i�l i i� Designer y7kal" trl" ����as #bedrooms �7 Approved design,flow----, gpd The issuance of this permit shall not be construed as a guarantee that the system will functi as designed. Date f " f Inspector Fee / 1d THE COMMONWEALTH OF MASSACHUSETTS t ' PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal Opstrm ConstrUrtlon Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon /r ( ) System located at /�4r� st (Akkr— K n 6 x and as described in the above Application fbr,Disposal System Construction Permit.,The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of tli�is,permit d I/.��1 4 -Date t Approved�by_�_ � 5 - CYO XIA `� Mtll`1�EI' SUi TC 5 U U tn� ROJYP a' V, y6. 5e Uti1D r LoO �' t�Pu,uJr1N s �fil wit PTV�- { A N��' Town of a r s. la Regulatory Services VA � rarr tl V CAL trrt 440,I) or 'Public llealth,mvi Sion trerrrrc. k.� �" *q ; trrstttr° a ^ a Address.- mii °sr a is$U0 ap rrat�t tea irast�tl�;wr V a e �,arrstlt: r septic S d ba, r s r ra a trtaw o b' 0 Ole? e ,srtar tl Codify al-al ttlr ptre sy�slim r� r rerr ilbove W" tisWl srrb tsr�ttla�tlt}°'4aceaaatt�'irr ats i 01c da rrq Pr rrahr in a tltar ar rra r approved tlr�an&s trc ass e°@ l relocation o ffie i trtl rri oa�.tl�a, and for septic tank. Strap out (if mquir a�� � try �rts�r��t� atra ty s �tls Wete,fband s tistravt rNy . . t eta€fy that the ScOi SYSt rlar r W,renc d aaha�� �� � instal kvlth,mar, r avrtr�ng.L;Y% ix a gat r rta�r ' tla t rtai i" tr ^ate ra ttla SAS or an y aricat t rtiork of array,COMP arra=Ot r tsrw. s rrr btr i tr a m �itStue Loc, tl Regulalion& Plan r isio a er` x ati rtl ra � r:otlr b x ra: r t tl+ tltl �w�. sstrr Ott!Q,re rm4 4 was iospwod ao&thc s ili' WC r 'Oti d sa I cerfif�, that the systvrn referenoed above was ca rtstra�md, its ,�r�t tia�-. r r�ras ca tl.r tl rapprov tl ttc .(sixa�pplica ble 1 . a. �a��s Lesr, rterasor.taarrC srrt?a . r °r�rrr 4 D'Am *t . TOWN OF BARNSTABLE LGCATION IZ Zf,h() (i► wy pd' SEWAGE#241 q f&-b VILLAGE {,}�','( {Tr1/�`LG ASSESSOR'S MAP&PARCEL,`10 - 1 262. INSTALLER'S NAME&PHONE NO.nj�(U I M & &0Y' SEPTIC TANK CAPACITY tU� LEACHING FACILITY:(type)414 V(1t MA Ksize) q1 iI_SE NO.OF BEDROOMS OWNERATE r 4 PERMIT D : q�A� COMPLIANCE DATE: 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -ICY' 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 leach' f ity) Feet FURNISHED BY © Crv<xei(- i x r AV- I,y✓ AS= 39' o oFiKE Town of Barnstable Public Health Division U.S.POSTAGE>>PITNEY BOWES 200 Main Street j / fie Hyannis,MA 02601ZIP 02601 L �r 02 4VV $ 006.670 7015 1730 0001 4987 9675 � 00003364.55 SEP. 14, 2018. 4 laq C�Mec r t� DS DEVELOPERS LLC __32..GORDON LANE UNCLAIMED C_ _ SC: 02601400200 *8369-06S44-14-41 L 01 3d013AN3 •.• • ' • • ONPELIVERY ■ Complete items 1,2,and 3. A.'signature ■ Print your name and address on the reverse X ❑Agent so that we can return the card to you. ❑Addressee ■ Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery or on the front if space permits. 1. Ai - -" D. is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No _D.S_DEVELOPERS-LLC___ 32 GORDON LANE I YARMOUTH PORT, MA 02675 3. Service Type ❑Priority Mail Express® IIIIII IIII IIIMll IIII I I III II IIIII II I II III ❑AAdultdult SSignature Bignature Restricted Delivery ❑Reo stered Mal Restricted i 9590 9402 3759 8032 3748 52 rtified Mail® Delivery i ❑Certified Mail Restricted Delivery Return Receipt for 9 ❑Collect on Delivery Merchandise 2—GrFido.Ni.�mhnr__lTrancfar_frnm_cenii�n-1nt+err n r. u�t Delivery Restricted Delivery ❑Signature Confirmation*"' 1 ail ❑Signature Confirmation I 7 015 1730 0001 4987 9675 ail Restricted Delivery Restricted Delivery I i if 5: PS Form 3811,July 2015 PSN 7530-02_000`9053 __ Domestic Return Receipt I'` Town of Barnstable Barnstable Regulatory Services Department "Ammica j IARNbTtABM + 6 q ,�� Public Health Division "" a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 9675 September 14, 2018 DS DEVELOPERS LLC - 32 GORDON LANE YARMOUTH PORT, MA 02675 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 124 Zeno Crocker Road, Centerville,MA was inspected on 08/30/2018 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Backup of sewage into the house due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Zs, PceaAmnl, S., CH0 Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\124 Zeno Crocker Road Centerville.doc oF'"E��wtio Town of Barnstable I ", �' U.S.POSTAGE>>RTNEY BOWES . Public Health Division O. BA RN ABLE. r� O MASS. g. 200 Main Street ti _ 'prE�MP+ Hyannis,MA 02601 ` 1 ZIP 0260 © 0 _7015 1730 0001 4987_9408 Y 02 4YV 45$006.6p g i CARVALHO, REGINALDO_E_ DS DEVELOPERS LLC v — 32 GORDON LANE_ , NIXIE 015 FE 1F7 � Z 7t1 RETURN TO SENDER ATTEMPTED - NOT KNOWN _ AUK ... SC: 02 6014 002 00 *e3s9-05841-2 s-42 �I -'^�•'Z fr�7:.�46f3 Z ..I a��l�llla'�laaas:�aa�a����a.�l��af,{y��14��3���Iai�.�-���ae����laly�i � 6 SECTION ON DE41VERY A.-Signature , ■ Complete items 1,2,and 1 ❑Agent ■ Print your name and address on the reverse X ❑Addressee so that we can return the card to you. ■ Attach this card to the back of the mailpieee, B. Received by(Printed Name) C. Date of Delivery : or on the front if space permitsY_„ _ 1 -- D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No CARVALHO, REGINALDO E ` DS DEVELOPERS LLC 32 GORDON LANE r YARMOUTH PORT, MA 02675 3. Service Type ❑Priority Mail Express® II I�III'I I'll I'I I II II I IIII I I III it I III III II I III Q 6 El Signature O Registered Mail dult Signature Restricted Delivery Registered Mail Restricted ertified Mail® Delivery 9590 9402 3759 8032 3744 56 ❑Certified Mail Restricted Delivery eturn Receipt for ❑Collect on Delivery Men handise ❑Collect on Delivery Restricted Delivery Signature Confirmation-i , 2. Article Number(Transfer from service labep —— --ail q Signature Confirmation t ` Restricted Delivery 7.015 17 3 0 0 0 01 4 9 8 7 9408 ail Restricted Delivery i Domestic Return R PS Form 3811,July 2015 PSN 7530-02-000-9053 Receipt FSME T°� Town of Barnstable Barnstable Inspectional Services Department ;edcaC 1 +� �ItNSTABLE. r MASS. Public Health Division i639• ATFa awl a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 SECOND NOTICE CERTIFIED MAIL#7015 1730 0001 4987 9408 November 27, 2018 CARVALHO, REGINALDO E DS DEVELOPERS LLC 32 GORDON LANE YARMOUTH PORT, MA 02675 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 124 Zeno Crocker Road, Centerville, MA was inspected on 600/2018 by can M.' Jones, certified Title V Septic Inspector for the State of Massachu"Setts.' - The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Backup of sewage into the house due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Kean, R.S., CHO Agent'of the Board of Health Q:\SEPTIC\Title V'Inspection Report LettersMailing\Failed or Needs Further Evaluation Letters\124 Zeno Crocker Road Centerville Second Notice.doc oFTHE�� Town of Barnstable i U.S.POSTAGE>>PITNEY BOWES do P Public Health Division �� "a„STAB`E. • 200 Main Street , �.�...C'� "rFn roa+"00 Hyannis,MA 02601 ,rr 11111151111111111 11 oil Igo '; 0Zip 2 4w601 14,$ 0o6wc018. `. 0000336455 SEP. �7015 1730 0001 4987 9958 T i I DS DEVELOPERS LLC _32 GORDON.LANE gb—TURN TO SdblDEP i 'di11+C.1LATWEC3 i5 it'L i`G QbLC _,6 SCo Z260`184fg0320 y y* 3g69-06y34g3eg14�f-41 T - o iV ' .. .::' • CO ON • • • • Zj ■ Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverse X ❑Agent i so that we can return the card to you. ❑Addressee ■ Attach this card to the back of the mailpiece, B. Received by(Rrinted Name) C. Date of Delivety I or on the front if space permits. 1. A D. Is delivery address different from item.1? ❑Yes 1 If YES,enter delivery address below: ❑No i CIS DEVELOPERS LLC 32 GORDON LANE YARMOUTH PORT, MA 02675 I IIIIII I'IiI'I I II II I IIII'I III II III I I III(III 3. Service Type ❑Priority Mail 1 Mail � ❑Adult Signature ❑.Registered MaiITMTM ❑kdult Signature Restricted Delivery ❑Registered Mail Restricted i 9590 9402 3759 8032 3748 69 ertified Mail® 1.1"griature elivery Certified Mail Restricted Deliveryetum Receipt for ❑Collect on Delivery erchaniiise nm_oamira_lahell ❑Collect on Delivery Restricted Delivery ConfirmationTm ai ❑Signature Confirmation 7 015 1730 0001 4987 9958 i a l Restricted Delivery Restricted Delivery i) € € PS Form 3811,JUly 2015 PSN 7530-02-000-9053 Domestic Return Receipt Town of Barnstable Barnstable Regulatory Services Department j edcac j tARNSTA$LL 9 Public Health Division a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 9958 September 14, 2018 DS DEVELOPERS LLC 32 GORDON LANE YARMOUTH PORT, MA 02675 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 593 Old Strawberry Hill Road,Hyannis,MA was inspected on 08/30/2018 by Sean M. Jones, certified Title V Septic Inspector for the State:of Massachusetts.. The inspection of the septic system showed that the system"Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility.with standing liquid level at or above the invert pipe (per Town Code 360-20h). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH - t=dnRcKean, R.S., CHO Agent of the Board of Health Q P P e \SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\593 Old Strawberry Hill Road Hyannis.doc Town of Barnstable P# Department of Regulatory Services. t.>z. Public Health Division Date to C( A 1639•Ail 200 Main Street,Hyannis MA 01601 Date Sciiedtiled_ �u/t Tim J a Fee Pd. 00 c cro Soil ,Suitability .Assessment for e s �sczl Performed'By: Fe. ,$4Z Witnessed By: LOCATION Br GENERAL INFORMATION Location Address '2� '7 _tea _{ p _ Owner's Name V S 'P� \ rt 0- Address 32 Gro�alw�e,r p^ Assessor'sMap/Parcel: ® �r'� �� Engineer's ma NEW CON5IRUCIION r REPAIR Telephone:# — 7^j— Land Use S V toted eJL Z, 2 Slopes(%) t Surface Stones Distances from: Open Water Body 7� ft 'Possible Wet Area Aj/t Drinking Water Well l—ft Drainage Way Y1 a ft Property Line Kft Other ft SKETCH:(Streets name,dimensions of'l ,exact locations of test holes&'pert tests,locate wetlands in proximity to holes) 4.4 ALk , ......_........ onh I Z15AJ�o ._ G>161U/_C5 Parent material(geologic) S Depth to.Bedrock. Depth to Groundwater. Standing Water in Hole: /V� __ Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TA13LE Method Used: Depth Observed;standing in obs.hole: _ —__ _ in, Depth to Soil mottles: Depth to weeping from side of ons.hole: in, around water Adjustment ft. Index Well# Reading Date: Index Well level Ali,factor ,• Adj..Clroundwnter lxvel.— ERCo Observation Hole# �. Time at V' Depth of Perc d� � S ,t� Dme at.6" Start Pre-soak Time.Q Time(9"-6°) --� ck' .� End;Prc-soak RateMim/frich t . Site Suitabitity.Assessinent: Site Passed,I SiteTailed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Dole Data To Be Completed on Back----------- ***If percolation test is to be conducted within'100' of wetland,you must first notify the- Barnstable Conservation Division at least one(1) Week prior to beginning. Q:\SEPTI0FERCFORM..DOC _...-- ...... ----..._._._.__._....,....._..__._._.....____. DEEP OBSERVATION BOLE LOG Hole Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling, '(Structure,Stones;Boulders., on istene 46 ravel 3Z S'� . DEEP OBSERVATION HOLE LOG Hole# - �-- Depth from Soil Hcrizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones„Boulders. Coniistencv.% ravel 6 Y3 to YYL l DEEP OBSERVATION'HOLE LOG Hole# Depth.frorr Soil,Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel) DEEP OBSERVATION HOLE LOG Hole,## Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in:) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consigeo Q_ravel) Flood Insurance Rate MUP: Above 500 year flood boundary No— Yes A Within 500 year boundary No Yes Within 100 year food boundary No Yes - Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring'per viou material exist in all areas observed throughout the area proposed for the soil absorption system? -e S If not,what is the depth of naturally occurring pervious material? _ CCI'{1flCatiOn L certify that on S (date)I have passed the soil evaluator examination:approved by the Department,of Environmental Protection and that the above analysis was performed by me consistent with . the required''train' ,expertise and experience described in 10 CMR:1$.01�7.� Signature Date Q:\S�EPTICIPERCEORKDOC Town of Barnstable Barnstable MAnificaCRY Inspectional Services Department HAAN BM I Public Health Division Are°µAS k 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 SECOND NOTICE CERTIFIED MAIL47015 1730 0001 4987 9408 November 27, 2018 CARVALHO, REGINALDO E DS DEVELOPERS LLC 32 GORDON LANE YARMOUTH PORT, MA 02675 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic inspected stem located at 124 Zeno Crocker Road, Centerville,MA was i p Y on 08/30/2018 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Backup of sewage into the house due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days from the j date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH j Kean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\124 Zeno Crocker Road Centerville Second Notice.doc Town of Barnstable Barnstable Regulatory Services Department AllAmefisac j w SAR AQQOLL *� ' 1 6'9. �� Public Health Division 'Eaw+a�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 9675 September 14, 2018 DS DEVELOPERS LLC 32 GORDON LANE YARMOUTH PORT, MA 02675 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 124 Zeno Crocker Road, Centerville,MA was inspected on 08/30/2018 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Backup of sewage into the house due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH I s PceaMM S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\I24 Zeno Crocker Road Centerville.doc f77DP13,:�- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 f 1«, --, 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owners Name information is X.- required for every Centerville Ma. 02632 8/30/2018 ;:, page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information � p filling out forms � # 13 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection r� Company Name 74 Beldan Lane Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/30/2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ 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 t5ins.doc•rev.6/16 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. Citylrown 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. ® ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts s Title 5 Official Inspection Form ,a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ ' Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System 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 gpd t5ins.doc•rev.6/16 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 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Zeno Crocker Road V Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of 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): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original system 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: ee5 Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks , vented through roof 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 gallons Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 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 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 How were dimensions determined? Measurements not taken Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in good condition. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form <o� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form M1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name required fo is Centerville Ma. 02632 8/30/2018 required for every page. Citylrown 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 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 showed signs of previous overloading. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 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, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was dry at time of inspection. Dark stain lines indicated that the pit was in failure when system was in use. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 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.doc•rev.6116 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 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 page. Cityrrown 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 s3 o ✓k( �� rS �2 3� A'5 45`e �3 30 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is required for every Centerville Ma. 02632 8/30/2018 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: 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: System fails inspection, groundwater elevation was not established. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 _ 1 Commonwealth of Massachusetts Title 5 Official Inspection Form � to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Zeno Crocker Road Property Address Reginaldo Carvalho Owner Owner's Name information is Centerville Ma. 02632 8/30/2018 required for every 'I page. Citylrown 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Parcel Detail Page 1 of 4 pbT-Itl77 &�\ Logged In As: Parcel Detail Thursday,September 13 2018 Parcel Lookup Parcel Info Parcel ID 170-132 I Developer'LOT 641 ) Lot Location F124 ZENO CROCKER ROAD I Pri Frontage 1107 Sec Road� ,�,,.�..���.. .,.,.�.. ....I Sec Frontage Village Centerville Fire District fC-O-MM Town sewer exists at this address NO � � ,� Road Index 1894 � �� I Asbuilt Septic Scan: Interactive h 170132 1 Map Owner Info owne I co-owners%DS DEVELOPERS LLC Streetl 32 GORDON LANE I Street2 �mI City ARMOUTH PORT I State MA zip 02675 Country Land Info Acres(0.36 Use Single Fam MDL-01 �I zoning[RC � I Nghbd 0105 I Topography LeyelnM1 m I Road Paved Utilities Septic,Gas,Public Water Location �) Construction Info Building i of 1 Year 1985 ( Root Gable/Hip �I Ext'"Wood Shingle Built Struct Wall Living 1266 I Roof sph/F GIs/Cmp I AC one I r ' BST, Area �. .�. Cover Type 1B Int Bed AWDV 4 o- Style Cape Cod ( Wall Drywall I Rooms 3 Bedrooms-1 , 41 Int Model Residential .I Floor(Carpet "I R oms Bath 13 Full-0 Half I Fris TQS io �-�- 2 11`2" " fI%iT Tol Grade Average ( Type(Hot Air I Rooms!9 � '= _ l 144 stories 3/4 Stories Fuel ation I Heat Gas Found Poured Conc. (1 e 4E Gross j2970 _ _I Area Permit Histo _ry http://issgl2/intranet/propdata/PareelDetail.aspx?ID=11358 9/13/2018 Town of Barnstable • RA"Wnst.e, Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: 6 Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doe TOWN OF BARNSTABLE LOCATION �ZL4 Z-e1(\,O CtPCJ-jf-- SEWAGE# VILLAGE( e"X l�-e— ASSESSOR'S MAP&PARCEL i nS ec C-S r ;8 NAME&PHONE NO.?AryJkS SC&)C—N SEPTIC TANK CAPACITY LEACHING FACILITY:(type) A (size) NO. OF BEDROOMS 1 OWNER_ S� 1IC�,�0 %�ti�ATE: 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 F t ' GC cc t4 r, (1�— �1� �31 - 1� l X32- Z3` b 0 °• COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTIONi, FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Z- 2e ,•„� ��-. Owner's Name: Owner's Address: r� Date of Inspection: Name of Inspector* le e t) �lr• Company Name: Mailing Address: Telephone Number: CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage di below is true,accurate and complete as of the g spinal system T this address and that the information reported time of the 'training and experience in the proper function and maintenanceinspection.The inspection was performed based on my approved system inspector pursuant to Section 15.340 ofTitl so 310 site Sege .000). systems.I am a DEP CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signa Date: Z O`o The system inspector shall submit a copy of this inspection report to the Approving DEP)within 30 days of completing this inspection.If the system is a shaApp roving Authority deli it gpd or greater, the of and the system owner shall submit the report to the appropriate or (Board of Health or DEP.The on y 8n ow of 10the ginal should be sent to the system owner and copies sent to the buyer, applicable, and the ae oo� authority. approving Notes and Comments c. ""This report only describes conditions at the time of Inspection and under the conditions o time. This inspection does not address how the system will perform in the future conditions of use. fuse at that under the same or different Title 5 Inspection Form 6/15/2000 page I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: CG-.�—V Date of Inspection: C) 2 Inspection Summary: Check AA CD or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that an ailure criteria 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated arey of thefindicatedbeloWscribed in310 CMR Co r' C ILr- B. System Conditionally passes: aired or more system components as described in the"Conditional Pass"section need to be replaced or rep stem, upon completion of the replacement or repair,as approved by the Board of Healt h,will pass. i Answer yes,no or not rmined(Y,N,ND)in the for the following explain g statements.If`hot de ed"please The septic tank is metal ver 20 years old*or the septic tank(whether me or not)is strut unsound,exhibits substantial infiltra or exfiltration or tank failure is ' filly existing tank is replaced with a complyin septic tank as a ystem will pass inspection if the •A metal septic tank will pass ' y sound, by the Bo of Health. indicating that the tank is less than 20 years old structurally souad,not le g and if a Certificate of Compliance ND explain: Observation of sewage backup or break out or ' stall ter level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or une distribution x.System will ass approval of Board of Health): y p inspection if(with broken pe(s)are replaced obs ction is removed stribution box is leveled or replaced ND explain: The system requ' d pumping more than 4 times a year due to broken or obstructed pipe(s). a system will pass inspection if(wi approval of the Board of Health): broken Pipe(s)are replaced obstruction is removed ND explain: T;a.. c z..�..o,.;,,., �.,. 4/1 cnnnn 2 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ASH 'Z Owner: r L. e., Date of Inspection: 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 failin protect public health,safety or the environment. 1. Syste will pass unless Board of Health determines in accordance with 310 CMR 1s 3(1)(b)that the system of functioning in a manner which will protect public health,safety and environment: _ Cesspoo privy is within 50 feet of a surface wafter _ Cesspool or vy is within 50 feet of a bordering vegetated wetland or a s h 2. System will fall unless the Boar f Healt6 and Public W system is funcdodng In a manner that otecb the public al Supplier'if any)determines that the th,safety and environment: _ The system has a septic tank and soil sorptio system(SAS)and the SAS is within 1 surface water supply or tributary to a surface supply. 00 feet of a — The system has a septic tank and SA A3 is within a Zone 1 of a public water supply, f " _ The system has a septic tank SAS and the S within 50 feet of a private water supply well. x _ The system has a septic and SAS and the SAS is 1 than 100 feet but 50 feet or more from a private water supply well* .Method used to determine distanc **This system pass if the well water analysis,performed at a D organic co ertified laboratory,for coliform bacteria and vo 'e or g compounds indicates that the well is free m pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less 5 failure Grit are triggered.A copy of the anal PPm,provided that no other analysis must be attached to this rm• � 3. Other: Ti+l- i incnortinn f.nrrn All 411MA 3 .aav y vl 1 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOMENTS PART A FORM CERTIFICATION(continued) Property Address: ZQy`p C 15C Owner. .t ca Date of Inspection: 0 y) D. System Failure Criteria applicable to an systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component due to oven Discharge or ponding of effluent to the surface the oaded or clogged SAS or cesspool clogged SAS or cesspool ground or surface waters due to an overloaded or Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or Jcesspool Liquid depth in cesspool is less than 6"below invert or available volume is less Requited pumping more than 4 times in the last year N mSII r4 day flow Of times pumped ST due to clogged or obstructed pipe(s),Number Any portion of the SAS,cesspool or privy is below high ground water Any portion of cesspool or privy is within 100 feet of urface water elevation. _ zwater supply, supply or tributary to a surface 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 o/ Any portion of a cesspool or privy is less than 100 feet but fly well. supply well with no acceptable water greater than 50 feet from a private water quality analysis. (This system passes If the well water an performed at a DEP certified laboratory,for collform bacteria and volatile organic compou ds� Initrogen ndicates that the well]s free from pollution from that facility and the presence of ammonia and ual are triggered. hcopy of the analate nitrogen Is ysis mto or less be attached topm,provided that no other failure criteria his form.] U (Yes/No) a system fail .I have determined that one or more of the described m 310 CMR 15.303, therefore the s tem fails. abOVe More criteria exist as Health to determine what will The system owner should contact the Board of necessary to correct the failure. E. arge Systems: T side o bered a large system the system must serve a facility with a design gpd. flow of 10,000 gpd to 15,000 You must indica ither"yes"or"no"to each of the following; (The following criten ly to large systems in addition to the criteria above) yes no. _ the system is within 400 of a surface drinking water supply _ the system is within 200 feet of a tary to a surface drinking r supply the system is located in a nitrogen sensitive Irate Zone II of a public water supply well ellhead Protection Area—IWpA)or a mapped If you have answered"yes"to any question ' ection E the system is "yes"in Section D above the lar e s y idered a significant threat,or answered significant threat under Sectio g or failed underailSection. TlD shall or operator y large system considered a 15.304.The system o s ould contact the appropriate regional office oupgradef the Departm accordance with 310 CMR Ti}ln lnonorlinn Rnrrs.4/1</1nnn 4 `\'` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:12H Z v-\0 Crecy Owner: . Date of Inspection; n Check if the following have been done.You must indicate"yes"or"no"as to each of the following: No _f 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? f Have large volumes of water been introduced to the system recently or as art o p f this inspection? J _ Were as built plans of the system obtained and examined?(If flay we„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 uncovereA of the baffles or tees,material of constructio en wed'and the interior of the tank inspected for the conditio n,dimensions,depth of liquid,depth of sludge n 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: Ygs no , _ Existing information.For example,a plan at the Board of Health. — Determined in the field(if any of the failure criteria is unacceptable)[310 CMR 15.302 3 related to Part C is at issue approximation of distance Titia S Tncnnrtinn Rnrm Al 5 r agc u u1 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Z L 2 Owner: .l Date of Inspection• RESIDENTIAL, OW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3� Number of current residents: 3 Does residence have a garbage grinder(yes or no):Lb Is laundry on a separate sewage system(yes or no):t�.o(if yes separate inspection required Laundry system inspected(yes or no);r-- ) Seasonal use.(yes or no):12D Water meter readings,if available(last 2 years usage(gpd)): SUMP Pump(yes or no):_-6 Last date of occupancy.—Tf-e jfv\!�— CObfM ERCIAL/INDUSTRIAL of establishment: Desi w(based on 310 CUR 15.203): --.gpd Basis of deal sea ts/persons/sgft,etc.): Grease trap present(yes or Industrial waste holding tank present ye Non-sanitary waste discharged to e S system y Fa Water meter readings,if e• Last date of oc y/use• OTHER(describe): Pumping Records GENERAL,INFORMATION Source of information: h 9-21--- Was system Punved as part of the Ins chon If yes,volume pumped; (Yes or no):-j c V Reason for pumping; _gallons—How was quantity d? Pumped Bete��_�� � . TYPE OF SYSTEM J 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 co on n to installed if known �' ll ( ) source of in rmation: Were sewage odors detected when arriving at the site(yes or no): Titla C rncnartinn >~n,,,,ail���nnn 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Zee, Owner: Date of Inspection: 'Z BUILDING SEWER(locate on site plan) Depth below grade: < Materials of construction:_cas line:t iron �40 PVC other Distance from private water supply well or suction l (slam). Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:—(locate on site plan) Depth below grade: Material of construcfion: concrete—metal —o�(exp�) g —polyethylene If tank is metal list age: Is age confirmed by a Certificate of Compliance mpliance(yes or no):_(attach a copy of Dimensions: Sludge depth; i ---T— Distance from top of sludge to bottom of outlet tee or baffle: t! Scum thickness: S 1�Z►i_ l �i Distance from top oft S�top of outlet tee or baffle: ' Distance from bottom of scum to bottom of o tlet t orb s 1 P -7 rX cxa }' l How were dimensions determined: - e v i v t��c S Comments on ns,inlet and outlet tee or baffle condition,structural irate ( pumping recom�„P..a as lated to outletvert,evidence le e,etc. : gritY,liquid levels GREASE TRAP:_(locate on site plan) Depth belo Material of construction: oncrete metal_fiberglass_polyethylene_other (explain): -- Dimensions: Scum thickness: Distance from top of scum o top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or b Date of last pumping: Comments(on pumpin ndations,inlet and outlet tee or baffle condition,structural irate as related to ou invert,evidence of leakage,etc.): ' uid levels Tula inonantinn Fnrm �ii vinnn 7 rage a or 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z Z yip 6 �-- Owner: Date of Inspection• 2 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below Material of construction• meta! fiberglass /� —Poly n� a other(explain): Dimensions: Capacity. goons Design Flow:_ a y Alarm present(yes or no): Alarm level: arm in working order(yes or no): Date of last mg: CO (condition of alarm and float switches,etc.): DISTRIBUTION BOX: (ifpresent must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or o4t of box,etc.): -e—\y O Q . e� LA' PUMP CHAMBER (locate on site plan) Plumes in working or o ; Alarms in working order(yes or no):— Comm nts(note condition of pump chamber,condition o a enances Titlo S fncnontinn Rnrrn/.��s/�nnn S3 rage V Ot 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO ASSESSMENTS PART C SYSTEM INFORMATION(continued) Property Address: 2 �OCIC � Owner: V Date of Inspection• 2 SOLI,ABSORpTTON SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: °J leaching pits,number: p c leaching chambers,number. leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number; innovative/alternative system Comments(note condition of so' signs of technology; etc.); iL gns of hydraulic failure,level of ponding, 1 damp soil,condition of vegetation, CESSPOOLS: (cesspool must be Pumped as art P of ins p ection)(locate on site plan) N and configuration: Depth— of liquid to inlet invert: Depth of soh ayer: Depth of scum lay Dimensions of cesspoo Materials of construction:_ Indication of groundwater inflow(yes o ; Comments(note condition of soil,signs of by c failure,level of ponding,condi tion o lion,etc.): pPJVY: (locate on site plan) Materials Of construction: Dimensions: Depth of solids: Comments(no ondition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, 8 n, etc.): T;tlo incnartinn Anrrn All imtinn 9 i • ' Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1223 CX Owner. `0\rQ Date of inspection: t9 fo, SIETCE OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet Locate where public water supply enters the building. a T �Z" 2 162 — 23 ® --� in OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ZL C Owner: C-t,.r- e- ,`zo Date of Inspection: n!!j 1 ZCo t O f-n SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet 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 _ Accessed USGS database-explain: Y u must daRibe how you a tablishe4 the high group water el tion: T41. q T—,.rtinn Fnr All Vinnn 1� I x T OF BARNST E I,QkCATI f `e �� SEWAGE # `'VILLAGE. ��/e ASSES SO MAP & LOTUME _ NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROO BUILDER OWNER PERMITDATE: 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 of le hi g faci ity Feet Furnished by , 19 _ n. .•,� _.as COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION C4 �r U".)� �1n J l7'd TITLE 5 OFFICIAL INSPECTION FORM—NOT S FOR VOLUNTARY ASSESSMENTS��,� SUBS URFACE SEWAGE.DISPOSAL SYSTEM FORM PART A /� CERTIFICATION Property Address: Owner's Name: Owner's Address-: Date of Inspection: Name of Inspector: please pri t) ��1^ Company Name: C—� Mailing Address: Telephone Number: _ �Z 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: Passe ditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatu e: !1 y /C Date: The system inspector shall submit a copy of this inspection report to the Approving Authority DEP)within 30 days of completing this inspection.If the system is a shared system or has a design now 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 Cone, 4 o`or ) 1 cvSfOrAec �� M 42 c a ""This report only describes conditions at the time of inspection:and�under the conditions time.This inspection does not address how the system will perform in conditions of use. the future under the same or different Title 5 Inspection Form 6/15/2000 page 1 �t ,1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: k1Z O Ot✓ Owner: Date of Inspection. Inspection Summary: Check A,B,C,D or E/AL_ WAyS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. bed in 310 CMR Comments: ` C orv1e e J�'s�ea B. System Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced or repaired. system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or no termined(Y,N,ND)in the for the following statements.If"not determined,,please explain The septic tank is metal and r 20 years old*or the septic tank(whether metal or not)is structm unsound,exhibits substantial infiltration tration or tank failure is ' existing tank is replaced with a complying imminent.System will pas ection if the mP ying s ' tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is s - indicating that the tank is less than 20 years old is ava' a sound,not leaking and if a cafe of Compliance ND explain: Observation of sewage backup or break out or ' static water le in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or en distribution box.Syste will approval of Board of Health): Pass inspection if(with o en 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 l ND explain: Title i Tncnor*inn T7nrm 4/1 4;i,7nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: L Date of Inspection: p 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 stem is fail' to protect public health,safety or the environment. 1. Syste will pass unless Board of Health determines in accordance with 310 CMR 303(1)(b)that the system i of functioning in a manner which will protect public health,safety the environment: Cesspool rivy is within 50 feet of a surface water — Cesspool or 'vy is within 50 feet of a bordering vegetated wetland o a salt marsh 2. System will fail unless the Board o ealth(and Public ater Supplier,if any)determines that the 1l system is functioning in a manner that p ects the publ' ealth,safety and environment: J _ The system has a septic tank and soil ab rpti system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface r supply. _ The system has a septic tank and SA nd the S is within a Zone 1 of a public water supply. — The system has a septic tank an AS and the SAS " within 50 feet of a private water supply well. The system has a septic nd SAS and the SAS is le than 100 feet but 50 feet or more from a private water supply well**.M od used to determine distanc "This system passes if the ell water analysis,performed at a DE certified laboratory,for coliform bacteria and volatile org c compounds indicates that the well is fre om pollution from that facility and the presence of ammoni "trogen and nitrate nitrogen is equal to or les 5 ppm,provided that no other failure criteria are trigg ed.A copy of the analysis must be attached to form 3. Other: Ti+lp C T11OTAP+IA11 Tnrm 411 chnnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: • C Date of Inspection: S 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 clogged SAS or cesspool due to an overloaded or ,1 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/:day flow Required pumping more than 4 times in the last year 1oTOT due to clo ed or obstructed i e s .Number of times pumped gg p'p ( ) ✓ Any portion of the SAS,cesspool or privy is below hi Any portion of cesspool or privy is within 100 feet of a surface water Sud water pply 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 supplywell. y 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, indicates that the well is free from pollution from that facility and the p performed at a DEP certified laboratory,for coliform bacteria and vola resence of ammonia tile organic compounds 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.] (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: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 You must at either"yes"or"no"to each of the following: (The following m ' a ly to large systems in addition to the criteria above) yes no — the system is within 400 feet o urface drinking water su the system is within 200 feet of a tributary to ace drinking water supply the system is located in a nitrogen itive area(Interim a Protection Area—IWPA)or a mapped Zone II of a public water su well If you have answered"yes"toquestion "yes"in Section D above large syst m has filed.Th owner orr opera o considered any larsignificant e a stem considered threat, answered significant threat and ection E or failed under Section D shall upgrade the system in accordance with 3 0 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title S ina+.s.rtinn Fnrm Aij ci,)nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Z� e p ` t(—P Owner: Date of Inspection: Q Check if the following have been done:You must indicate"yes',or"no"as to each of the followin Ygs 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? L _ Has the system received normal flows in the previous two week period? ,.,L Have large volumes of water been introduced to the system recently or as part of this inspection? .L — 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? �) yL. — 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 of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge anddeptfor rof sccondition m?��OII -J _ Was the facility owner(and occupants if different from owner)provided with maintenance of subsurface sewage disposal systems 7 information on the proper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y� no / — 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 a ro is unacceptable)[310 CMR 15.302(3)(b)) PP ximation of distance Tifln i T»a„or*inn 17—m 41i c/innn 5 l Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Z ocic,' Owner: Date of Inspection: RESIDENTIAL FLOW CONDITIONS Number-of bedrooms(design): 3 Number of bedrooms(Actual).- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 3 p Number of current residents: N Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): 1 of [if yes separate inspection required] Laundry system inspected(yes or no):ko Seasonal use:(yes or no):I\0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):]Lb Last date of occupancy:_n Y e S-CVT1 — COMMERCIAL INDUSTRIAL Typ of establishment; Design w(based on 310 CUR 15.203): gpd Basis of desi seats/persons/sgf3 etc.): Grease trap present(yes o Industrial waste holding tank present _ Non-sanitary waste discharge itle 5 sys es or no):_ Water meter readings ' ailable: Last date of oc ancy/use: O (describe): Pumping Records GENERAL INFORMATION t Source of information: � I 7 l-c Was system pumped as part of the inspection(yes or no If yes,volume pumped: aQ allons--How was quanti pty umpe�d e e �L Reason for pumping; f-- - ✓l TPE 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) _Tight tank ____Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(Y kno and source of info lion: rs Were sewage odors detected when arriving at the site(yes or no): Taln 9 inenpotinn 17 4/1 ei,7nnn 6 IA Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -Q Owner:---E. Date of Inspection: BUILDING SEWER(locate_on site plan). . _. _ . Depth below grade: t Materials of construction: cast iron 140 PVC_other(explain): Distance from private water supply well or suction line:+C /U�(X Comments(on condition of' ts,venting,ev' ence of le e et�n t �n SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: Jconcrete_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) 1 Dimensions: Sludge depth: Distance from top of sludge to ottom of outlet tee or baffle: Scum thickness: ! Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of utleyt tee or baffle: How were dimensions determined: b �(J Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural inte as related to outlet 'pert,eVdence of le ge,etc. 1tR liquid levels O VbAt - GREASE TRAP:_(locate on site plan) Depthij,elow grade: Material o truction:_concrete_metal fiberglass_polyethylene_other (explain): -- Dimensions: Scum thickness: Distance from top of scum to top of o tee or a Distance from bottom of scum to om of outlet tee or baffle: Date of last pumping: Comments(on pumpin commendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): T41a i Tnenantinn 17- <n c/,7nnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: h1q Zr Crockep- Owner: Date of Inspection: GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth a e: Material of cottstrucho . concrete metal fiberglass---Polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: --- Alarm in wor ' er(yes or no): Date of last pumping: Comments(condition of al and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) j Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of , leakage into or oft of box,etc. �V1AA l rt"T PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in wor der(yes or no): Comments(note condition chamber,condition of p es,a C. I Titlo G TnCTPI}tn�f Fnrr»�i�Si�nnn 8 Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Zt-{ h ( e(� Owner: G Date of Inspection: I SOIL,ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Tyne leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions; overflow cesspool,number; innovative/alternative system Type/name of technology: Comments(note condition of soil, etc.): signs of hydraulic failure,level of ondin \ P g,damp soil,condition of vegetation, CESSPOOLS: (cesspool must be p )( • pumped as part of ins ection locate on site plan) N and configuration: Depth—to liquid to inlet invert: Depth of solids a Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no . Comments(note condition of soil,signs of hydrau 'lure 1 ponding,condition of vegetation,etc.): PRIVY: (locate o e plan) Materials of truction: Dimensi .Dep of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc. Title. Tnonenhinn 17—m 41'g17nnn 9 A Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 'L �rO C Owner. . Date of Inspection: SXETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply ehters the building. z� 13z- . O . in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2�- �Lrn �— 'b Owner: CA-hD0 Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water L O ` feet 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) Accessed USGS database-explain: vy ' 2 S 3_Z i� _ (� f)j. 3 , C[ Yol��ust describe ho ou established the high ground water elevation: t 0 eb � g e V1 o T41. G Tnc"a-inn P^rm 4/1;hnnn 11 L_ _ BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop Ili Date of Inspec}(�_ 7�/,� Map VIPa'cel/ Owner d PART A CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. NONE OFTHE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. AS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. E FACILITYOR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP. THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. f—JALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. HE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. HE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. E FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION RESIDENTIAL F W CONDITIONS " No of Bedrooms No of Current Residents Garbage Grinder ytiz Laundry Connected to System Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: GALLONS � 7UMn rds and Source of Inf r atio . J SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS Reason for Pumping: TYPE OF S EM: Septic.tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes,attach previous inspection records, if any) Other(explain) Approxi , ag�e of.all:comp Hants ate installed,rf known. Source f Information. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) E TIIC 1A Depth below grade: Dimensions: Material of construction: ncrete Metal FRP Q ' Other} Sludge Depth: Distance from top of slud to bottom of outlet tee or baffle Scum Thickness F / Distance from Top of Scum to top of outlet tee o baffle DistanceJA- from bottom of Scum to bottom of outlet tee or baffle merits: G � s CoCommmenents:U I N DEPTH UOUID LEVEL ABOVE OUTLET INVERT - P B R: Pumps in working order? Comments: SOIL ABSORPTION SYSTEM SAS IF NOT PRESENT,EXPLAIN: Of TYPE: .-�S t om;ner>ra: s CESSPOOLS:' Q Number and configuration Depth—top of liquid to inlet Invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indicadon of.groundwater Inflow:(cesspool must be pumped) Comments: II PRIVY: Materials of construction Dimenskms Depth of solids Comments: n.. .;;SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT'LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' 7, DEPTH TO GROUNDWATER: ,$ DEPTH TO GROUNDWATER METHOD OF,DETERMINATION OR APPROXIMATION: . t L s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indicate Y-yee N-no ND-not determined.Describe basis of determination.If"not determined",explain why not.) Al Backup of Sewage into Facility? 'Al Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? L2Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiftration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR i 'ROBERT J:`BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS COMPANY.-: "BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT. I CERTIFYTHAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED'IS TRUE,:ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE:. V. I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT HA THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED.IN THE:"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR-15.303.'THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SE TIONOFTH IS FORM... C INSPECTORS SIGNATURE: DATE: ORIGINAL TO SYSTEM OWNER„COPIES:BUYER(if applicable),APPROVING AUTHORITY No.--- s-_ � � Fss.....-c....��.........c.... `�� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 4 \ ----------------..- ------.....OF...... -I - - *Appliratijau for UiupuuFal No Tuaiaratrtiuu rprutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ...t 'I" �-'( ----.......... �=------ - ------��f=---G�� zv..�:.LC.......------. Location-Address o Lot No. ...E�J L ddr �.� �!......................... Installer Address Type of Building Size Lot---- feet U Dwelling—No. of Bedrooms...........: .............. _..._Ex Expansion Attic--------- p ( ) Garbage Grinder ( ) aOth Other—Type of Building ............................ No. of persons-----_--_-_____-______--____ Showers ( ) — Cafeteria r fixtures . ..... W Design Flow..........................................gallons per person per day. Total daily flow._._........ ..............gallons. G: Septic Tank—Liquid'capacity PdI?gallons Length__�.V.t. Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width.._._...__......... Total Length................ Total leaching area....................sq. ft. � - De th below inlet.._ 3-..... Total leaching area.-_•..._._.__. .sq. ft. � Seepage Pit No__________ __________ Diameter_._......___ _ p g �'� z Other Distribution box (V/) Dosing tank ( ) '-' Percolation Test Results Performed by_.._ WW���___ .._ .............. Date.... .9-'.z �� ---.5. -••--- Test Pit No. 1_. '""_minutes per inch Depth of Test Pit......1'2-!...... Depth to ground water........ ............ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil.. 2�.._.. r2v�7 �.1_�--� -2�i . ..---5 a p- i- fit �17 ] W ..........••........•--... '...�' ----......�--•---••----... --$-•---l-z--•- ..Q. x -•-----•-••--•--------------••-•------...-•-•---•------------------•--•-•-•-•---•----•••••••--•-••---•-•-•-•----••-•••--•---------------------------------------------------------------------•------•-- U Nature of Repairs or Alterations—Answer when applicable___----___ _________________________________________________________________________________ --------•------------------------------------------------------------------------------------------•----•---------- -----------------------------------------------------------------------------•. Agreement: The undersigned agrees to install the aforedescribed Indivi ial Sewage Disposal System in accordance with the provis' iITL 5 of the State Sanitary o e— T e u r i ed further agrees not to place the ystem in operation a Certificate of Compliance has b n s e t o r of health. Signed-- ---------------------•-•--•-•-•••-•-•-• ..... ace icationApproved By•...•---•. . ••.••• . ... ........... .............................................. P = .................. Date Application Disapproved for th ollowing reasons----------------------------------------•------------------•---------------------------------------------------- -----•---....•-•--...--•---...•-•----•••...---•------•-•-----------•--•••------••.....--•--•-••----•-•-•.•----•-•--•--•-•••-----••--•------•----•-----------•----••-------•----•••---•---•-----•---••--- Date PermitNo......................................................... Issued-....................................................... Date L LOCATION SEWAGE PERMIT NO. VILLAGE Rd5 N d&ac�V r I N S T A LLER'S NAME A A'D,D"RESS �U I I-D E R OR OWNER VT PERMIT ISSUED t� � DATE , COMPLIANCE ISSUED 6 5 t �+ L©�1 :3� No................-....... FEB.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.....- ,....`...................... ............ .................................. Applirutiou for Disposal Works Toatotrurtiou nuti# Application is hereby made for a Permit to Construct ('I/) or Repair ( ) an Individual Sewage Disposal System at r Location-Address or Lot No. ' ......�.t )\A - ....................................... _.._..--••--•. --..__.... ..........------•............................. Own, lf .I� ilddr.....?..l !......................... Installer Address Type of Building Size Lot...I---I_._ ?' .`...Sq. feet U Dwelling—No. of Bedrooms.............).............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons.................---.--.---- Showers ( ) — Cafeteria ( ) a' Others fixtures __ ______ ____ ___ __ _ d _ __ ___ __ _____ __----"--""------......--•--"---------"....................--"---------........-- W Design Flow......f�.: ................................gallons per person per day. Total daily flow....................... : ....... WSeptic Tank—Liquid'capacity.L)f_ gallons Length__`�T2_-. Width................ Diameter---------.--.--- Depth.....--..--.---- x Disposal Trench—No. .................... Width.................... Total Length.........,.......... Total leaching area....................sq. ft. Seepage Pit No---------- -__--.--.. Diameter..----------f _. Depth below inlet....`"3-'._.. Total leaching area._,''`.�_Lsq. ft. Z Other.Distribution box (✓) Dosing tank (n ) aPercolation Test Resullt_s Performed by.-----------------------------------9..._."--.•-.--...-_-- Date_._...___......_...__................--. Test Pit No. 1................minutes per inch Depth of Test Pit-------_-�......... Depth to ground water..................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------••••-•-------•--:.:..-----------••--------"•----------------------------•---------------------•---------------•----•---•- ------- ----.-------- D Description of Soil-----...... 2 ...... ==='` ' r P �'� 1_i �; 5%�U f7 = !,Z U L=L x -- ------- -----------------....-•---•------ ----------------------------------u----•-•-•----------------- ......•--•••-----•--;=•---------•-•-•-----------•---•--•-------•••--•-•••-..... - --------------- 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 provisio TITLE 5 of the State Sanitary pC61e— The u der igned further agrees not to place the system in operation nt' a Certificate of Compliance has b enliss e theibod of health. _ Signed ``" ....+ 4 ate C.S cationApproved By......... •............. ..... ......... ................................................ .............'_'..................... Date Application Disapproved for the., ollowing reasons:----•---------•"----•"-•----------------------•-•-------•-----•---------------------------...--•--•------...__.. ------...--•-•••-------•...............•-.._.........---•-----------•---•-----••-----...................... Date PermitNo--------------------------------------------------------- Issued....................................................... Date THE COMMONWEACTH'OF MASSACHUSETTS BOARD OF HEALTH ._1.. :�..�r��:...1 ".......................................... fit Qrrtifir4tr of ToutpliFattrr THIS IS TO C RTIFY, That the hadimidual Sewage Disposal System constructed (`- or Repaired ( ) by......�+1✓ ! ,f" �!. _. !.... .=� 'Via'../ ^ ' ..................................................................... f �t �L " l_ ✓ ( Inst c.:}-.- -=-�= has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------------------------- ------------- dated--.----:._--.................................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CON TRUED AS A 7ARANTEE THAT THE `SYSTEM WILL F N T ON SATISFACTORY. DATE..................3. ....................................... Inspector............. / f THE COMMONWEALTH OF MASSACHUSETTS �— ff BOARD'PF HEALTH r r q 1 _ . ...........................................OF...... " ............................... No.---•----.................. FEE........................ Disposal. Ivor s Tott #rurtion rrutit r_ s .. � .�- . Permission is reby granted "✓� �' --�`�`.. ''e'� ':�: -+� .SY.. '... ............................ to Const uct or Repair ( ) an Indi idual ev!=a a Disp sal System at No ." ..... g, r ............................................. Stree� e),: - as shown on the application for Disposal Works Construction Permit No.�....... ..... Dated---------------------------............ S`' Board of Health DATE. `----------------------------------------- FORM 125 HOBBS & WARREN, INC.. PUBLISHERS i LEACHING DASIN SECT/ON NOT TO SCALE sheet z 'f z 24"C.l MH COVER EARTH FIL L BRICK AND MORTAR COURSES AS RE0'0• TO BRING COVER TO GRADE INLET _iB FLOW LINE �— _ 2"_r"TO%"WASHED PEASTONE FREE Of IRONS, PIPE FINES AND DUST /N PLACE OPENING WITH 4%B' /4 TO //2 WASHED CRUSHED STONE, FREE OF , OUTER DIAMETER IRONS, FINES AND DUST /N PLACE AND 13/q' INSIDE • ' M-TER D/A E E I. CONCRETE TO BE 4000 PSI 28 DAYS r, 2. REINFORCED WITH 6%6° NO. 6 GA. W.W.M. . ' 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR GREATER DEPTH REQUIREMENTS 4'0" 6 0 I 3'� 4. NUMBER OF PITS REQUIRED aN MIN. I EFFECTIVE DIAMETER NOTE: EXCAVATE TO ELEVATION '>S• R (NOT To ExcEEO 3 TIMES EFFECTIVE DEPTH; LOWER AS REQUIRED TO REMOVE ALL WATER T48LE LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH ,CLEAN TYPICAL PROFILE GRAVEL TO DESIGNED GRADE. /B STD. LT. WGT. C./.MH COVER yI,O !r o.� �.o 9• 4"c..I.PIPE 4"8/T.FIBER PIPE TIGHT ✓DINT OUTLET LEVEL i DWELLING FLOW LINE _ p TO FIRST JOINT /4 00 I I0U00 1 � .ODIZ 110 10011 C./. TEE . '• 1 ir0o0 00 11 11 TO, PRECAST CONC. �,24J T.D/S 1 1 1 0 0 0 00 1 1 BOX TO BE 00 • GAL.SEPTIC TANK. INSTALLED ON LEVEL, � I ( 0 00 O 0 0 1 g .•..:.s: :. STABLE BASE i i ,, 000 O 0 1 1 i _ i \SEPTIC TANK To BE I ' 1 0 0 0 O 0 1 11 I , INSTALLED ON LEVEL` I I 1 100 0 a 1 1 ' ' STABLE BASE. i 1 0 0 0 0 0 0 1 � i1040 G011 � i � LEACHING BASIN : i i I A 0100 0 1 1 1 BASE TO BE LEVEL i i 1 8 0 0 0 ► I L SOIL ANO PERC. DATA L 0�� TEST PIT NO. f- 3-7 0�� TEST PIT NO. 2 PERC. RATE � z MIN. /IN. y' "rvp• /gv135o1 � TEST BY _ t�IZu�it�GIrD �,� 1.1 r-> Utz-Is.vEl. WITNESSED. BY: _f-vN l-1 rrloitp_� µ MAD. Sa.rJp TEST PIT GR. EL `- � DATE: IZ, I ►.1 �� 5 N D �1.. N,o l� .1.►R�n�/�.1�� 3Q1'�' . DESIGN DATA GENERAL NO TES BEDROOMS NO HEAVY EQ;U;PMENT TO RUN OVER SYSTEM. DISPOSAL -- SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL.DAILY EFFL.�'�3`oGPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK loot/ GAL. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL AREAS GAL./SQ.FT. MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA 1•0� GAL./Sq.FT. SANITARY SEWAGE EFFECTIVE ON JULY 1 , 1977. LEACHING REQUIRED ZOO SQ,FT.. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING AREA OF HEALTH. 2�SQ.FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES 'A" / FT. UNLESS INDICATED OTHERWISE. s ' SEWAGE DISPOSAL SYSTEM �o MARTIN E. ^�, FOR S w MORAN L-�-t-'d�23417� � `iti �o�cc,s��•?:��`� _. G.�!.J 1'��V��i,Yam- , tM A. '� 5 . F0 0 SCALE AS INDICATED DATE- WM. M. WARWICK 8 ASSOC., INC. 8OX 801 - NORTH FAL MOUTH ` 44ASS. 02556 - 16171 563 -2638 PROFESSIONAL ENGINEER s SITE PLAN SHEET I OF 2 SCAL E: I 3 �� .a hT_T�ox� o I oo % �v- (oaa&A 4. L�e&c�� ri i W J� o ► d C.ao .A 1T � I i 4 N �j i3(z v7 uL O 1 10 6� "2- z7,00i' h l x 3 j 5aX�j Quo. ot{' � S MALLIAM m_ ,WARWICK ,•a,. No. 19771 t•GISTS. �QQ. 4 SUR VE FOR REGISTERED LAND SURVEYOR Lo,r ZONE G' G .�- r—\)I LLC, M PLAN. REF. DATE 7�� BENCHMARK DATUM '�'� +-�Re1' `"� Li mc� P) WM. M. WARWICK S ASSOC., INC. DOMESTIC WATER SOURCE W A 171z 8OX 801 - NORTH FA L MOUTH FLOOD ZONE. �A A- F= � MASS. 02556 - (6/7) 563 -2638 I IT rtio'�K dv� L L . V RQow� Li4vr�`�ti'r Zr,o� Y J 1 o --64 EXISTING CONTOUR LOCUS Stoney x 60.98 EXISTING SPOT GRADE �,ff —W EXISTING WATER SVC. o Musks et p N —G G EXISTING GAS SERVICE �� a 6iP o Pr'^ce �JGaA�— UNDERGROUND WIRES Qg�a H� H'"ckte cny Rd Ro °Q°'tltl�k ko TEST PIT D Ob5 Tucker(' m BENCHMARK F � Nauset Ln F Tomahawk V LEGEND Ames way Powderhorn Way LOCUS MAP NOT TO SCALE n S 35'29'06" W 114.84' FENCE LINE 0 LOT 641 15,540±S.F. /40 I 100.38 I x 34,100,47 ../ .'. :' i+99.57 10' 10' `F f P-1 42 TP-2 \ = EXISTING SEPTIC TANK (TO REMAIN EXISTING LEACH tallI TOP OF TANK, EL.=100.18E (FROM RECORD AS-BUILT) \` INV.(OUT)=98.83E O O TO BE PUMPED, FILLED WITH SAND & ABANDONED i 0�'73 - \o r ---� x 9 6 I / 101.45 � 100.72 • / X 1 o • + 100.57 \\ ' I I (0 __ DECK 1 W v _ 102.61 - M EXISTING DECK 1 o HOUSE 124 1 B�NCHNGE DOT�DECK T.0.F.=102.7 1 � o ELEV = 102.61 + 1OL27 / O O i0 / 101.55 I I � _ z 01.80 I I PAI/FQ., x /01.94 I I rr, 100,86� 11 I 101.59 / I Z Z 101.28 t L=27.00' A 80.04' 100.63 / Ri 86 87' N 35'29'06" E ® 99,83 edge 99.63 of pavement 99.10 CATCH BASIN 100.07 ZENO CR 0 CKER RD of "'ASSgcyG PARCEL ID: 170-132 �o PETER T. s McENTE PROPOSED SEPTIC SYSTEM UPGRADE PLAN E `=', � CIVIL "' a. 35109 124 ZENO CROCKER RD, CENTERVILLE, MA /S1ER�`� OWNER OF RECORD Prepared for: Reginaldo Carvolho, 124 Zeno Crocker Rd, Centerville, MA 02632 CARVALHO, REGINALDO E Engineering by: SCALE DRAWN JOB. NO. / ( ( � 32 GORDON LANE Engineering Works, Inc. 1"=20' P.T.M. 249-18 YARMOUTH PORT, MA 02675 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. %DS DEVELOPERS LLC (508) 477-5313 10/16/18 P.T.M. 1 Of 2 I z t NOTE: TO PREVENT BREAKOUT, FINAL GRADE SHALL NOT BE AT, OR BELOW, EL.=97.0 FOR A DISTANCE OF 15' FROM THE EDGE SEPTIC TANK OF THE PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & PROPOSED D-BOX OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & WATERTIGHT PROPOSED S.A.S. COVER SET TO 6" OF GRADE INSTALL RISER & COVER OVER ONE CHAMBER AND T.O.F.=102.7t SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT F.G. EL.=101.5t F.G. EL.=100.5t F.G. EL.=100.3t F.G. EL.=100.Ot MAINTAIN 2% SLOPE OVER S.A.S. L = 11' L = 13' ® S=1% (MIN.) 2" LAYER OF 1/8" TO 1/2" 4"SCH40 PVC 4"SCH40 PVC 6.+ DOUBLE WASHED STONE 10"I " 6 aBaSaaa (OR APPROVED FILTER FABRIC) 14" aa6a BBB EXISTING 48" LIQUID aaaaaaa �--3/4" To 1-1/2" DOUBLE LU. 4' 4 8' 4' WASHED STONE AD° INV.=98.07 PROPOSED INV.=97.90 INV.=98.83t D-BOX EFFECTIVE WIDTH = 12.8' GAS BAFFLE EXISTING INV.=96.50 PROPOSED SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN H-10 RATED NOTES: TOP CONC. ELEV.=97.3t 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE BREAKOUT ELEV.=97.00 INVERTS, PRIOR-TO INSTALLATION. INV. ELEV.=96.50 ease aBaaa 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE aaaaaaaBaaa ON A MECHANICALLY COMPACTED SIX INCH CRUSHED BOTTOM ELEV.=94.50 STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 4' 2 x 8.5' = 17.0' 4' 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0. PERVIOUS MATERIAL - 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 5' (MIN.) ABOVE G.W. LEACHING SYSTEM SECTION AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. NO G.W., EL=88.2 - SEPTIC SYSTEM PROFILE GENERAL NOTES: EXISTING / OUSE(#12, 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. DECK 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DECK LOCAL RULES AND REGULATIONS. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE BACK DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. N 01- ALL ELEVATIONS BASED ON,AN ASSUMED DATUM. _ - - - 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF N -� THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. ^0 ? 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. _ a I 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. ^ �` 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE / Cx DIRECTED BY THE APPROVING AUTHORITIES. / C.) 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). SEPTIC LAYOUT 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND SOIL LOG NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. 14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC DATE: OCTOBER 24, 2018, 2018 (REF15,808) SYSTEM COMPONENTS NOT SHOWN ON THE PLAN SOIL EVALUATOR: PETER McENTEE PE(SE 1542) WITNESS: DONALD DESMARAIS R.S.HEALTH AGENT ELEv. TP-1 DEPTH ELEv. TP-2 DEPTH 99.7 A 0 100.0 A 0 11 LOAMY SAND LOAMY SAND 10YR 4/2 10YR 4/2 DESIGN CRITERIA 99.4 B B 4" 99.5 g" LOAMY SAND LOAMY SAND NUMBER OF BEDROOMS: 3 BEDROOMS 10YR 5/4 10YR 5/4 97.0 32" 97.2 34" SOIL TEXTURAL CLASS: CLASS I C C PERC DESIGN PERCOLATION RATE: <2 MIN/IN 34"/52" DAILY FLOW: 330 G.P.D. DESIGN FLOW: 330 G.P.D. F-M SAND F-M SAND 2.5Y 6/6 2.5Y 6/6 GARBAGE GRINDER: NO-not allowed with design LEACHING AREA REQUIRED: (330) = 445.9 S.F. •74 88.2 138" 88.5 138" EXISTING SEPTIC TANK: 1000 GALLON CAPACITY PERC RATE <2 MIN/IN. "C" HORIZON PROPOSED D-BOX: 1 INLET, 3 OUTLETS, H-10 RATED NO GROUNDWATER ENCOUNTERED USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 124 ZENO CROCKER RD, CENTERVILLE, MA SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: Reginaldo Carvalho, 124 Zeno Crocker Rd, Centerville, MA 02632 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:............................................I................. 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 249-18 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD (508) 477-5313 10/16/18 P.T.M. 2 Of 2