HomeMy WebLinkAbout0189 GUILDFORD ROAD - Health (3) 58 WARWICK WAY
CENTERVILLE
A = 148 017
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TOWN OF BARNSTABLE
LOCATION SI� SEWAGE# V,'71— ;7W'
VILLAGE ASSESS R'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.��DB���D-9�3 ✓GS{�,��(J14/"i"O
SEPTIC TANK CAPACITY /,Oed `
LEACHING FACILITY:.(tyke? —5 0(J G% (size) �3 X Z S
NO.OF BEDROOMS 3
OWNER S/,.. rD'!�/ �UYI� V � RIO
PERMIT DATE: "/y ",`�/ 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 G✓/22
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13 1
411
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No. Fee G y
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L�—
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplitation for,.Misposar *pstrm Construttiun 3permIt
Application for a Permit to Construct( ) Repair VAPgrade(L�bandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 8 C� ji/1 C kJ,�/ Ownne 's Name,A�ess,and Tel.No.
Assessor's Map/Parcel %!� rt7 /✓
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building: Cat 5b g- 2290 0 7 11-5-2-2, JJ
Dwelling No.of Bedrooms Lot Size i U sq.ft. Garbage Grinder( )
Other Type of Building �L ��t '/�E� No.of Persons Showers( ) Cafeteria( )
Other Fixtures e,/l✓l/�2tZ
Design Flow(min.required) �. gpd Design flow provided gpd
Plan Date ;W25 Num er of sheets Z Revision Date 'v
Title J /< �G .�/•� /�/
Size of Septic Tank J lJe9 Type of S.A.S. ZvJ CJ S`�Q
Description of Soil AYv
III& lCAJ vim.
//i
Nature of Repairs or Alterations(Answer
when applicable)
/
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Si Date
Application Approved by Date �—
Application Disapproved by Date
for the following reasons
Permit No. J J Date Issued 7 7 �--
y, t
No. �' P'Tl / fC� Y " ` 1't FeeV
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ff��+-.
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Iication for&-bisupsat *pstrm Construction Vermit
Application for a Permit to Construct( ) Repair(PoO pgrade(t4-Abandon( ) ❑Complete System ❑Individual Components E-^`
Location Address or Lot No. f,�i �'jyjC/� =Y=Zj Own e 's Name,Address,and Tel.No.
Assessor's Map/Parcel 41"l-oAl,7/ lGw'1✓v(A, (�>✓aU� �/t)c''
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building: CO-11 50
Dwelling No.of Bedrooms _ Lot Size /C,a/6:;�,S _ sq.ft. Garbage Grinder( )
Other Type of Building °U�/'n?tYAr ' No.of Persons Showers
YP g ( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ' gpd Design flow provided v - gpd
Plan Date 6 4 70.:. Number of sheets 2 Revision Date 'U
Title t M11<1 /S-�G �! �I>' ' W/Z/
Size of Septic Tank ,ItJ �9 Type of S.A.S.
Description of Soil /�,✓j�, .- /
04, _uC? .
11A �/, ✓
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: i
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
i
Compliance has been issued by this Board of Health.
Si ed j ���:P,/ Date
90
Application Approved by / , m '""""" Date 53//51/c)-
Application Disapproved by Date
for the following reasons
Permit No.�� / tl� Date Issueds-
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ` ) Repaired��) Upgraded
Abandoned( )by CE /G' N, -V6 S
at IVA12 tul�'f' '����� v� � '�' „�'YG: �' has been constructed in accordance / J
with the provisions of Title 5 and the for Disposal System Construction Permit No 91_/iodated 5//1/ 4 'I
Installer "a 4A_V Y� Designer -e �Zl-/'(l"V�qC. r
#bedrooms Approved design flow. O gpd
The issuance of this permit shall not be construed as a guarantee that the system wi�ll'facttiot/y as designed.
Date r(/ f X Inspector
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( )/ Repair( ) Upgrade(V) Abandon( )
System located at `/mY
and as described in the above Application for 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'bLe.�com°pleted within three years of the date of this permit.
' Date // //r � Approved by,,
a
j
i
Town of Barnstable
Inspectional Services
g Public Health Division
&6 Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
R
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: S'-f 9-Zl Sewage Permit# 2010/— J Assessor's MapWarcel 11114M&fl 7/
Designer: Z!�'s 15i),Avey'Z C_ Installer: cedar
Address: �� �'Z2 q Address: 99/ 04,w/*/� '4q,
On 21 l ��4c��5 was issued a permit to install a
(da ) (installer)
septic system at based on a design drawn by
y
v' dated
(designer)
V I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of he
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed 't o ;ance with the to rms of .
the.I\A approval letters (if applicable)
DAVID i
D.
LAHERTY, JR.
(I ler's Si nat e) 0.b. 1211
3
i
�dITAM
(Desl e s Si nature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
WoMdeptMEALTtASEWER connectUPTICOesigner Certification Form Rev 8.14-13.DQC
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4
f
T Town of Barnstable
�IK T
: BA E Inspectional Services Department
MASS*
BA' ASS* ' Public Health Division
y
47 i6J9• ♦0
'°rFc► " 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL47015 1730 0001 4988 0480
April 7, 2021
RIOS, GILSON GONSALVES
58 WARWICK WAY
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 58 Warwick Way, Centerville was inspected on
03/27/2021 by Chad Hathaway, 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:
• Static liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool.
You are ordered to repair or replace the septic system within one (1)year 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 E BOARD OF HEALTH
Thomas Mc ean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\58 Warwick Way Centerville.doc
Town of Barnstable
3 9. Inspectional Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
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
❑ Structurally unsound septic tank or SAS
O 1 YEAR DEADLINE CRITERIA
Static liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool
❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation
❑ A portion of the cesspool is located within a Zone I to a public well
❑ A portion of the cesspool is located 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:
OISEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts 1400 04-1
i� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name /
information is required for every Centerville Ma 3/27/2021
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 5 l t'S5
on the computer,
use only the tab Chad Hathaway
key to move your Name of Inspector
cursor-do not Hathaway Septic Inspections
use the return Company Name
key.
P.O.Box
151
Company Address
Forestdale Ma 02644
City/Town State Zip Code
774 274 2581 12866
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
3/27/2021
Inspector's Sign re Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
t� w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This inspection is not a guaranteeand applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described components. This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
Information on care and do's and don'ts can be found at town health dept or mass.gov
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
cam, Commonwealth of Massachusetts
loTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t, 58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is Centerville Ma 3/27/2021
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® El or
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 '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is Centerville Ma 3/27/2021
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cost.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® ❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
([''a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2-3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 373 gpd
9 ( Y 9 (gpd)):
Detail:
2020 129,000 gal. 2019- 144,000
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: 2019 per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
r= - F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owners Name
information is required for every Centerville Ma 3/27/2021
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
orig. tank leaching and Dbox 2010
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 26+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
sewer line has belly between house and tank resulting in a upward pitching pipe into tank.
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1000 gal tank level of tank is over outlet pipe
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle level over tee
Distance from bottom of scum to bottom of outlet tee or baffle 20"+-
How were dimensions determined? tape and sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tank over full. inlet above water line outlet tee level of tank is at top of tee. pipe is full
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is Centerville Ma 3/27/2021
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
c Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M Y 58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
6"+
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.):
Dbox is overfull. ran camera down tank outlet to Dbox. Dbox is overfull due to failed leaching
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® teaching chambers number:
12 Arc 3616
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. Cityrrown State Zip Code Date of Inspection
D.. System Information. (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
system is in failure probed area wet prob. Dbox is overfull
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M. 58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
p
s
f
D
2 0
I
Ll
L s
A,,) I l ° U A
133 0�,D
15insp.doc•rev.7/26/20111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: greater then 11'
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: 2010
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:
perc and permit no water at 11'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Warwick Way
Property Address
Gonsalves
Owner Owner's Name
information is required for every Centerville Ma 3/27/2021
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
SEASON / ��#•1%
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TOTAL 12 ARC 36HC BIODIFFUSERS
(6 BIODIFFUSERS EACH TRENCH) ,
\ `:\ PROPOSED DISTRIBUTION BOX
1ECTION PORT WITH 3�9. � '3' crO .
GRADE(TYP OF 2) 559
' TP 1
h
•/ Benchmark
� �' � 30� : .,Z� ;(• ���) '' Nall Set in B.H.Corner
Elev.=57.00
Approx. M.S.L.
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MAP 148
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EDGE OF PAVE EP
5 � ARWICK WAY �1 n�OMs �VN�1N n
(4V WIDE LAYOUT)
No. L5�60 —J ttv f
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippYtcation for Digogal *pgtem Cottgtructiou Permit
Application for a Permit to Construct( ) Repair h.{1 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. SO WA4 Owner's Name,Address,and Tel.No. 611 I S„N 211-S
Assessor's Map/Parcel tj 17( t Aim
I
Installer's Name,Address,and Tel.No. 04PQ4Jiu! CJv1 'Ps�jCs Designer's Name,Address and Tel.No.
q 2t- q0 Z i;o 1 o sc 7 6 3 2 9,5'`l (✓lGn G j�'`1 "
Type of Building:
Dwelling No. of Bedrooms 3 Lot Size i(oj 0 Z"S t sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures Design Flow(mirquired) 33o gpd Design flow provided 3 46. 3 gpd
Plan Date I,)'
�La Number of sheets Revision Date
Title wofv►0_
Size of Septic Tank Type of S.A.S. `� s' �� --•
Description of Soil se-a- QI,9-"
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: °2 co
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed no X Date
Application Approved by [usDate
Application Disapproved by: Date
for the following reasons i
Permit No. p� c ^ 34 ro Date Issued g
���� �.,� �.4i�V ., s�� I raj * ��°•i �` ,
No. � Gw _� � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pprication for Cow9truction Permit
Application for a Permit to Construct( ) 1,Repair()� Upgrade( ) Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. 58 WAf w Owner's Name,Address,and Tel.No. C.'+
Assessor's Map/ParcelVCj' SAr�
Installer's Name,Address,and Tel.No. C4,Oew,66 -,I ily vr)(S Designer's Name,Address and Tel.No.
y2 — LIU79 I26 i3ox -7G3 2ff f C✓/1ns"
Ce",l�r dr M4 v�
Type of Building:
Dwelling No.of Bedrooms Lot Size 1 b� 07,5 r sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(mi ccrequired) 33o gpd Design flow provided 314(o. 3 gpd
Plan Date Number of sheets Revision Date
Title LA.)N IJ (,1i
s� I
TSize of Septic Tank 1 O(3Q Type of S.A.S. t S T �*�. T� -
Description of Soil dQ-0- P)4srt
1
Nature of Repairs or Alterations(Answe eapplicable)
I
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 BnvironmentaFCode and not o place the system in operation until a Certificate of,
Compliance has been issued by this Board of Health.
t r
Signed } i Date
Application Approved by ` Date L)
Application Disapproved by: Date
for the following reasons
Permit No. p2o a ^ 3 C7 Date Issued S
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( )
Abandoned( )by CrAR^�(c) (to too j P LC
at50, W Af-.J o c k- Wile - ."""j!tzt"t I( has been constructed.in accordance
� with the $provisions of Title 5 and the for Disposal System Construction Permit No. oZ O rQ^ 546 dated
��
Installer C..A eeW 1'CL 6n k1,p,-,5es LCC Designer S C- C K •=t 9 k
#bedrooms 3 Approved deli flow 3'-/ . 3 gpd
The issuance of t i pe I it shall not be construed as a guarantee that the system wil func i as designed.
Date r !J InspectorNo. 'golo
�e ?
----------------------
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
lizpoal �&p!5tem Construction Permit
Permission is hereby granted to Construct ( ) Repair (�) Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this p�L,,
Date 2—0-f Approved by
i
'f'own of Barnstable
-� Regulatory Services'niomas F. Geiler,Director
IIANN8YA91.P., :Public Health Division
lgAlyts,
1 19 8 Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862.4644 !'tax; S!:18 '71i :. •t
Date: - 0 -i 3-t U__. Sewage I'ernlit#-WO—3 4 p Assessor's Map/Parcel
.Installer& Desianer Certification Form
pesi�;ner: S Ect ct e.ec c -no�...._ Installer: !; k e{pc i s .>
Address: Address:
!�a>\ Wmttin�,nl tjA 0I 3�
Sz 6•�'7 33^0 3 7.7
On $—l( -2ofo was issued a permit to install a
c � is t.�ic,,
septic syy Wcicu"'
ten-1 at J_.:..w..._.....__ -._._ based on a design drawn kiy
dated el, 0
(designcr)
---✓ 1 certify that the septic system referenced above: was installed substantialk according .o
the design, which may include rninor approved changes such as lateral relocation of tho
distribution box ,anal/or septic tank. Stripout (if required) was inspected and the soili
were found satisfactory.
I certify that the septic system referenced above was installed with ► ajor changes (i.Q.
greater than 10" lateral relocation of'the SAS or any vertical relocation Of.'ally cotrlprmcnt
of the septic system) but in accordance with State.& Local Regulations. Plan revision ur
certified as-built by designer to follow. Stripout (if required) e: +r s wcted and the soils
were found satisfactory. �Pk"„OFJGNN
CNUficHIU. ^.
•. J11. Y
ler's Signa..._red..._.__.� _.... iv+l.
41W
escgner . Sc mature (AffixDc gn l-Cre)
P -A&I RETURN TO` ARNS�I�.�►,j4il�L+. PUBLIC HEAL1 DIVISIVN,. C j, , TIFIC:ATE
OF LIANCF. WLL NOT IJE ISSUD UNTIL BOTH 'C IS FORM AND AS-
BUrI D ARE RECEIV 1) BY THE BARNSTABLE PUBIJC_HEALTH DIVISION,
THANK Ya
q tolYr.'c ro>its\ilesigncrcc;rtit'1l Hill?Il�OII1L(.�OG
T •'. . . r-.—— — . — .--.—.-. t��,Tv77�,Tr.•.�1f� ,.lu !>�• .'�T I'.1 Tfa7_CT_nflN
TRANS. NO.:
CITY/TOWN4 Centerville
APPLICANT: Capewide Enterprises
ADDRESS: 58 Warwick Way Centerville MA
DESIGN FLOW: 330 gpd
REVIEWED BY: DATE:
RAL F N
NO
My
Legal boundaries denoted [310 CMR 15.220(4)(a)] X
Street, Lot, tax parcel number and lot number noted on plan [310
CMR 15.220(4)(u)] X
Locus Provided [310 CMR 15.2204(t)] X
Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for
components) [310 CMR 15.220(4)] X
Easements shown [310 CMR 15.220(4)(b)] X
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]- if not, a variance is required [310 CMR 15.412(4)] X
Location of impervious surfaces (driveways,parking areas etc.)
[310 CMR 15.220(4)(d)] X
Location all buildings existing and proposed 310 CMR
15.220(4)(c)] X
Location and dimensions of system components and reserve areas.
[310 CMR 15.220(4)(e)] X
System Calculations [310 CMR 15.220(4)(f)] X
daily flow X
septic tank capacity required andprovided) X
soil absorption system (required and provided) X
whether system designed for garbage grinder X
North arrow [310 CMR 15.220(4)(g)] X
Existing and pro osed contours [310 CMR 15.220(4)(g)] X
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)] X
Names of soil evaluator and BOH representative [310 CMR
15.220(4)(h) and (i)] X
Location and date of percolation tests (performed at proper
elevation?) [310 CMR 15.220(4)(i)] X
Percolation test results match loading rate? [310 CMR 15.242] X
Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] X
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)] X
Address 58 Warwick Way Centerville MA Sheet 1 of 7
N/A OK NO
Location of every water supply,public and private, [310 CMR
15.220(4)(k X
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply X
within 250 feet of the proposed system location in the case X
within 150 feet of the proposed system location in the case
of private water supply wells X
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR. 15.211 and any catch basins
located within 50 ft. [310 CMR 15.220(4)(1)] X
Water lines and other subsurface utilities located [310 CMR
15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) X
Profile of system showing invert elevations of all system
components and the bottom of the SAS [310 CMR15.220(4)(o)] X
Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)] X
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR. 15.220(3)] X
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR. 15.102(2) or as
approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] X
Test hole adequate to demonstrate four feet of suitable material?
[310 CMR 15.103(4)] X
Test Holes adequate to confirm adequate groundwater separation?
[310 CMR 15.103(3)] X
Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] X
Materials specifications noted? [various sections of 310 CMR
15.000] X
System components not> 36" deep (unless Local Upgrade
Approval or LUA requested) [310 CMR 15.405(1 b)] X
Address 58 Warwick Way, Centerville MA Sheet 2 of 7
N/A OK NO
Size OK? [310 CMR 15.223(1)] X
Inlet tee located ten inches below flow line [310 CMR 15.227(6)] X
Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR
15.227(6)] X
Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] X
Note regarding installation on stable compacted base [310 CMR
15.228(1)] X
Separation between inlet and outlet tees (no less than liquid
depth) [310 CMR 15.227(2)] X
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or permitted for
upgrades under LUA [310 CMR 15.405(1)(k)] X
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1) and 310
CMR 15.232(3)(0] X
Three access covers (inlet and outlet must be 20" or greater) -
middle access at least 8" (by 7/07) [310 CMR 15.228(2)] X
Access to within 6 " of grade - one port for systems<1000gpd,
two for systems>1000 gpd [310 CMR 15.228(2)] X
All at-grade covers secured to unauthorized access? [310 CMR
15.228(2)] X
> 10 ft from building foundation [310 CMR 15.211(1)] X
Buoyancy calculation Required/Done [310 CMR 15.221(8)] X
H-20 Where appropriate? [310 CMR. 15.226(3)] X
Setbacks from resources [310 CMR 15.211] X
wl
�
Required when other than single-family dwelling or flow>1000
d [310 CMR 15.223(1)(b)] X
First compartment 200% daily flow; Second compartment 100%
daily flow [310 CMR 15.224(2) and(3)] X
"U" pipe through or over baffle, outlet of each compartment with
gas baffle or approved filter [310 CMR 15.224(4)] X
Address 58 Warwick Way, Centerville MA Sheet 3 of 7
N/A OK NO
Located at least ten feet from any water line? [310 CMR
15.222(2)] X
Disposal piping at least 18" below water line (when water and
sewer cross, see 310 CMR 15.211(1)[1]) X
Cleanouts required/provided? [310 CMR 15.222(8)] X
Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] X
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
[310 CMR 15.222(6)] X
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] X
Siphonproblem/(leachfield below pump chamber) X
Endca s or vent manifoldspecified? X
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252(2)(h)] X
Materials specified (310 CMR 15.251(5) specifies various pipe
types allowed) X
:DTBCN BqX
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.232(2)(a)] X
Splash plate or baffle tee required on inlet/provided? (when
pressure sewer to d-box or steep pitch of gravity sewer) [310
CMR 15.323(3)(a)] X
Riser if deeper than 9" [310 CMR 15.232(3)(f)] X
Inside minimum dimension 12" [310 CMR 15.232(2)(b)] X
Minimum sum 6" [310 CMR15.232(3)(e)] X
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
[310 CMR 15.232(3)(d)] X
Capacity(emergency storage above working=design flow)?7310
CMR 231(2)] X
Proper setbacks [310 CMR 15.211 (same as septic tanks)] X
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE [310 CMR 15.231(5)] X
Service components accessible(not too deep with piping,
disconnects accessible) X
Alarm floats - alarm on circuit separate from pumps specified? X
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.231(6) and (8)] X
Stable Compacted Base [310 CMR 15.221(2)] X
Buoyancy calculations needed ?Provided? [310 CMR 15.221(8)] X
Address 58 Warwick Way, Centerville MA Sheet 4 of 7
SOIABSORTIONSSTMS(SEAS)„ N F T. yt N/A OAK NO
... x... no",
Calculations correct? X
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(1)1 X
Required separation to groundwater? [310 CMR 15.212)] X
Aggregatespecified as double washed [310 CMR 15.247(2)] X
System Venting required/provided? (system under driveway or
>36" deep) [310 CMR 15.241] X
Inspection ports specified and within 3"final grade? [310 CMR
15.240(13)] X
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document] X
GALIER�I� ,��'ITS,C �25�,3�10�CM1�5:2�53 `
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)] X
Each structure with one inspection manhole(if>2000 gpd must
be to grade) [310 CMR 15.253(2)] X
Aggregate I' minimum- 4'maximum. [310 CMR 15.253(1)(b)] X
2' sidewall credit maximum [310 CMR 15.253(1)(a)] X
In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)] X
Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] X
100 feet-maximum.length [310 CMR 15.251(1)(a)] X
Minimum separation 2x effective depth or width whichever
greater(3x if reserve between trenches) [310 CMR 2510)(d)] X
Situated along contours [310 CMR 15.251(2)] X
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] X
B4EDSAS (Maxirnum e of .e;a o £iel 000
g T m 1W, .
minimum distribution lines [310 CMR 15.252(2)(a)] X
Maximum se aration between lines 6' [310 CM R15.252(2)(d)] X
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)] X
Aggregate depth below discharge pipes 6" minimum, 12"
maximum. [310 CMR 15.252(2)(g)] X
Separation between beds 10'minimum. [310 CMR 15.252(2)(D] X
Bottom area-used in calculations only [310 CMR 15.252(2)(i)] X ,
Address 58 Warwick Way, Centerville MA Sheet 5 of 7
N/A OK NO
Pressure Dosed System ? Provided pump and piping
calculations as required [310 CMR 15.220(4)(r)] X
Pressure dosing required on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals] X
If used in gravelless system- make sure jet is directed as not to
scour soil interface [Guidance Document] X
Inspections once per year(systems<2000 gpd) or quarterly
(>2000 d) good to note on plan [310 CMR 15.254(2)(d)]
Construction in fill - Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)? X
Impervious barrier and/or retaining wall ? [Guidance Document] X
Impervious barrier installation must be supervised by
designer [310 CMR 15.255(2)(b)] X
Retaining wall must be designed by Registered Professional
Engineer [310 CMR 15.255(2)(a)] X
Side slope not exceed 3:1 ? [310 CMR 15.255(2)] X
Breakout requirements met? [310 CMR 15.252(2) and
Guidance Document] X
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [310 CMR 15.255 (2)(e)] X
GGYaverlessS stem I/A royal�etteis� " �
Check DEP Approval letters for credits and design conditions X
If used with pressure dosing do not allow pressure discharge
to scour soil interface X
turn t eeptac111111 5yslem 11
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions? X
Is the technology being properly applied and does it meet all
DEP Approval Conditions? X
Is there a note on the plan regarding the requirement for
perpetual maintenance agreement? X
Any alarms involved on separate circuits X
Did the applicant submit an operation and maintenance
manual? X
Has applicant submitted a copy of a maintenance X
Are the variances listed on the plan ? [310 CMR 15.220
(4)(q)] X
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)] X
New construction or increased flow proposed- [Refer to 310
CMR 15.4141 X
Address 58 Warwick Way Centerville MA Sheet 6 of 7
"VA
7
N/A OK NO
clro e Area £,
o- fR# �
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216 - also refer to Policy regarding upgrades of such
existing systems] X
Is the system proposed on the same lot as served by private well ?
[310 CMR 15.214(2)] X
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(1)] X
Miscellaneous 3 : ri
Pumping to septic tank ? [ 310 CMR 15.229] X
Shared System [310 CMR 15.290] X
Address 58 Warwick Way, Centerville MA Sheet 7 of 7
Town of Barnstable
Department of Regulatory Services
BARNSrAB[.B, : Public Health Division Date 7 z0' o
hUm
26 200 Main Street,Hyannis MA 02601
Date Scheduled 0 Time. l r� Fee Pd.
Soil Suitability Assessment for Sewage iSP
osal
PerformedB illf��� CimW 7 CSC 0 t , ,f
Y Witnessed By: d,
LOCATION& GENERAL INFORMATION
Location Address S p W ; 1, Owner's Name f
Address -scyM e-
Assessor's Map/Parcel: r qd—b-7! Engineer's Name CHQ¢wrk F-Sc,( F-64 ieej t v►C,
NEW CONSTRUCTION REPAIR ✓ Telephone# 5 d 8— 273—0 37 7
Land Use 5(q)kC F0�tY dwei n Slopes(%) 1- 2- Surface Stones
Distances from: Open Water Body ft Possible Wet Area r ft Drinking Water Well ft
Drainage Way — It Property Line 1 ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test.holes&pert tests,locate wetlands in proximity to holes)
set_ at aekle_( e(CI
Parent material(geologic) O� "+cs� • 7 i 2-o cjs
g ) Depth to Bedrock _ ..
Depth to Groundwater: Standing Water in Hole: ( - u S Weeping from Pit Face -7 j 20
Estimated Seasonal High Groundwater
DETE IVIINATION FOR EA OVAL NIGH WA R T
Method Used: +rCe f dbSei�a�ican
Deptht 20
Depth Observed standing in obs.hole: . 7 170 in. to soil tnottles: in.
Depth to weeping from side of obs.hole: > 120_ _ in. Groundwater Adjustment —ft.
Index Well# Reading Date: Index Well level — __ Adj.factor _ Adj.Groundwater Level
PEItC(JI.A' IONETat� t-s-�QIm� ( ty
Observation
Hole# i Time at 9" —
Depth of Perc 36 Sy Time at 6"
Start Pre-soak Time @ 10'51 Art _ Time(9"-6") .
End Pre-soak 10: A?/
Rate Min./Inch 4 2
Site Suitability Assessment: Site Passed e-5 Site Failed: Additional Testing Needed(Y/N) .N
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
DEEP OBSERVATION HOLE LOG
Depth from IIOIe# l.
P Soil Horizon Soil Texture Soil Color Soil
Surface(in.) (USDA) Other
(Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel
F l�
6. A LS !bf'r3/1
i3-36
�S 10Y� s/6
36-120 C K-GS 2.5Y`4 `
DEEP OBSERVATION HOLE.LOG Hole# Z
Depth from Soil Horizon Soil Texture Soil Color
Surface(in.) Soil Other
(USDA) (Munsell) Mottling (Structure,Stones,Boulders.
F
Consistency,%Gravel
/vYr 31e
3�-i20 C, ; v�
;-Zi
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color
Surface(in.) Soil Other
(USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
DEEV OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,To Graveh
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No✓ Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? 25 .
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on I6-2-7 97 (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and perie�escribed in 310 CMR 15.017.
Signature v Date -�0
E AV
Q:\.SEPTIC\PERCFORM.DOC
I
a
YOU WISH TO OPEN A BUSINESS? s
For Your Information: Business certificates (cost$40.00 for 4 years . A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate, ou must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Fla][) and get the Business Certificate that is
required by law.
DATE: 6 G / Fill in please:
ti APPLICANT'S YOUR NAME/S: G
BUSINESS YOUR HOME ADDRESS: R ����� R/M r✓/I' � t
t _ p
m
TELEPHONE # Home Telephone Number
NAME OF CORPORATION: Z: �` "" Pity °1 S 5 I
NAME OF NEW BUSINESS TYPE OF BUSINESS °t l t� d OA
IS THIS A HOME OCCUPATION?=,! Y_E NO �`�r��; �c� MAp/PARCEL NUMBER 1 180 7) (Assessing]
ADDRESS OF BUSINESS C.t IYI /y1 �� S
u0 rVI t t
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main Sr._ =trgrner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this touvn.
1. BUILDING COMMISSIONER'S OFFICE
r� This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has een r 11� the permit requirements that pertain.to this type of business.
i'�Vttu HAZARDOUS MAOMPLY TERIALSITH REGUL
Authorized Signature** CATIONS
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
\ �TOWN OF BARNSTABLE Date: 6 06 I C
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: 66 QS q ',17 (�I
BUSINESS LOCATION: a Pc L. , INVENTORY
MAILING ADDRESS: a U/ 'c k of V C414v t TOTAL AMOUNT-
TELEPHONE NUMBER: 66-6aU-- a
CONTACT PERSON: _ y4Aj Rl'cs 774-36g--003cf
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION/RECOMMENDATIONS: Fire District:
Uq +P o rc r'I of -e-Gf G id, e-xc>-s' C.moM s'
Af
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers ` may be toxic or hazardous (please list):
Metal polishes 1��
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
c
• �`�''� (O
YOU WISH TO-OPEN A BUSINESS?
For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME.in town(which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town CierWs Office, I'FL,367
Main Street,Hyannis,MA 02601 (Town Hall)
DATE:
Fill in please: m
APPLICANT'S YOUR NAME: 61150.v) CO e 'Roc'
C I O S
BUSINESS YOUR HOME ADDRESS: C/C LUay
TELEPHONE # Home Telephone Number 50
NAND OF NEW BUSINESS e5' i TYPE OF BUSINESS
THIS A HOME OCCUPATION?s.YES ENO
slave you 1�`e�:n given.approval fratn.thWbuildin diirision?. YES NO /7
ADOR S91�F BUSIIV SS a r rvi I MAP%PA1ACEL NUMBER
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of thq,Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd.&Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this.town.
71
1. BUILDING CO SSIO. ER'S OFFICE
This individ al h s e infs -of y ermit requirements thft pertain to this type of business.
Authori S' e*
CON4MENT
2. BOARD OF HEALTH.
This individual has been' ormecLof the permit requirements that pertain to this type of business.
Adfhorized Signature*
COMMENTS: A-A`
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
Hazardous Materials Inventory Sheet Checklist
/ a?� Date
Physical Street Address-Check database to ensure it exists
Working Phone Number
Actual Amounts-(le.gas being used to fuel machines,thinner to
clean brushes all count as hazardous materials)
--flvt K Storage Information-location of storage,how long is storage for?
If none,note that. '
z,"' Disposal Information-where and who?If none,note that.
Applicant Signature-understand what is listed and noted
Staff Initial-any questions,know who to ask
Vehicle WashinglRinsing? -provide a vehicle washing policy and
explain it-note that it was given
Attach the Business Certificate with your sign off and comments
"The inventory form should explain what the business consists of and the procedures
y Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS. MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: Ge-he Si5 T1 ai-n I(_trq
BUSINESS LOCATION: 5� "KWi d CUO - Ce- te-ryi Ile INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER: 603- �QO- 3�o2s
CONTACT PERSON: Gi lSOy> G. `Rios
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: Pa1`Yd ,\
INFORMATION/RECOMMENDATI NS: 11C-eS tvP- 6W7 11/I6- Fire District:
Waste Transportation: Last shipment of hazardous.waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
* or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor & furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers - in-t- 1 .5 Ste- ®VA -tgue K
(including bleach) 140y;@
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
PPrication for Oigpogal *pgtem Congtruction permit
Application for a Permit to Construct( )Repair( 4pgrade( )Abandon( ) ❑Complete System 14<dividual Components
Location Address or Lot No. Ul/9 t?W/C It AvO? Owner's Name,Address and Tel.No.
C£.�T P/'L 1(-/a.<7TN S us O A
Assessor'sMap/Parcel d D 0,0AT Cif AS d �.'o S a �Wle
W o/ 7 SoP SP- /?"o-C
Insta�l1ler's Name,Address,and Tel.No. 5-4 r' S'- Z 8 v Designer's Name,Address and Tel.No.
w•f'r9�e
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)_ o Y �'F 6��,�C r p/ r 7—
A- 7--
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 Certifi-
cate of Compliance has been is ed by this Board of Hea
Signed Date e-e2 -o/
Application Approved b Dater �► f
Application Disapproved for the following reasons
Permit No. ��Sf Date Issued 15 Z
,r
Fee 6
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
21pplication for Mi,5poaf *pgtem COttgtruction J)ermit K
Application for aPermit to Construct( )Repair( ►')Upgrade( )Abandon( ) O Complete System 1416 ividual Components
Location Address or Lot No. d`''� �//q/PW C O er)Name,Address and Tel.No.
Assessor's Map/Parcel pP U (',c/,U 7 C 1-1F-JS F rr'3
In er's,N,ame,Address,and Tel.No. 0 o Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date umb(1153P sheet �� Revision Date
Title
Size of Septic Tank i Type of S.A.S.
Description of Soil ... _ '` `7 `A . � `r, `c
.Nature of Repairs or Alterations(Answer wh 7—
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 id operation until a Certifi-
cate of Compliance has been issued by this Board of Hea
Signed Date g, ,2 - a/
Application Approved by Date e—:;? 4
Application Disapproved for the following reasons
Permit No. Date Issued �
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( )Reppaired( �fJpgraded( )
Aband�ned( )by /'� /9 N C O 3 S a /ti /41/tO
at 8 � 9/'L V 4-v'9 y' C T ti T has been constructed in accordance
with the pro ' •ons of Title 5 and the for isposal System Construction P — dated
n ! .
Installer L4.9 d- - Designer
The issua c f this permit shall not be construed as a guarantee that the s t will funct n esi
Date �' :,? Inspecto
No. .�Y ./.s ' Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mfi6po.5al *p5tem Con5trUction Vermit
Permission is hereby granted to Construct( )Repair( 41Upgrade( )Abandon( )
System located at 7 6v,y/p Gv/ r A- !.v y' C �A,7'
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of e t.
Date: r Approved b 4":�A�_
1 .
Aff
t-
� � LLC\Z
�o
rA
3
4 l
In 3
Pf
44
s •�
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS /
DEPARTMENT OF ENVIRONMENTAL PROTECTION
y
V�
350 MAIN STREET
WEST YARMOUTH,MA
OWN0 508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 58 WARWICK WAY
CENTERNIMLE,MA 02632 RECEIVED
Owner's Name: FRANCIS BEKSHA
Owner's Address: 58 WARWICK WAY
CENTERVILLE,MA 02632 AUG 14 2001
Date of Inspection JULY 27,2001
Name of Inspector:(please print) JAMES D.SEARS TOWN OF BARNSTABLE
HEALTH DEPT.
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection. The inspection was
performed based on my training and experience in the proper function and maintenance of on site sewage
disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310
CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority.
Fails
Inspector's Signature: Date: �] —Ca 7-a/
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of
Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a
design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the
appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot
he buyer,if applicable,and the approving authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANCIS
Date of Inspection: DULY 27,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N.ND)in the ' for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Forni 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANCIS
Date of Inspection: JULY 27,2001
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CNM 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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well*". Method used to determine distance
This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANCIS
Date of Inspection: JULY 27,2001
D. System Failure Criteria applicable to all systems: N/A
You must indicate"_yes" or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in pit is less than 6"below invert or available volume is less than''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CUR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes" or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANCIS
Date of Inspection: JULY 27,2001
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the bates or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
X Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANCIS
Date of Inspection: JULY 27,2001
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): YES
Water meter readings,if available(last 2 years usage(gpd)): LAST WATER READING 1999 1,000 GALLONS
Sump pump(yes or no) NO
Last date of occupancy: UNKNOWN
C OMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1983 PER?MT#83-316
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANCIS
Date of Inspection: JULY 2T 2001
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: I-
Material of construction: X concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: III,
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: ASBUILT AND TAPE
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 AT WORKING LEVEL. OUTLET BAFFLE. TANK AND COVERS F BELOW GRADE.NO SIGN OF
OVERLOADING SEEN IN TANK.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 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: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANC IS
Date of Inspection: JULY 27,2001
TIGHT or HOLDING TANK: N/A (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/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
D-BOX IS CLEAN,LEVEL.NO SIGN OF OVERLOADING SEEN IN BOX.D-BOX IS 26"BELOW GRADE.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANCIS
Date of Inspection: DULY 27,2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X 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.)
ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER Y BELOW GRADE. PIT DRY,WALLS CLEAN LIKE
NEW. STAIN LINE 4"UP WALL.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
I
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANCIS
Date of Inspection: DULY 27,2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
�Fc
33—�s
5 "
3s' a0'
O
.3q_y
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 58 WARWICK WAY
CENTERVILLE,MA 02632
Owner: BEKSHA,FRANCIS
Date of Inspection: JULY 27.2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 47.2 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:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA. WELL SDW 252 AT 47.2',ZONE D 3.3',ADJUSTED 43.9'
Title 5 Inspection Form 6/15/2000 11
TOWN OF BARNSTABLE
LOCATION S"& ilk ar w t C)C u0a4 SEWAGE#
VILLAGE ASSESSOR'S MAP&[PARCEL N16 -7/
INSTALLER'S NAME&PHONE NO. _�.a f3 cam`\ i r\ A J)A W %
SEPTIC TANK CAPACITY 1000 gcx`t 1k lcD C--x t sFrN
LEACHING FACILITY.(type) IZ are 3�\(! 14 Nj (size) 1t,Sg K 30
NO.OF BEDROOMS .3
OWNER
PERMIT DATE: S 1( - 2.aGo COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility O 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 OAg/73,-s Gt�
FIl y�,g
P13 ,y
fty 14
(45 5M.0
82 ZZ•0
33�y
LOCATION SEWAGE PERMIT NO.
lot 42.Warwick Way Centerville 83-.316
;1VILLAGE
INSTA LLER'S NAME & ADDRESS
obert B. Our Co. Inc. Great Western Rd, No. Harwich,Mass. o 645
® UIL0ER OR OWNER
T.M a Gg rdon
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �� /�
(lJa cl< oft- ywk-sc-
3 l 43 -;z
3
r• TOWN OF BARNSTABLE
LOCATION W iC/(' wd Y SEWAGE #
VILLAGE. C £A-7- A 14 -: ASSESSOR'S MAP & LOT
INSTALLER'S NAME 6z PHONE NO. A & B CANCO 775-6264
_SEPTIC TANK CAPACITY 6,ON O V Coo, /L.o fw. ,4 £
LEACHING FACILITYAtype) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 05.4 /r //V ✓
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
j z Irk-
. M
r
j3z
0
No............ Finc..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
----7-7'awd...............OF.............jj�..
Aplifiration for Bhiposal Varkii Tonstrurtivit Prrutit
Application is hereby made for a Permit to Construct (X) or Repair an Individual Sewage Disposal
System at:
//U 11.1e,WL/_ C)�_el W&Y Z-0--r
.............. ............ - 4 .4;�:................
cation-Address or Lot No.
:4 --—------- ............
*- ----- ---------------------------------------- -----------*------------
..... ...�7z ...... ............................................ .................................................................................................
77
. Owner Address
0.......... ..... . ..................................................... ...............................................................................................
Installer Address
Type of Buil Size ---------- f
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage ri er
Other—Type of Building ............................ No. of persons............................ Showers Cafet is
Otherfixtures ......................................................................................................................................................
Design Flow...........45��.........:................gallons per person day. Total daily flow.............—,730......... p ...............................gallons.
9 Septic Tank—Liquid capacity&;ZP.gallons . '!�*... Width.... I .......
p Length.__.......... Width...___..._.`flow...._.._....
Diameter................ Depth.....4-1
Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No........_,.._._.... Diameter.... ....... Depth below inlet.....24t.......... Total leaching area6_e.&4..iq-.+t�PJ>
Z Other Distribution box (Y,) Dosing tank (' )
.Percolation Test Results Performed by A49-0.. .... Date....j�//
Test Pit No. ....minutes perinch Depth o�Test Pit.. . . .... Depth to ground ate ......................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.__..........._..... Depth to ground water._____..............____
P4 .................................. -------I---------------------------------------------------------------------------------------------------------------
0 Description of Soil........S5 ........ ........................................................................................................................
W
.........................................................................................................................................................................................................
........................................................................................................................................................................................................
U Nature,of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL I Ti ILj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sigp4ed........................................................................ " .............
a
.........
Application Approved B
y . ................................................................................ ....
D
.
Application Disappro2dfor the following reasons:...............................................................................................................
.............................................. ..........................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
No..t . �` � Fma....'`� ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,''E' +� r", 4 ....................... ''
. ` rAppltrtttton for DwpaiiFal Workii Tonstrurtion Prrmit
Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal
System at:
A lie 4
............... ........ ... '"'................ - � . Vi. ....................
cation- ess or Lot No.
• -- ...... . `t:�------•-•------------ ----------•-----------•----•---
•' Owner Address
Installer Address r
d Type of Buil 'ng Size Lot../tf----- -►------.-Sq. feet
V Dwelling—No. of Bedrooms...................._.._....._.._..._....,Expansion Attic ( ) Garbage Grinder ( )
a Other—Type T e of Building _..._:_........... No: of persons............................ Showers p,, yp p ,. ( ) — Cafeteria ( )
Otheri ures .-------............................................... •-•----•-••----------------------•------•-----------------•-------._.............-•.------
W Design Flow............................................gallons per person p day. Total dail flow............ ! .................galloons.
W Septic Tank—Liquid capacrtyd? d.gallons Length................ Width__. ..... Diameter................ Depth.....
_..__..
x Disposal Trench—No. .................... Width..__... i.__..._.. Total Length . .Total leaching area....................sq. ft.
Seepage Pit No........./......... Diameter Q __ Depth below inlet-...:j!'':....... Total leaching area��/r _,a@V4tf.;PJ>
Z Other Distribution box (Y.) Dosing tank ( )
'-' Percolation Test Results Performed by.......Aak ..o,� �-�- �-ter_. Date.... 'xf•t�•U d w
Test Pit No. 1.4.��.....minutes per inch Depth of Test Pit_. . �.... Depth to ground 4 ater�Q 1'_ *M
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water 6'--
D Description of Soil........ a �r ...................................................................
W ....................•--•--•-----•--•--.....•-••...--•---•........................... ...........-•--•-----.....-•-----•---•---------------•----•---• -----••-•---
x -•--•••---------------------•-•-----•------•----••-------•-----------•----- ---- ----••. •-----•-----------------------------------------------------. ............
U Nature of Repairs or Alterations Answer when applicable._............................:...................................................:.............
...----•--------------------------------------------------------------------------•--••---.......----•----...------------------------------ .......................................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITiS 5 of the State SanitaI.ry Code=The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig -•--•-•--•--••-------------•------------------------------...........-•--•------•-• ------ ------
•-----•-
ate
Application ApproveZdfol"Ohe
'":.!l,�y...=l.....................••-•-----•-------•--.............................. � ,' ..............
Date
Application Disappro following reasons:-------•--------------------••------•-------------------------•------------------------------------------.••----
..-•--•.....-•-------•--------•-•........................•--••--•--••-•••--•--••-•---•......_....•--•-••.
Date
Permit No...................... Issued---------------•----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEA I--If
(Irrttftrab of Tontpliatt r
Y `PHIS Tr I KTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
' b = '
----
... Installer
at.- ......V. .......... --------------- ----
has been installed in accordance with the proviaivhs of TIT F r'5 of The State Sanitary Code s de ribed in the
application for Disposal Works Construction t No.__. _.-...__:. dated_..g_.,_,,rr._'� f. . .........:........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE .CONSTRII ® A GUARANTEE THAT THE
SYSTEM WILL UN ION SATISFACTORY.
I..-
DATE....... ..� ....r Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.....................................................................................
No......................... FEE........................
�t o tt1, nr (gnu� frttrttott �eruttt
Permission is herebygranted........... YAe:�?:c: ..
r g 0 �....
to Construc ✓y or Repair ( ) an Individual e age D' p s ' System
at No....� ./-�.�------------------------� 1!_'?..GLt :=
s treet
as shown on the application for Disposal Works Constru ion rmit No....... ..... ...... D ted--------.--._------------------------------
•--- - ----•-----------------------•------
............. ` Boa d of Health
DATE.:_-
FORM •1255 A. M. SULKIN, INC., BOSTON
LOT 44 CENTERVILLE
CB
OLD STAGE ROAD
LOT 45
4�
LOCUS
2
�..... .. -o "tee 'Qo
tSt .... O #2 \
LOT 46 /// i ol
"Deo"x 20\\ LOCUS MAP
Cs LOT 43 LOCUS INFORMATION
'p.��� S j j� � 1 PLAN REF: 350/55
TITLE REF: 16116/090
PARCELZONING:
I RC" GP DST.148 71
TBM=50.7
BLHD IN STATE ZONE II
` FLOOD ZONE: "X"
0
�0� \ COMMUNITY PANEL: 25001CO561J DATED:07/16/14
LOT 42 - __ _-= SEPTIC SYSTEM
AREA=16,025f S.F. REPAIR PLAN
LOCATED AT:
#58 = 58 WARWICK WAY
- - _-- CEN TER VI LLE, MA.
o, 3—BEDROOMS\ =_� - -
oo, TOF=51.0 =_— — PREPARED FOR
GILSON GONZALVES RIOS
May 10, 2021
w I /
J
m
U -- \ Ci Pit H OF Af ASsq P�`,A OF k4 s
LOT 41 / \\vq 49 iP o EDWARD c s o� DAVI
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GRAPHIC SCALE G \\ �;&ova //� �P E. A. S.
SURVEY, INC.
20 0 10 20 40 so \ / [ P.O. BOX 1729
SANDWICH, MA. 02563
Q'' / CELL:(508)527-3600
/
( IN FEET ) cB /"I ' �\P EMAIL: eas.surveypyahoo.com
1 inch = 20 ft.
/
SHEET 1 OF 2 J#2253
a
PROFILE OF 2" LAYER OF
SEWAGE DISPOSAL SYSTEM 1/8" - 1/2"
1OF=51.0
DOUBLE WASHED STONE
(NOT TO SCALE) CLEAN SAND FILL PER 310 CMR 15.255 OR FILTER FABRIC
49.3 49.3 49.3 49.6 49.6
.............. -/77777777
48.52 ...................................... .................. ........ ........ ........ ......... iiiiiiii iiiiiiiii iiiiiiii i
.............. ....... ........ .......... ....... ....................................... ..............n... ....�... ....... ,,,,,,, ,,,,,RISER RISER 4" SCHEDULE 40 P.V.C. RISER RISER RISER
MIN. PITCH 1 8" PER FOOT� 46.6
16' ® S=.OB ��L
loll LIQUID LEVEL •r FOR 2' 10' ® S=.015
P47.52 MIN. 14" 47.27 6' SUMP � ® ® ® ® ® ® 0
45.92 6 BASE OF 45.75 ® ® ® ® ® ® ® ® ® ® ® 000 MECHANICALLY 5.6 t4i
® ® ® ® ® ® ® E2 ® ® ® o48" A GAS COMPACTED GRAVEL g� gm BED 120 0BAFFLE PROP. (H-20)DB3 3/4" TO 1&1 2 � 43.6
DISTRIBUTION / "
BOX W/"T" DOUBLE WASHED STONE
25'
EXISTING 2(H-20)500 GAL. �CH�AMBERS Z o
1 ,000 GALLON TANK (5 w X 8 -6 L X 3 -o H) Of
(TO REMAIN) CL
SEPTIC SYSTEM DETAIL PAGE SOIL ABSORBTION (TRENCH FORMATION)
#58 WARWICK WAY SYSTEM (S.A.S.) 13' X 25'
CEN TER VI LLE, MA. BOTTOM OF TEST PIT ELEV.= 38.1
MAY 11 , 2021
GENERAL NOTES DESIGN DATA:
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF
TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR 15.017 TO CONDUCT NUMBER OF BEDROOMS......... 3
FOR SUBSURFACE DISPOSAL OF SEWERAGE. SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED GARBAGE DISPOSAL................. NO
2. ALL ACCESS PORTS OVER TANK TEES SHALL BE BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE TOTAL ESTIMATED FLOW -
ACCESSIBLE WITHIN 6" OF FINISH GRADE. DESCRIBED IN 310 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY (110 GAL./BR./DAY X 3 BR.) __33_0___
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE SOIL EVALUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM,
CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE ARE U � TE D CORDANCE WITH 310 CMR 15.100 THROUGH 15.107. 330GPD X 200% = 660 GAL
UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEN THEY USE EXIST. 1000 GAL. TANK
MUST WITHSTAND H-20 LOADING. � � INSTALL: 2(H-20) 500GAL CHAMBERS (W/4' CRUSHED STONE
4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION
OF ALL UTILITIES PRIOR TO ANY EXCAVATION. A A. SYONE, CERTIFIED SOIL EVALUATOR ON THE SIDES AND ENDS) AND BACKFILL
5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE
OR WITHIN 6' OF GRADE SHALL BE MORTARED IN PLACE. WITH CLEAN SAND FILL PER 310 CMR 15.255
6. FINISH GRADE SHALL HAVE A MINIMUM OF 2% GRADE
OVER THE S.A.S. AND DISTRIBUTION BOX. TEST PIT #21114 RESULTS:
SOIL CLASSIFICATION................ 1
-
7. SEPTIC TANK SANITARY TEES SHALL BE CONSTRUCTED OF <2 MIN./IN.
SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE DESIGN PERCOLATION RATE.....
THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND SOIL TEST DATE: APRIL 28 2021 EFFLUENT LOADING RATE.........__74 _
LOCATED DIRECTLY UNDER THE CLEANOUT MANHOLES. REQUIRED LEACHING CAPACITY.....33_O GAfDAY
8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN B.O.H. AGENT: DON DESMARAIS LEACHING CAPACITY PROVIDED.....352 GADAY
2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT SOIL EVALUATOR: EDWARD A. STONE
ELEVATION OF THE OUTLET PIPE.9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES. SIDEWALL:(13' + 25')x2x(2 SIDES)(.74)= 112 GAL/DAY
BACKHOE: JOEY DEBARROS BOTTOM: (13' x 25')(.74)= 240 GAL/DAY
10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS
BAFFLE, 4 INCHES IN DIAMETER AND CONTRUCTED OF 4" PVC.
11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND ,r TOTAL= 352 GAL/DAY
FIRST TWO FEET OUT OF THE DISTRIBUTION BOX SHALL TH#1 E L.= 49.6 (P E R C BOTTOM @ 46 <2 M P I)
BE LEVEL. 352 GPD PROVIDED - 330 GPD REQUIRED = 22 GPD RESERVE
12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION ELEV. DEPTH (IN.) HORIZON TEXTURE COLOR MOTTLING OTHER
TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW 49.1 0"-6" A LOAMY SAND 10YR3/4 N/A
AND APPROVAL. 46.9 6"-32" B LOAMY SAND 7.5YR6/6 N/A
13. IN STATE ZONE II 38.1 32"-138" C COARSE SAND 2.5Y7/4 N/A
NO MOTTLES, NO GROUNDWATER �It" °F NgSSAc
CONSTRUCTION NOTES: TH#2 EL.= 49.6 Q. DAVID s E• /� • C.
y SURVEY, INC.
1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND i D. �.
ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING ELEV. DEPTH (IN.) HORIZON TEXTURE COLOR MOTTLING OTHER FLAHE T P.O. BOX 1729
WORK ON THE SITE.
48.9 A LOAMY SAND 10YR3/4 N/A 2 SANDWICH, MA. 02563
2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE CELL:(508)527-3600
WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 46.8 8"-34" B LOAMY SAND 7.5YR6/6 N/A SST
IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.3. ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING 38.1 34"-138" C COARSE SAND 2.5Y7/4 N/A RAF EMAIL: eas.survey@yahoo.com
TAPE OR A COMPARABLE MEANS. NO MOTTLES, NO GROUNDWATER SHEET 2 OF 2 J#2253
T.O.F. EL.= 57.5'± INISH GRADE OVER D-BOX= 55.6'± 4„SCHEDULE 40 PVC , GENERAL NOTES
PROVIDE EXTENSION RISER FINISHED GRADE OVER BIODIFFUSERS = rjQ,,$, - rjj,rj
WITH COVER OVER INLET&
REMOVABLE WATER-TIGHT COVER OVER @ MIN. SLOPE 1% SLOPE @ 2% MIN. 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION
FINISH GRADE
OUTLET TO WITHIN 6"OF F.G. RISER TO WITHIN 6"OF FINISHED GRADE INSPECTION PORT WITH ACCESS METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
@ FND. EL.= 56.0, F.G. OVER TANK EL. = rjrj,$'-I_- 5" DIA. OUTLET(S) BOX TO WITHIN 3"OF F.G. CODE AND ANY APPLICABLE LOCAL RULES.
--__ (ONE PER TRENCH)
2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
EXISTING 4" PROPOSED 4" 9" 9"MIN.
MIN.
SEWER PIPE PVC SEWER PIPE 1 j
36 MAX. 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
- �-��
36"MAX. TOP OF SAS/B.O. = 52.50' SYSTEM UNLESS OTHERWISE NOTED.
6' 3"DROP MAX 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
6" 3" 3„ g" L„_ � ��� PROVIDE WATERTIGHT
2"DROP MIN MIN.sroPe�,� JOINTS (TYP.) ELEVATION =52.50' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
4 PVC IN FROM CLEAN SAND 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
14" �._*j3,rj'± SEPTIC TANK e
C OUT TO 1EAHE =71 .33' T 16"TYPTHE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
ING FACILITY 0.90' P4Pf E�IHEE (TMP ) 10.75"TYP 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
CONTRACTOR CONTRACTOR SHALL , 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
SHALL VERIFY SIZE 48" VERIFY CONDITION OF OUTLET TEE 53.00 52.83 52.07' - 51 .17' (LAID FLAT) 2.875'(34.5")--I- 5.75' 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
AND CONDITION OF EXISTING TEES GAS BAFFLE CRUSHED STONE (TYP.)EXISTING SEPTIC AND REPLACE AS ER MECHANICALLY 5 0 FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
TANK NECESSARY COMPACTED BASE (TYP.) 5'MIN. 11.50' AND DESIGN ENGINEER.
OUTLET DISTRIBUTION BOX NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
5 30.0'(TYP FOR BOTH TRENCHES) 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 57.00' ESTABLISHED
TO BE INSTALLED ON A LEVEL STABLE ON TOP OF BULK-HEAD CORNER AS SHOWN ON PLAN.
BASE. FIRST TWO FEET OF OUTLET GROUND WATER ELEV.= < 45.40'
EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
BIODIFFUSER PROFILE BIODIFFUSER END VIEW THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
CROSS SECTION VIEW 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR
SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL 12 - ARC 36HC (#3616BD) BIODIFFUSERS TO THE DESIGN ENGINEER.
TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT.
% _ 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
(2 1� ,, • •r • ' • i TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
�C •°\ ¢0 • • w APPROPRIATE AUTHORITY.
PERC NO. 13026
• • " ; + ; ••+ • +w • INSPECTOR: David W.Stanton, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
w w
` : • � EVALUATOR: Michael Pimentel, E.I.T. LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE
(3 1) THEY SHALL WITHSTAND H-20 LOADING.
C.S.E. APPROVAL DATE: Oct. 1999
1\ II '* • i • • ' 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
j , * • , DATE: August 5, 2010
ZONE 2 "• + ' '� ! TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
4) HC-2 y • "� • • w �" MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
ELEV TOP = 55.40 11 .R� • T REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
*t1 , •• �• ` ,• ELEV WATER= <45.40' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
' + ' • • 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
w q + ', PERC RATE _ <2 min./inch SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
DEPTH OF PERC = 36"-54"
a DECK EXISTING ! J O ; 16. PROPOSED PROJECT IS LOCATED WITHIN:
Cn MAP 148 3-BEDROOM TEXTURAL CLASS: 1 ASSESSOR'S MAP 148 PARCEL 71
p HCA DWELLING �i • * OWNER OF RECORD: GILSON GONSALVES RIOS
m PARCEL 73 TOF - 57.5± i!"8 fry 1'1 • rf LO�,�U� H 0" 55.40' ADDRESS: 58 WARWICK WAY
MAP 148 CENTERVILLE, MA 02632
IL 0 1 N Fill
PARCEL 74 -__ �
"
SWING-TIES SCALE: 1"=20' / • 6 Loamy Sand 54.90'
• • 4 A " 10Yr 3/1 FEMA FLOOD ZONE C
PROP. TOTAL 12 ARC 36HC BIODIFFUSERS ,5 DESCRIPTION HCA HC-2 ` . `1 F��r Yr 1111 8 54.73 COMMUNITY PANEL# 250001 0015 C
(6 BIODIFFUSERS EACH TRENCH) BIODIFFUSER CORNER(1) 52.1' 22.2' �/ s o * B Loamy 10Yr 5/6 Sand 17. DEED REFERENCE: DEED BOOK 16116, PAGE 90
BIODIFFUSER CORNER(2) 60.6' 33.7' * 36" . 52.40' 18. PLAN REFERENCE: PLAN BOOK 350, PAGE 55
\ '' '`• � •*\ Perc =i 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION., �� \ PROPOSED DISTRIBUTION BOX BIODIFFUSER CORNER(3) 48.2' 46.3' -- � '� � 54" .."- 50.90'
PROPOSED INSPECTION PORT WITH O �a \ y�
g - _��O BIODIFFUSER CORNER(4) 36.9 38.8' 23 • 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
ACCESS BOX TO GRADE (TYP OF 2) S5 1%j ��� EXISTING LEACHING PIT TO BE PUMPED AND (. - • • * / Y FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
FILLED WITH CLEAN, COARSE SAND & ABANDONED 1 � �i � � . � � Medium-Coarse Sand FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
TP 1 2.5Y 6/6
•
as % / \ EXISTING 1,000 GALLON SEPTIC TANK TO `' ; C
•�' • '''� N (5-10%gravel)
MAP 148 c9 55.4' ko BE UTILIZED AS PART OF THIS DESIGN
PARCEL 75 � `S p � \
s` 30 % LP 6) Benchmark
'S5 'CQZik L,5 Nail Set in B.H. Comer LOCUS PLAN
i 55•
Elev. =57.00' SCALE: 1"= 1000'
•�4 o Approx. M.S.L. 120" 45.40'
0 2� No Mottling, Standing or Weeping Observed
- - -
o
o DESIGN DATA TEST PIT DATA LEGEND
56- - PERC NO. 13026
MAP 148 INSPECTOR: David W.Stanton, R.S.
( NUMBER OF BEDROOMS (DESIGN) 3
PARCEL 72 EVALUATOR: Michael Pimentel, E.I.T. 50xO EXISTING SPOT GRADE
\\ / DECK EXISTING DESIGN FLOW 110 GAUDAY/BEDROOM C.S.E.APPROVAL DATE: Oct. 1999 - - - 50 - - - EXISTING CONTOUR
TOTAL DESIGN FLOW 330 GAUDAY
\ 3-BEDROOM DATE: August 5,2010
DWELLING DESIGN FLOW X 200 % = 660 GAUDAY 50 - PROPOSED CONTOUR
TEST PIT#: 2
i
TOF = 57.5'± 1 USE EXISTING 1,000 GALLON SEPTIC TANK ELEV TOP= 55.40' E/T/C - EXISTING UNDERGROUND UTILITIES -
2 \� MAP 148 �h ~ ELEV WATER= <45.40'
PARCEL 71 / GAS -- -- EXISTING GAS LINE
p \ / / PERC RATE _
oo, �cc 16,025 S.F. t / INSTALL 12 - ARC 36HC (#3616BD) BIODIFFUSERS w w EXISTING WATER LINE
DEPTH OF PERC =
/ TEXTURAL CLASS: 1 TEST PIT LOCATION
SYSTEM CAPACITY
N, EXISTING 1 000 GALLON SEPTIC TANK 5 (TOTAL L.F.OF BIODIFFUSERS)(7.8 SF/LF)(0.74 GPD/SQ.FT.)= GPD O O O '
(60.0')(7.8 SF/LF)(0.74 GAUSQ.FT.)= 346.3 GAL. LEACHING/DAY 0" 55.40'MAP 148 1p1 / 9s �g°AO g$ ���� Fill PROPOSED 4„ SOLID SCHEDULE 40 PVC PIPE
PARCEL 70 F �� \ 'QP`�� 6" 54.90' PROPOSED DISTRIBUTION BOX
IL OF TOTALS: Loamy Sand 0
� A 8„ 10Yr 3/1 54.73'
0 PROPOSED ARC 36HC(#3616BD)BIODIFFUSER
TOTAL NUMBER OF BIODIFFUSERS: 12 Loam Sand
u �5A TOTAL NUMBER OF COUPLINGS: 0 B 10Yr 5/6
TOTAL LEACHING AREA: 468.0 SQ.FT.
~ VIP TOTAL LEACHING CAPACITY: 346.3 GAL./DAY 36" 52.40' REV. DATE BY- APP'D. DESCRIPTION
0 PROPOSED SEPTIC SYSTEM P
��.� UPGRADE
AV � PREPARED FOR:
a NOTE: Medium -Coarse Sand CAPEWIDE ENTERPRISES
C
h i EFFECTIVE LEACHING AREA OF 7.80 SF/LF OBTAINED FROM THE 2.5Y 6/6
DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER (5-10%gravel)
"MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO LOCATED AT
NOTES: ADVANCED DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003(LAST 58 WARWICK WAY
MODIFIED FEBRUARY 18, 2010). TRANSMITTAL NUMBER=W000052.
1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF CENTERVILLE, MA 02632
EACH SEPTIC SYSTEM COMPONENT. 120" 1 45.40' SCALE: 1 INCH = 20 FT. DATE: AUGUST 8, 2010
'0ow 0 10 20 40 80 FEET
No Mottling, Standing or Weeping Observed °� `"Pss� •
2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF011
THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST �ONN� PREPARED BY:
RESERVED FOR BOARD OF HEALTH USE ,$ CNUR �'"`'R� JC ENGINEERING, INC.
PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL �. v��
BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. 080� 2854 CRANBERRY HIGHWAY
EAST WAREHAM, MA 02538
3. PROPERTY IS LOCATED WITHIN A DEP APPROVED ZONE 2 AND ALSO SITE PLAN y� ` 508.273.0377
WITHIN THE ESTUARINE ZONE WATERSHED. - -1 -
SCALE: 1"=20' Drawn By: MCP Designed By:MCP l Checked By:JLC JOB No.1860
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