HomeMy WebLinkAbout0200 OAK STREET (CENT./W.BARN) - Health 200 Oak Street
Centerville
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UPC 10259
No. H_1630R
NASTINOY. UN
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
David B.Mason,R.S,Certified Title V Inspector,508-833-2177
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 200 Oak Street,Centerville,MA �
Owner's: Taber
Owner's Address: 200 Oak Street,Centerville,MA
Date of Inspection: March 20,2009
Name of Inspector: (please print)David B. Mason
Company Name:—N.A.
Mailing Address:4 Glacier Path
East Sandwich,MA 02537
Telephone Number: 508-833-2177
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 Signat Date: c3 Z�
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments: System as inspected is operational. Increase in occupancy may result in failure.The
information as identified represents only the condition of the system on March 20,2009 at 3:30 PM and the
inspection is not an indication of the future operation of the system.
****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.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 page 1 L4 �31 D(I
I
Page`2 of I 1
PART A
CERTIFICATION (continued)
Property Address: 200 Oak Street,Centerville,MA
Owner's: Taber
Date of Inspection: March 20,2009
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:
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 ears old* or the septic tank whether metal or not is structurally. Y P ( ) ucturally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
COMPLETED) distribution box is leveled or replaced (THIS IS REQUIRED TO BE
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:
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 2
Page'3 of 11
PART A
CERTIFICATION(continued)
Property Address: 200 Oak Street,Centerville,MA
Owner's: Taber
Date of Inspection: March 20,2009
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
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 I of a public water supply.
- p
— 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 3
Page 4 of l l
PART A
CERTIFICATION(continued)
Property Address: 200 Oak Street,Centerville,MA
Owner's: Taber
Date of Inspection: March 20,2009
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds '
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
_NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 4
i
Pagd 5 of 11
PART B
CHECKLIST
Property Address: 200 Oak Street,Centerville,MA
Owner's: Taber
Date of Inspection: March 20,2009
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 baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
_X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
_X_ _ Existing information.For example,a plan at the Board of Health.
_X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302(3)(b))
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 5
I
Page 6 of 11
PART C
SYSTEM INFORMATION
Property Address: 200 Oak Street,Centerville,MA
Owner's: Taber
Date of Inspection: March 20,2009
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): (per assessors records)Number of bedrooms(actual): septic design
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): (440 gpd capacity)
Number of current residents:_2_
Does residence have.a garbage grinder(yes or no):NO(Not Allowed)
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Per owner
Laundry system inspected(yes or no):NA
Seasonal use: (yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)):07; 164,000 gpd,08; 89,000 gpd
Sump pump(yes or no):No
Last date of occupancy:current
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
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:
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: System pumped moments after inspection due to the need for maintenance 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 a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):no
I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 6
Page 7 of 1 I
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Oak Street,Centerville,MA
Owner's:Taber
Date of Inspection: March 20,2009
BUILDING SEWER(locate on site plan)
Depth below grade:Approximate;24 Inches
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:_NA
Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident
leakage.
SEPTIC TANK: N.A.(locate on site plan)
Depth below grade: 12 inches
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: Typical 1500 gallon tank
Sludge depth: II"
Distance from top of sludge to bottom of outlet tee or baffle: 14"
Scum thickness: 10 inches
Distance from top of scum to top of outlet tee or baffle: 15"
Distance from bottom of scum to bottom of outlet tee or baffle: 12.5"
How were dimensions determined: Actual measurements with tape and scour stick.
Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.) PVC inlet tee in good condition,PVC outlet tee in good
condition,Effluent level with outlet pipe. In need of Maintenance Pumping. No evident structural issues.
GREASE TRAP: 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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 7
i
Page 8 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Oak Street,Centerville,MA
Owner's: Taber
Date of Inspection: March 20,2009
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:_(if present must be opened)(locate on site plan)
Depth of liquid level even with outlet invert: liquid level even with outlet pipe inverts
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):Box is 24 inches below grade. Flow levelers are on outlet pipes. Indication of scum
carryover. No staining in dbox indicating effluent above outlet pipe inverts.
PUMP CHAMBER:,(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 8
i
Page 9 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Oak Street,Centerville,MA
Owner's: Taber
Date of Inspection: March 20,2009
SOIL ABSORPTION SYSTEM (SAS):_X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
_leaching pits,number
_leaching chambers,number:
X _leaching galleries,number: 8
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,
etch 8 plastic chamber units without inspection port. Probed leaching area with no indication of dampness. No
excessive vegetation growth,no ponding indicated.
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 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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 9
Page'10 of 1 I
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Oak Street,Centerville,MA
Owner's: Taber
Date of Inspection: March 20,2009
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.
AC 20'
aWzBC 26'
A o .e.D30'
BD 31.5'
F-i F`]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 5 Inspection Form 6/15/2000 10
f
'Page'I I of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Oak Street,Centerville,MA
Owner's: Taber
Date of Inspection: March 20,2009
SITE EXAM
Slope
Surface water
Check cellar (crawl space)
Shallow wells
Estimated depth to ground water_20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X_Obtained from system design plans on record-If checked,date of design plan reviewed:
_X_Observed site(abutting property/observation hole within 150 feet of SAS)
_X_Checked with local Board of Health-explain:Recent Test Holes, Existing_engineer records with BOH
X_Checked with local excavators installers- attach documentation)_ ( ocu entation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting
site topography. Groundwater Contour Map.
Title 5 Inspection Form 6/15/2000 11
P-5
NO. THE COMMONWEALTH OF MASSACHUSETTS FEE PO
_ BOARD OF HEALTH
fOu/y! OF
�I PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (� Repair ( ) Upgrade ( ) Abandon ( ) - [:]Complete System ❑Individual Components
Loca � Owner's Name
/�3 tion
Map/ X reel# 7,7 Address
7:2,9 .
Lot It Telephone#
Installer's Name CAesigner's
dress /Z 5! �%/ ess
(� ✓7 Telephone N V Telephone#
Type of Building: A/e6 � -- Lot Size -3 "Z-,sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min. required) 3 gpd Calculated design flow 3"17.P gpd Design flow rovided gpd
Plan: Date S- -7 d Number of sheets Revision Date 8 -�u-le
Title -f-SE w.o e,� a D or- /v r 'i 04-X-- 1:37YL- re_ "
Description of Soil(s) P�n�Qe•
Soil Evaluator Form No. Name of Soil Evaluator 0/d,(e Date of Evaluation -7
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 a4eagrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date O V
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. THE COMMONWEALTH OF MASSACHUSETTS FEEL/
2C"-" 5k,1, A BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( )
by: // //
at G-O tz S� � m4
has been installed in accordance with the provisions of 319 CMIZ 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. 9� 7h dated � ��/ Approved Design Flow 3, -� (gpd)
Installer
Designer: Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
-----------------------------------------------------------------------
No. w THE COMM WEALTH OF MASSACHUSETTS FEE
llev��Ir,_BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby ran d Constr c. air, U A a 7 ( ) an individual sewage
disposal system at ' as described
in the application for Disposal System Construction Permit No. 9('S n dated
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
Date Board of Health '
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON
No. V/ THEwCO 'MONWEALTH OF MASSACHUSETTS
= BOAR D .•OF' /H,E/ALTH
00
O PPLICATION-FOR+DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for.a-Permit to:Construct ( Repair ( ) Upgrade ( ) Abandon O - ❑Complete System ❑Individual Components
Local '�T 0 ner's.Name ion
' Map/Parcel# ' Address
Lot# Telephone#
` t Installer's Name esigner's
1 , ,
SUS F33-I ,tress �J,Addytss
Telephone# Telephone# �`
- liy=pe of Building: kGi/dG� ' s Lot Size 't 3Sq.feet
'Dwelling—No.of Bedrooms ^"" Garbage Grinder ( ')
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
j Other fixtures
Design Flow min.required) d Calculated design flow �/ 2.� d Design flow rovided �l' S� d
g ( q ) gP g gp g 8 .it gp
Plan: Date '13. -7- `(� Number of sheets Revision Date
«: Title ITE -r SE w a�c C 0�.t-,� _, D G �v i i O S 17Z c' i" G En .2.✓✓K^"'^�_
,, • Description.of'Soil(s)
.!Sbil+Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu a agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
' Signed �. SDa 'C,�'
.frspeetiom m
f'
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
_ ! 1
t
No. / THE COMMONWEALTH OF MASSACHUSETTS FEE
/ 011544, 4 BOARD- OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ",SF]-Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( )
by:
has been installed in accordance with the provisions of 319 CMV, 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated 2 Approved Design Flow 3�� (gpd)
Installer
Designer: Inspector Date a w�
The o issuance f this certificate shall not be construed as a guarantee that the system will function as,designed.
ti. r.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. �'h/ THE COMMONWEALTH OF MASSACHUSETTS FEE
MO&A BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby rant d Construct ( air U !! )cAb n ( ) an individual sewage
disposal systerq�at V . i� as described
in the application for Disposal System Construction Permit No. 5 ` dated��
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN'" PUBLISHERS- BOSTON
8
TOWN OF BARNSTABLE
LOCATION
L o"C �. C.a,4 i� SEWAGE #
VILLAGE C'� us ��� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. R
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 'Ff (size)
No.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wedand and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
6e- r -d
b� TOWN OF BARNSTABLE
LOCATION LoT SEWAGE ti ?Ty(o
VILLAGE C c-y17-cA v► ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. -e-iJ► Lc`CA U d co/ix-r--
SEPnC TANK CAPACITY
LEACHING FAClLrrY: (type) Tri-y d. . (size)
NO.OF BEDROOMS c./
BUILDER OR OWNER ty"t"W-240. C aA p
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�..5 Cl>
+ e,
1
,Sf -^)•b
,e
SEPTIC PROFILE TEST HOLE LOGS
T.O.F. AT EL. 6 4.5' NOT TO SCALE)
ACCESS COVER TO WITHIN 6" OF FIN. GRADE (
t. ACCESS COVER (WATERTIGHT) TO ENGINEER: WP OLDHAM ASSOC.
6" WITHIN 6" OF FIN. GRADE JERRY DUNNING y
63.5 MINIMUM .75' OF COVER OVER PRECAST /� 2% SLOPE REQUIRED OVER SYSTEM 6f'.S WITNESS: I
� 4
DATE: 7/25/88 wC/o
RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE
61.90' FOR FIRST 2' < 5 MIN. PER INCH
_lk
PROPOSED 1500 3' �,�AX. PERC. RATE _
r , I 7014 ow
61.67' GALLON SEPTIC 61.42 61.5 CLASS SOILS P# / p
1
TANK (H- 10 ) GAS61.24' b
BAFFLE 61.41' IS
�
0 1.0' (7) HIGH CAPACITY o 3 AT SIDES
(2 % SLOPE) �6" CRUSHED STONE OR MECHANICAL INFILTRATORS ELEV. ELEV. p
COMPACTION. (15,221 (21) oo��o 00 60.1' O„ 64.7' �" 64.2' p
DEPTH OF FLOW = 4 ( 1 % SLOPE) ( 1 % SLOPE)
TEE SIZES: 10„ 3/4" TO 1 1/2" DOUBLE WASHED STONE
INLET DEPTH TOPSOIL TOPSOIL
OUTLET DEPTH =
14 _ 12" 63.7' 12" LOCATION MAP SCALE 1 " _ �ryT.S.
FOUNDATION- 11' SEPTIC TANK 2' D' BOX 26' LEACHING CLAY CLAY ASSESSORS MAP 173 PARCEL 90
FACILITY 6.58'
42" 61.2' 42" 60.7' ZONING DISTRICT: RF
2g'44 YARD SETBACKS:
F/M F/M FRONT = 30'
8a�O
SAND SAND SIDE = 15'
108" 59.2' 108" REAR = 15'
BVW #4 ADJ. WATER ELEV. 53.5' PLAN REF. - 392/49
EDGE OF WETLAND 1988 ADJUSTMENT CALCS MED. SAND FLOOD ZONE: C
I I WELL SDW 253 MED. SAND
h I BVW #3 ZONE: B AND AND
-� ADJ.: 3.3' STONE
1998 ADJUSTMENT CALCS STONE
BVW #2 WELL_: SDW 252 135.5" ad• water 53.5' 135.5" ad, water 53.0'
BVW #1 ZONE:_: B
ADJ. 2.4'
/ / I 174" obs. water 50.2' 174" obs. water 49.7
NOTES:
i I ,
'`0� SEPTIC DESIGN: (GARBAGE DISPOSER Is NOT ALLOWED ) 1. DATUM IS ASSUMED
/ b AVAILABLE
IF UNSUITABLE SOILS ARE ENCOUNTERED YV
DESIGN FLOW: _ BEDROOMS ( i 1 u GPD) _ d:,O GPU 2. MUIVII�If HL H IT. 1 .)
o
LOT 2 I IN AREA OF SEPTIC SYSTEM, REMOVE FOR USE A 330 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
43,782 sq.ft. / / �� �-� 5' AROUND PERIMETER OF SYSTEM DOWN SEPTIC TANK: 330 GPD (2) = 660 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10
/ 1.01 Acres / / i / TO SUITABLE SOIL LAYER. REPLACE WITH 5. PIPE JOINTS TO BE MADE WATERTIGHT.
/ / �� I o S CLEAN MED. SAND USE A 1500 GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
I , / LEACHING: ENVIRONMENTAL CODE TITLE V.
7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
[7(6.25) + 2' + 1'1 x [3' + 3' +3' +1'1 = 467.5 SF USED FOR LOT LINE STAKING.
467.5 (.75) = 350.6 GPD 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
k SILt FENCE_ �� `6Q_ TOTAL: 467.5 S F 350.6 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
LIMIT - . _ - INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
LINE _ \ _ _ USE (7) HIGH CAPACITY INFILTRATORS WITH 3 OF STONE FROM BOARD OF HEALTH.
AT SIDES AND 1' OF STONE AT ENDS
10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE
--� \ \62- - LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR
/ -6 TO COMMENCEMENT OF WORK.
LEGEND SITE AND SEWAGE PLAN
1 100.0 PROPOSED SPOT ELEVATION OF LOT 2 OAK STREET
10ox0 EXISTING SPOT ELEVATION IN THE TOWN OF:
ro
TH2 100 PROPOSED CONTOUR (CENTERVILLE) BARNSTABLE
21 - - 100 - - EXISTING CONTOUR PREPARED FOR: MARKWOOD CORPORATION
W
TH 1
30 0 30 60 90
/ �S BOARD OF HEALTH
�Nz APPROVED DATE MA SCALE: 1 = 30 DATE: AUGUST 7, 1998
/
J / off 508-362-4541
l / fox 508 362-9880
�0N OF
OF
6goa down cape engineering, Inc. o���`tARNEti� � ''RNEH•`�4��
H. wAtA
gERM m BENCHMARK - TOP CIVIL ENGINEERS 3 OA
OF CONC. BOUND $ No.2 a oe
EpF� TREE EL. = 66.1 (ASSMD) LAND SURVEYORS /7 9�
63 S A N l zzf
St tI - --
98--261 OAK 939 main st. yarmouth, ma 02675 A H. OJA LA, ., P.L.S. DATE
T.O.F. AT EL. 64.5' SEPTIC PROFILE TEST HOLE LOGS
ACCESS COVER TO WITHIN 6" OF FIN. GRAD; (NOT TO SCALE) WP OLDHAM ASSOC.
ACCESS COVER (WATERTIGHT) TO ENGINEER:
' 0 WITHIN 6" of FIN. GRADE JERRY DUNNING �,.
63.5, MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 64.5' WITNESS: I
7/25/88 s
RUN PIPE LEVEL 2' DOUBLE WASHED PEASTONE DATE. tr0
\61�.9 FOR FIRST 2' PERC. RATE _ < 5 MIN. PER INCH
PROPZL7
3 MAX.
GAL 61.42' 6 i.5' CLASS I SOILS P# 7014 b
61.67 TANK GAS 4'
' BAFFLE 61.41 �� 61.2
2 1 0' (7) HIGH CAPACITY 3' AT SIDES O
7
( 7. SLOPE) �6" CRUSHED STONE OR MECHANICAL INFILTRATORS ELEV. ELEV.
COMPACTION. (15.221 (21) $� 0 60.1' EP 4
DEPTH OF FLOW = 4' 1 �
( 1 % SLOPE) ( % SLOPE) 0" 64 7' 0" 64.2
TEE SIZES: loll 3/4" TO 1 1/2" DOUBLE WASHED STONE
INLET DEPTH = TOPSOIL TOPSOIL
OUTLET DEPTH -
14 12" 63.7' 12" LOCATION MAP SCALE 1
FOUNDATION- 11' SEPTIC TANK 2 D' BOX 26' LEACHING CLAY CLAY ASSESSORS MAP 173 PARCEL 90
FACILITY 2g. 6.58'
42" 61.2' 42" 60.7' ZONING DISTRICT: RF
4¢.
YARD SETBACKS:
8a pp F/M F/M FRONT = 30'
SAND SAND SIDE = 15'
BVW #4 -
108" 59.2' 108" REAR = 15'
ADJ. WATER ELEV. 53.5' PLAN REF. 392/49
EDGE OF WETLAND 1988 AD USTMENT CALCS ME D. SAND FLOOD ZONE: C
I
WELL; SDW 253 MED. SAND
h BVW #3 ZONE: B AND AND
I ADJ.: 3.3' STONE
U' 1� BVW #2 1998 AD,"USTMENT CALCS STONE
WLEL,_. SDW 252 135.5" ad•. water 53.5' 135.5" ad. water 53.0'
BVW #1 ZONE: B
�`° `+ _�_ ADJ.: 2.4'
174" obs. water 50.2' 174" obs. water 49.7'
NOTES:
/ ro
SEPTIC DESIGN: (GARBAGE DISPOSER Is NOT ALLOWED ) 1 . DATUM IS ASSUMED
3 110 _ AVAILABLE
IF UNSUITABLE SCILS ARE !="dCOUNTER4� DESIGN FLOW: BEDROOMS ( GPD) - 3�Q-GPD 2. MUNICIPAL WATER IS
/ LOT Z / % IN AREA OF SEPTIC SYSTEM, REMOVE'FOR USE A ��u GPD DESIGN FLOW 3. MINIMUM NINE PI I CH f0 BE 1/8" PER FOOT.
43,782 sq.ft. / / / / `sue 5' AROUND PERIMETER OF SYSTEM DOWN SEPTIC TANK: 330 GPD ( 2 = 660 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10
1.01 Acres �/ i Il S TO SUITABLE SOIL LAYER. REPLACE WITH -) 5. PIPE JOINTS TO BE MADE WATERTIGHT.
CLEAN MED. SAND USE A 1500 GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
LEACHING: ENVIRONMENTAL CODE TITLE V.
7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
[7(6.25) + 2' + 1'] x [3' + 3' +3' +1'] = 467.5 SF USED FOR LOT LINE STAKING.
467.5 (.75) = 350.6 GPD 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
K SILT FENCE 6 _ 467.5 350.E
\L MIT A TOTAL: S.F. GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
-LINE \� USE (7) HIGH CAPACITY INFILTRATORS WITH 3' OF STONE INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
AT SIDES AND 1' OF STONE AT ENDS FROM BOARD OF HEALTH.
"62_ _ _ 10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE
LOCATION
OMEOUNDERGROUND & OVERHEAD UTILITIES PRIOR
6 TO COMMENCEMENT OF WORK
C� 59 59- >
zz � LEGEND SITE AND SEWAGE PLAN
- AEG 5gR GpR / .62� 100.0 PROPOSED SPOT ELEVATION OF
LOT 2 OAK STREET
�/ 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF:
6�
� 6 100
61 TH2 PROPOSED colvTouR (CENTERVILLE) BARNSTABLE
W
- - 100 - - EXISTING CONTOUR PREPARED FOR: MARKWOOD CORPORATION
TH 1
30 p 30 60 90
BOARD OF HEALTH
� r
P 1�1 rn Z MA 1" = 30' AUGUST 7, 1998
?,Es / /66, APPROVED DATE SCALE: DATE:
ro I
off 508-362-4541
/ fax 508 362-9880
�tl1 Of
0a ^ I �1N OF MAf •>1�,�'
69 down cape engineering, Inc. ot�� ARNE yc ARNEH. �
H. OJALA �.
GERM BENCHMARK - TOP CIVIL ENGINEERS s o2
6" as a CIVIL a
OF CONC N
. BOUND LAND SURVEYORS $o� �, o
,/ Ep srrg EL. = 66.1 (ASSMD) `ass, q T
98-26
939 main st. armouth ma 02675
OA Y A H. OJALA, ., P.L.S. DATE