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HomeMy WebLinkAbout0490 MAIN STREET (CENT.) - Health 490-Main Street Centerville A=207 - 046 N SMEAD No.2-153LOR UPC 12534 smead.com • Made in USA J�tcyc T� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes at lftatiOn for Th5po5af 6p5tem Con5trurtton Verm t Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components 417 �s.Location Address or Lot No. 0 v,9'1 Y1 Owner's Name,Address,and Tel.No. c v1 it( 1 Assessor's Map/Parcel 9OZO✓O 4 C44 1�4`/ ' � 41 7 Installer's Name,Add ess,and Tel.No. to �0 9 Designer's Name,Address and Tel.No. Type of Building: �/ Dwelling No.of Bedrooms "J Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or literations(Answer wl*n applicable) �� 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt :YK ig Date Application Approved X Date Application Disapproved by:.. Date for the following reasons Permit No. —40?__ Date Issued 1 - _4 Fee - v { T'T s Entered in computer:E�COMMONWEALTH OF.MASSACHUSE ~ PUBLIC HEALTH-DIVISION 7 TOWN OF BARNSTABLE, MASSACHUSETTS Yes A . 4 Zipplication for OigpOgal *pgtem Cougtruftiou permit Application for a Permit to Construct( Repai4 Upgrade,.( ) Abandon( ❑ Complete System ❑Individual Components Location Address or Lot No. r,, /9 �� Owner's Name,Address,and Tel.No. G LE/'l lI�., r. Assessor's Map/ParcelP0 _ 7 }r e ✓O �i,Jw � 1`� -7 Y O i �� Installer's Name,Ad ress,and Tel.No. I-n4I la 8 9 Designer's Name,Address and Tel.No. S.wi . �[>�t h>SG � r if 1�0/ A i ��e r 5 So c I,,a fo.S Type of Building: / t Dwelling No.of Bedrooms ! Lot Size sq. ft. Garbage Grinder ( ) Other'' Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided _ gpd Plan Date Number of sheets Revision Date o Title " Size of Septic Tank Type of S.A.S. Description of Soil r` Nature of Repairs or Iterations Wswer wKen applicable) I k t 1/ 71414 ` Date last inspected: Agreement: V'. The undersigned agrees to ensure the construction and maintenance of tEeafbrei escribed on-site se g-disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a t"ertificate of Compliance has been issued by this Board of Heal . Q Sig ed Date ll'j, I Application Approved by t , Date "� Application Disapproved by: Date for the following reasons Permit No. ----yirr ----------- (J, w,a igd THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS certificate of Compliance THIS IS TO CERTI/F�-Y,that the O -site Sewage Disposal ,yst m Constructed ( ) Repaired (�) Upgraded ( j -� Abandoned( )by�(/ C RO t .�Cil'7 �Df C. 51 rv/Gig, atq 7p 41 r) (/-1114 has been constructed in accordance q with the provisions of Title 5 and the for Disposal System Construction Permit No. '( 7 j+/G( dated / ��X, 7. Installer V� l r C114 Designer �,��p #bedrooms 4-1 Approved dig flflow 6 (,�� gpd The issuance of this pe(r)mit hall not 10-4— e construed as a guarantee that the system will funs;on s de`gned. Date `7 Inspector --------------------------------------------- No. i9v/ /0(1 THE COMMONWEALTH OF MASSACHUSETTS CAW e PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Digpont *pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair ) Upgrade ( ) Aba don ( ) System located at 9 1q /i7 S f G y/ ✓(// b N and as described in the above Application for Disposal System Construction>Permit.,The applicant recognizes his/her duty to comply with Title 5 and ft following.local provisions or special conditions- Provided: Construction must be completed within three years of the hate of this e it., Date ( I Approved>by �' 20 - o�� - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments CPO 490 Main St. Property Address TJLC LLC Owner Owner's Name cr) information is as required for every Centerville, Ma. 02632 9/30/2016 page. Citylrown State Zip Code Date of Inspection m W 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. General Information on the computer, use only the tab 1. Inspector key to move your cursor-do not Raymond Dumas use the return Name of Inspector key., Dumas Landscape Const. �y Company Name 564 Old Stage Rd. Company Address Centerville Ma. 02632 Cityrrown State 508-778-0249 _ _ S1437 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority a, 9/30/2016 Inspecto s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-W13 TAIe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �d ,TVs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville, Ma. 02632 9/30/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or EJ always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System.Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 0 Y 0 N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'r 490 Main St. Property Address TJLC LLC Owner Owner's Name information is Centerville, Ma. 02632 9/30/2016 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (corn.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ft.3113 Tdle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 490 Main St. Property Address TJLC LLC Owner Owner's Name Irequired for every Centerville, Ma. 02632 9/30/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal c oliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ms-3/13 Tdle 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville, Ma. 02632 9/30/2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ms•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments 490 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville, Ma. 02632 9/30/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flown Conditions: Number of bedrooms(design): 4 — Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °- 490 Main St. Property Address TJLC LLC Owner Owner's Name information a required for every Centerville, Ma. 02632 9/30/2016 page. Cityffown State Zip Code Date of Inspection D. System Information Description: 1500 GALLON SEPTIC TANK, D-BOX AND 3 500 GALLON CHAMBERS Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes Z No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2015 1000 gallons 2014 137000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: 2015 Date Commercial/industrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.fL, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3y13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Main St Property Address TJLC LLC Owner Owner's Name information is required for every Centerville, Ma: 02632 9/30/2016 per_ cilylrown State Zip Code Date of Inspection D. System Information (cant.) Last date of occupancy/use: 2015 Date Other(describe below): General Information Pumping Records: Source of information: 8/28/2013 Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: 1`500 gallons How was quantity pumped determined? estimate Reason for pumping: Maintanance 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): 1500 GALLON SEPTIC TANK, D-BOX,AND 3 500 GALLON CHAMBERS AS PER PLAN ON FILE AT B.O.HEALTH t5h s W13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments 490 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville, Ma. 02632 9/30/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) Approximate age of all components, date installed(if known)and source of information: INSTALLED 2007 AS PER PLAN ON RECORD Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: 22 INCHES BELOW TOP OF FOUNDATION Material of construction: ®cast iron ®40 PVC CAST IRON IN BASEMENT TO other(explain): PVC OUTSIDE Distance from private water supply well or suction line: TOWN WATER CONIES IN ONRIGHT SIDE BEHIND BULK HEAD Comments(on condition of joints, venting, evidence of leakage, etc.): 2 cast iron pipes exit foundation walls, one at left side of house(south side)and one at back side(west side)and all joint together outside and go to septic tank and were inspected with a camera Septic Tank(locate on site plan): Depth below grade: 12 INCHES BELOW GRADE WITH RISERS 6 INCHES BELOW Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ats-3r13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of'Massachusetts Title 5 Official Inspection Form -Subsurface Sewage Disposal System-Form - Not for Voluntary Assessments -490 Main St. Property Address TJLC LLC Owner Owner's Name information is Centerville, Ma. 02632 9130/2016 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (coat.) Septic Tank(cant.) Distance from top of sludge to bottom of outlet tee or baffle all water Scum thickness none Distance from top of scum to top of outlet tee or baffle none Distance from bottom of scum to bottom of outlet tee or baffle none How were dimensions determined? dipstick ruler Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): not needed Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal n 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 t5ms.3113 - Title 5 Official InspeChon Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 -Offic-ial Inspection -Form -Subsurface Sewage-Disposal System-Form -Not for Voluntary Assessments -490-Main St. Property Address TJLC LLC Owner Owners Name on s required for every Centerville, Ma. 02632 9/30/2016 required page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PVC TEES LOOK OK Tight or Holding Tank(tank must-be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal 0-fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day A 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 t5hs•3113 Idle 5 Official inspection Form:SLAnufam Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments .490 Main St. Property Address TJLC LLC Owner Owner's Name information is required for every Centerville, "Ma. 02632 9/30/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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 24 INCHES BELOW GRADE LEVEL AND NO CARRYOVER AND WATER LEVEL AT LEVEL Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition-of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located,explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection Form .Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -490 Main St. Property Address TJLC LLC Owner Owner's Name information is Centerville, Ma. 02632 9/30/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: ® leaching chambers number. 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative--system `Type/name of technology: Precast Comments(note condition of-soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): All good 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 tW%s•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form -Subsurface-Sewage-Disposal System-Form -Not for-Voluntary Assessments -490 Main St. Property Address TJLC LLC Owner Owners Name information is required for every Centerville, Ma. 02632 9/30/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): all good Privy (locate on-site plan): Materials of construction: Dimensions Depth of solids Comments(note-condition-of soil, signs of hydraulic failure,Ievel of ponding,condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official tn. spection Form Subsurface.Sewage Disposal System-Form -Plot-for Voluntary Assessments -49.0 Main St. Properly Address TJLC LLC Owner Owner's Name Information is required for every Centerville, Ma. 02632 9/30/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (covet.) 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 t5irts•31`13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -490 Main St. Properly Address TJLC LLC Owner Owner's Name information is required for every Centerville Ma. 02632 9/30/2016 page- Cityfrown State Zip Code Date of Inspection D. System Information (coat.) Site Exam: Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high-groundwater: Greater than 11 ft 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: 8/30/2007 Date 11 Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board,of Health-:explain: As per plan at Board of-Health ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Records at Board of Health shows no water at 132 inches wick is 5 ft below bottom of(each chambers as per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Assessing As-Btult Cards http:l/www.townofbamstable.ustAsseWngfHMdisplayasp?mappar.. TOR7V OF BAMSTABLE LOCATION ,l AAA ST. SEWAGE# U 7- tQD VILLAGE Lc yt 8y1 CC E ASSESSOR'S MAP&PARCEL o%b7•q,6 INSTALLERS NAME dt PHONE NO.twn,E_te6,.c.__ QAb! Sr,.wrr 2F7W$ h SEPTIC TONIC CAPACITY 1--,-bp bG1/d,s LEACHING FAcum:(type) 3 X Sdd pry.,rllS (size)dX 13 X-W _ NO.OF BEDROOMS 4 OWNER C. f PERMIT DATE: 9 h:2/&7 COMPLIANCE DATE: 9/r3�o7 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 of within 200 feet of leaching facility) — Feet Edge of Wetland and Leaching Facility(If any wetlands exist _ within 300 feet of leaching facility) FURNISLEDBY DesoSti P/ d,tyd T-30-07 f ANK -I: �3'tr'• A flu A--):. 33' `A t3•�= Lq� t p $'3_ 40 s�roN& M6 = AV 1 Of 1 9/24/16 2:31 PM f f' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, I ; use only the tab 1. Inspector: key to move your _ 4 cursor-do not David J Burnie Sr use the return Name of Inspector key. David J Burnie Management Inc my Company Name 3 Perry's Way Company Address E. Harwich MA 02645 Cityrrown State Zip Code 1-866-980-1440 S1386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 771 ' 5/7/11 s ctor's Sign topf Date The system inspector shall submit a copy of this inspection report to the Appro ing Autho ty(Bo:�rd of Health or DEP)within 30 days of completing this inspection. If the system is shared Vystem-ar has a design flow of 10,000 gpd or greater, the inspector and the system owne6shall subr'�i jt the-n, report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I Commonwealth of Massachusetts Elm Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was found in good working order at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): S ❑ 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 ElY ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: " This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 490 Main St Property Address George Campbell Owner Owner's Name information is Centerville MA 02632 5/7/11 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ❑ ® Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ❑ ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): SAS@ 459.9gpd 1 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(if yes separate inspection.required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage 10-236gpd 9 ( Y 9 (9Pd))� 09-288gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current DatCommercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: bate Other(describe below): General Information Pumping Records: Source of information: Owner-system has not been pumped Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2007 per plan on file at Barnstable BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'10"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): We ran a sewer camera up the line and it was ok. Septic Tank(locate on site plan): 5" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gal 6„ Sludge depth: Commonwealth of Massachusetts NEI Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2+ 3,' Scum thickness Distance from top of scum to top of outlet tee or baffle 4"+ Distance from bottom of scum to bottom of outlet tee or baffle 10 + How were dimensions determined? estimated I ii n r r ri Comments(on pumping recommendations, inlet and outlet tee or baffle cond t o , st uctu alin teg ty, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: • ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: .gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owners Name information is required for every Centerville MA 02632 5/7/11 page. Cdy/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): The box was found in good condition and the cover is 2T' deep. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-Diffusors ❑ 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.): The SAS had 1"of standing water in it. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7111 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � o C] I ' A , 33 ' D 19 q0 Commonwealth of Massachusetts Form Title 5 Official Inspection F o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 11'+ per plan dated 2007 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: Test hole dated 8/28/07Date ❑ 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: MIW-29 Zone B 2-3 Water Level 7.1 1.4x12= 1'5" adjustment You must describe how you established the high ground water elevation: Test hole dated 8/28/07 shows no water to 132". The bottom of the SAS is at 72". This allows for a 5' seperation per the plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Main St Property Address George Campbell Owner Owner's Name information is required for every Centerville MA 02632 5/7/11 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file - P T4` = 1`II • teIIAEML _ 200 MWM-ftwt,IH S,MA OMI Office: 508-862.4644 Fax: 508-790-6304 hulailer a AgigLaer-Cerfficadon Perm Date: �"�5ewage-PeiMAW G3_� ✓qd Assessor's r4w)Parc4 Designer: td�ller AAssociates der: inTm E Robinson Sr Septic :::Address: PO Box 417 -Address. -PO , Box 1089.. Centerville Centerville Wm:-E.-Robinson•-s-r- Sept icwas dapemi#to.mstaila {date} �). septic-systernsl..:. 490-.-Main Street... Centerville based. adesigudrawn-by We . -er..& Associates: dated :08-30-07.. . (desjVnw)_-. :I-certify that the s�tic.: .refe ced above was installed'substa ulially:according to -design, wbich may_=in+chede-mmor ved.6aj%es:sisch.as-lateral-rel;occation of : 'disin`bution"box I certify-ffiat the septic refer.above.was--mstaled..with'•majoi-Cll&ges-(ie. - greaten than:TO' larval relocation of the SEAS or any vertical relocation of any component,- : ---. - .e. _ ... .. certified-as-built.by desipier to fDHO OF DANIEI.E. �. BRAAAI�N CIVIL q (Installet'S Si$nallue) No.32686C AL (Designer's Signature) (_ err's Stamp Here) PLEASE.:.R URN:-T0 MLIC-'MRAL1rH -D1 SiON.- -CERTIFICATE OF COMPLL&NCE VOLL_NOT--BE-_lSSUKD IIi�1TIL BOT$ iiORNi AAII3 AS-BUILT CARD ARE RICCl n-BY THE BARNSTABLE PUBLIC EMALTH nMISON TSANK*OU �:1Eiea ilSeptiicJDesigaer Ctitfcafiomfwm3-26-04.doc ToWnbfBarnstable of �. Re_ a o . Se ees . _.-. =- Thomas F-tse�Ter -Director ion fluna M61[kan -Director 200 Main Street;.Ryaniei%MA O?.I Office: 508-8624644 Fax: 508-790-6304. - Ins# er&Designer Certffication Form Date: ✓l�b��`�p�Sewage PeriaAt# a. Assessor's MapWareel Designer: Weller & Associates Iuser: Wm E Robinson Sr Septic Address; PO Box 417 Address: PO Box 1089. Centerville Centerville - 9Wm. E- Robinson Sr Sept iccwas_=ueda permit to-install a (date).- (installer). - - septic systemat--.-. 490 .Main Street, .Cen.terville based on adesigadrawuby (address) WeWEer & Associates:-- dated -- 08-30-07-- (designer)_. i certify that the septic-: tem-refereri d above was iustalled snbstaantially according to ttie design, which may include.mmor--_approved.cha3iges such-as lateral-relocation of the distributiou.box and/or.-septic tank.. . I certify thatthe septic system refer-above-was--installed with-major changes {i.e. .. _ greater than:l0' lateral relocation of the SAS or any vertical relocation of any component of the septic s tetiij" in-accord ce witli State&Local llegulations: --Plan revision or certified.as.built.by designer to follow. - of o� DANIEL E.BRAKAN _,� !%�l.k J D ,ter✓. CIVIL (Installer s Signa#arej No. 32686C Gig AL (Designer's SiVnattare) (AMC Designer's Stamp Here) PLEASE:-. RETURN:.TO-.::BARNSTABLE -PUBLIC 'HEALTH CERTMCATE OF COW2LUNCE W LL.NOT-BE TSSUKD UNTEL BOTH THIS FORK AND AS-BUELT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISTON.-THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04-doc TOWN OF BARNSTABLE ---7N LOCATION MAI j -r-"l' SEWAGE# D 7- L/0a VILLAGE GenReQv)CCE ASSESSOR'S MAP&PARCEL a67° Y6 INSTALLERS NAME&PHONE NO. yM,E. �o6rs��e sc4b, 5u✓ut Sbfi'a7S S7>6 SEPTIC TANK CAPACITY /-SW LEACHING FACILITY:(type) 3 X Aro-tus (size) 01X/3 X.7y NO.OF BEDROOMS L/ OWNER PERMIT DATE: ��0/T� COMPLIANCE DATE: 9/13/a 7 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) "1 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Qcsie, A- d,,h- d 7-30-0 7 I ANK A-( = 3-3= Ll a�P �17 ,o N . DESI DATA � N GN DAILY FLOW: ( BEDROOMS x 110 GPD = "o GPD PIPE TO BE LAID LEVEL FOR SEPTIC TANK:�X4>GPD x 200% '��' GPD Ek� 2' OUT OF DISTRIBUTION BOX USE: GALLON PRECA5T 5EPTIC TANK DISTRIBUTION BOX. 4" 5GH 40 PVC PIPE 2" LAYER OF 3/8" FffA5TONE OVER USE: D13-6 T.O.F. @ 3/4" - 1 1/2" DOUBLE WA5HED STONE Q 501E A1350RPTION SYSTEM: < b TOP @ EL. �� USE: Co) sx�S', �°h' ��` $., EL. ..rro. ✓ :2'1 - G....� A 101. 23" /�. SO"O'Y .Gw ey'`,iJti'-G.-C,..^d' 1 _ ��/ ""7' r`/.." - ! t°.-'..^°✓G-:. O ..'h Y. � � _ BOTTOM @ EL. y'w;',� c.. INSTALL 6A5 BAFFLE IN OUTLET TEE—� T e:5 7 tl/ ? CAPACITY: � Lu � C �q ;✓(i°Jo 51DIfWALL AREA: . .�X G.-, >c' / BOTTOM AREA: �3' X 3:F,-7 'Xv.25"/ 3 G Z a Q BOTTOM TH #3 @ EL. ' Alo 5 E F'T 1 C 5Y5T E M F RO E I L - DEEP OBSERVATION HOLE LOGS DATE: ✓ TEST BY: Y! - 1�r WITNESS: kPERC RATE: -� ��-�i.✓,fiticy-�/ I DEEP OF35ERVATION HOLE #I EL. DEPI't1 501L 501L 501L COLOR 501L 7 FROm HORIZON TEXTURE OTHER ; SURFh,CE (MUNSELL) MOTTLING � GENERAL NOTES r 27 de 05 h�. - ._..... "^G! r ✓w. �JZ /� ✓'°I :I >J�4.re/'� � I f �%�YG'3`G. {o�fJ` ' w 1 �C-ON T RACTOR -v "vE RESPON5;RLE FOR SHE LOCCA PON ..� I i s OF ALL UTILITIES, ABOVE * UNDERGROUND, PRIOR TO iI ANY EXCAVATION OR CON5TRUCTION. 1 2. SEPTIC SYSTEM 15 TO BE INSTALLED IN COMPLIANCE M DEEP 055ERVATION HOLE #2 EL. , Y wITH 3 10 CMR. 1 5.00: TITLE V. 3. TH15 PLAN 15 NOT TO BE USED FOR PROPERTY LINE Rom 501L 501L 501L COLOR 501L FUM HORIZON TEXTURE OTHER 5 U R.FACE i DETERMINATION. (/MUNSELL) MOTTLING 4. ALL DISTURBED AREAS ARE TO BE LOAMED � SEEDED. 5. CONTRACTOR TO PROVIDE 48 HOUR NOTICE FOR ANY 1 REQUIRED INSPECTIONS*. Cam" I G. TN15 SYSTEM 15 NOT DESIGNED FOR THE U5E OF A y GARBAGE D15PO5AL1 DEEP OE55ERVATION HOLE #3 EL. 5E>, a " DEPTH SOIL 501L 501L COLOR 501L r HORIZON TEXTURE (MUNSELL) MOTTLING ER ; FROM TH SURFACE I r 1 _ DEEP 0135EKVATION HOLE #4 EL. DEPTH EPTH ROM SOIL 501L 501L COLOi 501L OTHER SURFACE HORIZON TEXTURE (MUNSELL) MOTTLING I 99 V a 1--- a --� -. . ,��t,r mac.••;.�:;:�..=i _ ' 4.+'re-/L.l -r"e'/'G3G✓w r✓_ • s.+t^" ' �,i /Y ,�' °a.-, � -.,. .'�°'° � r T. r, ^". ` '"""'` 517E - 5EWAGE PLAN F OR Y I PREPARED FOR i a t 1 SCALE: DATE: DRAWN BY: E } sT vEr�w. c .r JOB NUMBER: REVISION: 5f1EET NUMBER: ,. 3cn 5B 1 v, J � 81 6 GIST;—C � �� JOWAI � � WELLER A550CIATE5 ` -01 1 G45 FALMOUTH KD., SUITE 4C P.O. BOX 4 1 7 CENTERVILLE, MA 02G32 2 Wllv� I \Iv/'.I , #232 NANTUCrf , ;,AIA 02504 TEL.: (508) 775-0735 FAX: (506) 775-0754 p EMAIL: trl5weller@�OMC05t.net PROFESSIONAL ENGINEERS LAND SURVEYORS f 7 t _