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0221 PHINNEY'S LANE - Health
221 Phinneys Lane A= 230—002 Centerville SMEAD No.2-153LOR UPC 12534 •meed.aom • Made In USA t 1�@tUS®N MS PYODtICr t!E SFI OFD*SR ��o h TOWN OF BARNSTABLE LOCATION,a,al�.' h nA e(4 1,4_ SEWAGE# 2,0 � VILLAGEe V�t�e. ASSESSOR'S MAP&PARCEL c23o AA INSTALLER'S NAME&PHONE NO. �� 5 A A. J6u-A1'lt�_$3 S � SEPTIC TANK CAPACITY LEACHING FACILITY:(type(- ) p�q((A 06,�size) NO.OF BEDROOMS J OWNER e- PERMIT DATE: ��(.{ 1 S COMPLIANCE DATE: 1 It Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 11 Z;% t Private Water Supply Well and Leaching Facility Of 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 Ul0' u c,- 13 - 4 G e5 �LWia o No. �d�sy��O Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y-4 s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS CIO 00 2ppYitation for h:7u osal 6pstem Construction jermit 0' Application for a P it to Construct( ) Repairpgra e( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or L No.o� i%►�e[' AW Owner's Name,Address,and Tel.No. �hn 6e q h4." Assessor's Map/Parcel o�j�jJ�) Installer's Name,Address,and 1. ,j q �. fp�/Z� Designer's Name,Address,and Tel.No. 4 � A) 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 ?1 Design Flow(min.required) 33l) gpd Design flow provided 3y9 gpd Plan Date "A 4y Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Stc /dr o, Or Nature of Repairs or Alterations(Answer when applicable) 4 e,*j � 1-2 g' ,e -2s O 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 thi =oflth. Si Date Application Approved by Date__y Application Disapproved b Date FT for the following reasons Permit No. Oo iy- 066 Date Issued 4 1 / ►I h No. g�0�s_ ��g f Fee ( Entered in com uteri THE�COMMONWEALTH'OF MASSACHUSETTS p Yes PUBLIC.HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS , 21ppliLAtion for Disposal .pstrm Construction 3per mit Application f�Pit to Construct( ) Repair Upgra l e( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or L No. % w o( h •Owner's Name,Address,and Tel.No. �ti^ /��y/7101 1 Assessor's Map/Parcel�o?jv Installer's Name,Address,and el. j v A A. .jpv7/k Desl ers Name,Address,and Tel.No. g" ' N` (, l( i4/ 7- Wes /S*a,r,.S7li r , e - s -A2 Type f Building` r V 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) 33f� gpd Design flow provided 3z gpd 9 Plan Date ���Z � Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. q Description of Soil le c /Q q Nature of Repairs or Alterations(Answer when applicable) /!e Ky /7,/� �.� �J. O I i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i 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 thi of Health. Si Date L Application Approved by Date < Application Disapproved Date for the following reasons Permit No. ('�� Date Issued L/ I 14 ?..e)I h THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( e�' Upgraded( ) Abandoned( )by �AS dl • ��74 J at has been constructed in accordance L-A9)5- wi �taprovisions of ' le 5 and the for Disposal System Construction Permit NoXI5—OSf dated ti /N i Installe Designer j #bedroom Approved desi o �0 gpd The issuance f this permit shall not be construed as a guarantee that the system will(func lo as des' ned. Date 1 t Inspector V�✓ 1 i�- ----------------------------------------------------------------------------------------------------------------------------------- .' No. 00% Fee � � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal *pstPm Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at -2 21 0 41,m-f 4 ( X/1 ��t�.i.�d•l/c 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 be completed within three years of the date of this permit. Date L Approved by i Town of Barnstable Regulatory Services Richard V. Scali,Interim Director sn MSTAI 3 = Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: �'2� ' Sewage Permit# Assessor's Map\Parcel Designer: TNNnM MC Lt- .QtV P.C. Installer: Address: Ray, l l t 3 Address: e - awy is M A o 1-6`l 1 On was issued a permit to install a (date) (installer) septic system at 2 Z I 'P H I IV AA_4(S LA NG based on a design drawn by (address) -(Ncr>)A S mcuEwN dated 11-Zq -I Q (designer) N/ .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 the 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 in compliance with the terms TD s of the IAA approval letters (if applicable) (Installer's Signature) l ..lam, '(Designer's Si n ture) (Affix Desig4er ! 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. Q:\Septic\Designer Certification Form Rev 8-14-13.doc f Town of Barnstable oFTHE r Regulatory Services Thomas F. Geiler, Director Y M "Q'A MASS.M ` Public Health Division 9Q ih639�.� `�� v'°rE1639. Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: L Sewage Permit# d . Assessor's Map/Parcel �3ola Installer& Designer Certification Form Designer: ` Qe t� Installer: - $ w � 4t? o1JZ,�- Address: QJ Dr4 6- Wa 3 Address: 601myt, fl On /y 16- _3_4S vn A.Sou Ze* was issued a permit to install a (date) (installer) septic system at 0?07 d �/)�' e A/ . AeWte,4& ased on a design drawn by (address) - dated it Z ,, (designer) �— 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 the distribution box and/or septic tank. Stripout (if required) was inspected and the soils z 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. Stripout (if required) was inspected and the soils were found satisfactory. (Insta ignature) (Designer's Signature) (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. q:\office forrns\designercertification form.doc Town of Barnstable Barnstable �.�. Board of Health I MAsa g 200 Main Street, Hyannis MA 02601 2007 i639• �� rfp MA•l�' Office: 508-862'4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi January 29, 2015 Mr. John Denham 14 Lofty Heights Road Westerly R.I. 02891 E-mail idenham34kverizon.net RE Extension of Tune to Repair or Replace Septic System ``, 221.Phumey's Lane Centerville, MA R Dear Mr. Denham, At the December 9, 2014 meeting of the Board of Health, you were granted a one year extension until December 31, 2015, to repair or replace the septic system at 221 Phinney's Lane, Centerville. You stated the dwelling is presently vacant. The house contents have been cleared and the water is turned-off. You indicated that you will need additional time for the engineering plan to be designed and a new system installed. In the meantime, the home will remain vacant. The Board has no objections to your request for an extension of one year with the understanding that the home will not be occupied and the water service remains turned-off. Please submit official documentation from the Water Department or from a licensed plumber indicating the water is turned-off. This extension is not transferable to a new owner of this property. Sin rely yo , ayne iller, M.D. Chaff an Board of Health Q:\WPFILES\DenhamExtension2Ol5.doc Glacier Page 1 of 1 McKean, Thomas ' From: JDENHAM Udenham34@verizon.net] Sent: Friday, November 21, 2014 1:04 PM To: Health Subject: 221 Phinneys Lane Septic System Re: Certified Mail#7012-1010-0000-2851-3924 Attn: Dr. Wayne Miller Please be advised that the subject property belonged to my sister Jean E. Bliss who passed away on March 19th of this year. Presently the house contents have been cleared out and it is now vacant so the septic system is not in use. Water to the house has been turned off as well. I have recently employed the Robert B. Our Co. and we are definitely looking to resolve the problem. An Engineer is now developing a plan to repair, or replace, the existing system but that is in progress and not available to date. My understanding is that the plan will require approval by your agency. The referenced letter allows just 60 days to bring the system up to code. In view of the conditions of the house as noted above, I respectively request an extension of time to allow a one year period to bring the system up to your requirements, providing the house stays vacant. My plan is to put the house on the market for sale but the septic system plan must be in place to go forward with that process. Please advise me as to your decision on this matter at your earliest convenience. Respectfully, John Denham 11/21/2014 Crocker, Sharon From: Crocker, Sharon Sent: Friday, January 30, 2015 3:58 PM f To: Crocker, Sharon Subject: FW: 221 Phinney's Lane -J. Denham John Denham called today, 1/30/15, and said he sold the property as of 1/15/15. Any questions, his phone number is 401-322-1189. I forwarded the phone message to TM. -----Original Message----- From: Crocker,Sharon Sent: Friday,January 30, 2015 10:37 AM To: 'jdenham34@verizon.net' Subject: 221 Phinney's Lane Hello John, Please email me back your mailing address so we can send you the official decision letter from the Board of Health. Thank you. Sharon Crocker Administrative Assistant 508-862-4739 1 6 VIE Town.of Barnstable P# e Department of Regulatory Services s Public Health Division Date 200 Main Street,Hyannis MA 02601 lfG bAA't A Date Scheduled_ 8' � T.. Ime Fee Pd. Soil Suitability Assessment,for Sew ge is osal P Performed By: Witnessed By: I 0 ( LOCATION& GENERAL INFORMATION Location Address 22-1 pNIN/eyS, GN Owner's Name d£'4 n/ B Li s,f CCN-rEQvl Lit Address S/0m'F M. Assessor's Map/Parcel: 23a`Z Engineer's Name -FHO/hA) /'` NEW CONSTRUCTION REPAIR I,/ Teleph one# (5�0a 3�q. 610ge Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) 0 1,N) tJ � Parent material(geologic) QV(W Spy i Depth to Bedrock N6 Depth to Groundwater. Standing Water in Hole: NONE Weeping from Pit Face �� • Estimated Seasonal High Groundwater /10mr, DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: /Vim' ^ ' Depth Observed standing in obs.hole: A)12A�j —in, Depth to soil mottles: ,r v 04)b) In. Depth to weeping from side of obs,In /" ]n. Ornundwater Adjuatment ft. Index Well# Reading Date: index Well levol a Adj.factor Ad,.Groundwater Level s PERCOLATION TEST Date 1 i•?a•1�Time yd�� Observation I Hole# Time at h" _ _� Depth of Perc I-5 Time at 6" -7 . _ Start Pre-soak Time @ 'time(9"-6") / )-A) End Pre-'soak Rate Min./Inch { /rl f/v I N . Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) /V � Original: Public Health Division Observation Hole Data To Be Completed on Back----------- 4 ***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:\.SEPTICIPERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil . Other Surface(in.) (USDA) (Munselq Mottling (Stnucture,Stones,Boulders. orlsistency.%(3ravel) 4 6 A S,4 U)'1 b .2 `V N D Q CAM V1 LIX) o R.. 6 3 (0 G 1 r)"lr $A1v9. 2,5 . Z Z DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten % ravel) h OIZA 5AiJN L'M Ib �# 6t, d o" Cl ►NE S,aM9 S-51 1 ,Z i 3 Z.° G 2 M EV SAIT 2.S`( N DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con i to Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No. Yes Within 500 year boundary No= Yes _ Within 100 year flood boundary No_ Yes Dept h 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? If not,what is the depth of naturally occurring pervious material? Ceitif iication I certify that on (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 experience described in 3 10 CMR 15.017. Signature Date Q:WEPTIC`\PERCFORM.DOC Postal IOKILT. RECEIPT (Domestic Er For delivery information visit our website at www.usps.come Ln .. � Postage $ IlJ Certified Fee N N rS/I,J C ostmark O Return Receipt Fee D�e 0 p (Endorsement Required) N Restricted Delivery Fee JO� C (Endorsement Required) 1- R/p Total Postage&Fees � sp S / Jean E. Bliss C/o John Denham 14 Lofty Heights _Uk-gfpr'Nt RI 02891 � Certified Mail Provides: ,> ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: • Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery'. ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. t j` IMPORTANT:Save this receipt and present it when making an inquiry.. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 COMPLETE • ■ Complete items 1,2,and 3.Also complete A. ignature item 4 if Restricted Delivery is desired. x ❑Agent ■ Print your name and address on the reverse ❑Addressee,.) I so that we can return the Card to you. OR ceived by(Printed Name) C.,Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. `� D. Is delivery address different f m item'T7.MYes 1. Article Addressed to: If YES,enter delivery addrpelow; Vh iVo Ilk :Jean E. Bliss c/o John Denham 14 Lofty Heights 3. service Type ❑Certified Mail O Express Mail Westerly, RI 02891 ❑Registered ❑Return Receipt for Merchandise ------ ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes I Z._Article Number - - I (Transfer from service label) I 7 012 1010 0000 2 8 51 3924 PS Form 3811.February 2004 Domest c Return Receipt 102595-02-M-1540 'i UNITED STATES POSTAL SERVICE I First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • II I I Town of Barnstable I I Public Health Division I 200 Main Street Hyannis, MA 02601 I I i I Town of Barnstable Barnstable KAM Regulatory Services Department 1 " , ' Public Health Division m " A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 28 51 .3 924 November 5, 2014 Jean E. Bliss c/o John Denham 14 Lofty Heights Westerly, RI 02891 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 221 Phinney's Lane, Centerville, MA was last inspected . on 9/27/2014, by Joe Martins, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (3.10 CMR 15.00) due to the following: • Sign of heavy staining and backup of sewage into facility or system component due to overloaded or clogged SAS. • There is no distribution box present. Distribution box must be installed.. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OFT E BOARD OF HEALTH omas McKean, R.S., CHO Agent of the Board of Health 3 Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\221 Phinney's Ln Nove 2014.doc r21J P ll QI 1 1P p 1 P - �- o �htk ; iss 2 intranet ro data ParcelDetail,as atI0=163t71 �• �t X �live search p Application Center(3) F Application Center(2) 91 http--www.town.barnstable... ®Application Center ®Suggested Stes• : Web Slice Gallery Favorites Parcel Detail7 s. Owl ..s BARNSThif1 E $Nhti � Logged In As: Wednesday, Parcel Dietail f. I Parcel Info Parcel 23i1002 -- — I Developer LOT4 ID Lot Location PHINNEY'S LANE--- I Frontag 221 9 e 30 I ' Sec I Sec I ' w Road Frontage is I Village I CENTEROLLE Fire District C'C�;If�l Town sewer exists at this �i address Na Road Index 11242 I $ Interactive —� Map t Owner Info (honer BLISS,JEAN E I Co-Owner ' Street1221 PHINNEYS LANE I Street2 I , A4 y City ICENTERVILLE I State NIA Zip�6�32Country Land Info a`gl Y I g Acres=049Use Single Fam M -01 Zoning I SPLIT RD-1,RC Nghbd 0104 �I�! Local intranet .......... &—starit 11110 Parcel Detail-Windows I,,. Q 1 10,22 AM Computer name : HEALTH899JF User name : flvnni Operating Svstem : Windows NT(5.1) I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Cw ner ON ner's Name inforrnation is required for every Wi--,ter1 V RI 02991 9/27/2014 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. Impo out f General Information When A. omaon filling out rr on the computput er, 3�y69 use only the tab Martins key to move your Inspector. ,Accu Sepcheck cursor-do not 17 Nor hsidt- Di use the return ��of Inspector " -� key. S. Dennis, MA 0266t�' ICE Corny Narne Company Address mim City/Town 5-0 SO'3� State � � ��� Zip Code Telephone Number License• License Number B. Certification >v � I certify that I have personally inspected the sewage disposal system at this addre s end that the information reported below is true, accurate and complete as of the time of the inspection. The anspecl,M was performed based on my training and experience in the proper function and rnQttnance of sites i sewage disposal systems. I am a DEP approved system inspector pursuant to:Section 15.34fl of Title 5 (310 CM R 15.000). The system: " a ❑ Passes ❑ Conditionally Passes Fails ltf ; ` _= ❑ Needs Further Evaluation by t e Local Approving Authority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. f:inns•3113 - Title 5 Official Iris pec lion Form Subsurface sevsge Disposal system•Page/of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Ow ner Omf ner's Name information is required for every Westerly R T 02991 9/270014 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Con ' ionally Passes: ❑ O e or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND) for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 TMe5official Iris pec bon Form Subsurface Savage Disposal System•Page 2of 17 I - : Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Qv ner O,v ner's Name requiredinforrmt for Is Westerly RI 02891 9/27/2014 required for every page. Cityrrown State Zip Code Date of inspection B. Certification (cunt.) ❑ Pump Chamber.pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or breakout or high static water level the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or unev 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 pump' g more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspecti n if(with approval of the Board of Health): ❑ broken pipe(s re replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction s removed ❑ Y ❑ N ❑ ND(Explain below): C/Fh aluation is Required by the Board of Health: ❑ exist which require further evaluation by the Board of Health in order to determine if is failing to protect public health, safety or the environment. will pass unless Board of Health determines in accordance with 310 CMR )that the system is not functioning in a manner which will protect public health, the environment spool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of bordering vegetated wetland or salt marsh ins-W3 Title 5 Official Inspec bon Form Subsurtace Sewage Disposal System-Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Q"ng Cw ner's Name information is 7 Q required for every We�te ��r � — Co — 91 /2$14 page. Cityl Tow n State Zip de Date o pec ton B. Certification (cunt.) 2. System will fail unless the Board of Health (and Public Water Supplier,i ny) determines that the system is functioning in a manner that protectsth ublic health, safety and environment: ❑ The system has a septic tank and soil absorption system(SA and the SAS is within 100 feet of a surface water supply or tributary to a surface wa supply. ❑ The system has a septic tank and SAS and the SAS i Rhin a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and th AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and a 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 ater analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates ab nt and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, pro ' ed 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 Si&-A/S d,0- X euV y Jj�Nl a?l 1� Backup of sewage into facility or system com onent due to overloaded or f� clogged SAS or cesspool ❑ [A Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than% day flow t51re•3113 Title 5 Official lre paction Form Subsurface Savage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Cw ner Cw ner's Name informon is requiretifore Westerly R1 A/ 7/7(114 required for every 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. ❑ j 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- Y`� 10,000gpd. ❑ The system fps. I have determined that one or more of the above failure 71 criteria exist as described in 310 CM 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 m 'serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"n " o each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is w in 400 feet of a surface drinking water supply ❑ ❑ the syst is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the stem is located in a nitrogen sensitive area(Interim Wellhead Protection a— IWPA)or a mapped Zone II of a public water supply well Ifyou have answe d"yes"to any question in Section E the system is considered a significant threat, or answered "y in Section D above the large system has failed. The owner or operator of any large system consi red a significant threat under Section E or failed under Section D shall upgrade the system in cordance with 310 CMR 15.304. The system owner should contact the appropriate regional fice of the Department. 15ins•3113 - Title 6Official Ins pection F orm Subsurface Sewage Disposal System•Forge 5of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Our ner Cw ner's Name requirefo is Westerly RI 02891 9/27/2014 required for every page. Citylfown 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 I!Q ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 09 Were any of the system components pumped out in the previous two weeks? ❑ R— Has the system received normal flows in the previous two week period? ❑ 0� 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) L�f ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? IAc-(�/ D� ❑ Were all system components, ding 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: ❑ ET" 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): = Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 35a t5im•3(13 Title 5 Official Ins pectionForm Suhsiafate sewage Disposal System-Page 60117 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Ory ner ON ner's Name requir on is Westerly RI 02891 9/27/2014 requiredd for every page. Cityrrown State Zip Code Date of ttspection D. System Information Description: �adO /C Number of current residents: Does residence have a garbage grinder? ❑ Yes [R/No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes L'� No information in this report.) Laundry system inspected? ❑ Yes X No Seasonal use? ❑ Yes�x No Water meter readings, if available(last 2 years usage (gpd)): d Detail: O l Q o O 0�0 I Yoe 0 Sump pump? ❑2Yes �No � Last date of occupancy: / 0 Date''��''�� Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): nsperday(gpd) Basis of design flow(seats/persons/sq.ft., Grease trap present? ❑ Yes ❑ No Industrial waste ing tank present? ❑ Yes ❑ No Non-s ' ary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Mrs•3113 Title 6Official Ire pec ton Form Subsurface Sewage Disposal System-Page 7of 17 Commonwe Ith of as ��_. _ - a sachuseits ». — ltle 5_oWIC al Inspection Form Subsurface Sewage Disposal System-Form -Not for Voluntary,Assessments h �F-221•Pliin iey's-Law.' 4Centerville MA '- � .� ;Property Address ,f Jean E Bliss do John D rt e am":14'Loft- 'H i r e is Cw ner Cw ner's Name information is required for every Westerly RT 1 9/27/2014 page, Crty/Town State Zip Code Date of Inspection It egc•.a. D.'System Information`(&nt*) }' 1_ast dateof occupa ncy/use 'Date»- ^-- .»�- - --7 Other(describe"below)' - F _ x ,e.• . r K ae.++ 'F - <"3 9^."!• - - - .es4 .TM,.•+-..g. 'F'TS aY;.: e, —i •�`- it Y C 1 r x t y z v General Information,, 4 Pumping-Records:- x _ Source of information ' Was system pumped as part of the inspection? , t❑ Yes r "No �K %.,., W If yes, volume pumps ' galbns Hovrwas quantity pumped determined? Reason for pumping: Type of System a. .^ :u•" -.' wp`.•L'"` b .^er ay;w:`+ �is .,... �Septic tank, d ion box,�soil absorption system ❑ Single cesspool - ❑ Ove rflow cesspool a ❑ Privy a ❑ . Shared system(yes or no) (if yes, attach previous inspection records; if any) ❑ Innovative/Altemative 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 VA system by system operator under contract :. - ❑ Tight tank. Attach a copy.ofthe DEP approval. ❑ Other(describe): t5ins•3M3 Title6 Official Iris pec ton Form Suburface,Se •.. vr�ge Disposal System•Page 8of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights ON ner ON ner's Name information is required for every Westerly RI 02891 9/27/2014 page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ff4o PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): D(c NO �-Pa �� -P y•caDP� Septic Tank(locate on site plan): Depth below grade: ©� feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: year Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: O l 11 X l x 7 11 to 101, l d QQ C) Sludge depth: ./ t5ins•3113 Title 5Official Inspection Form Subsurface Sewage Disposal System-Page 9of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham M Lofty Heights ON ner Cw ner's Name. information is required for every Westerly RI 02991 9/27/9014 page. City/Town State Zip Code Date of Inspection D. System Information (corn.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle lr Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? CC)re'`"'•�^ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): /44s p✓ e co_-t Cklh�e r-T:P_ t ' Liau / 0 toil Y&If' y -e v ' d-e o c x. c)(- kept Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(expla' Dimensions: Scum thickness Distance from top of scum to of outlet tee or baffle Distance from bo of scum to bottom of outlet tee or baffle Date st pumping: Date 15irs•3113 Title 5Offcial lrspectlonForm Subsurface Sewage Disposal Sp iem•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights O,v ner ON ner's Name information is required for every Westerly RI 02991 9/ 7/ _014 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.): 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 ❑ poly e ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date ast pumping: Date omments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t<.rlrs•3113 Title 5 Official Ins pectlonForm Subsurface SewageDlsposal System.Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Cw ner ON ner's Name require for is required for every We¢tP.r1 V R1 n 7 R91 9/97/?0 14 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.): NO DISoX Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, conditionZmpspurtenances, etc.): * If pumps or alarms are not in work' g order, system is a conditional pass. Soil Absorption System (SAS locate on site plan, excavation not required): If SAS not located, explain y: t5irs-3113 Tide 5 Official lrspectonForm Sibsuface SevageDisposal System-Page 12of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville NM Property Jean E Bl Address , , iss c/o John Denham 14 Lofty Heights Ouo ner Owner's Name inforis requiredlon forevery Westerly RI 02891 9/27/2014 page. City/fown State Zip Code Date of Inspection D. System Information (corn.) Type: leaching pits number. Lou ❑ leaching chambers number. ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure level of ponding, dam soil, condition of vegetation, etc.): 0-2" Ivay/lu /71 w 6 ale) !A z Ro w s �jo��s QyarCa� Same,. salcclr �� P�A2 at Sr�� Cesspools(cesspool must be pumped as part of inspection)(locate o site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Ins pecbonForm Subsurface Savage Disposal System•Page 13of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Cw ner Cw ner's Name information is required for every Westerly RI 02891 9/27/2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 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 hydr is failure, level of ponding, condition of vegetation, etc.): .sins 3113 Title 5aficlai Ins pec ton Form Subsurface SewageDlsposal System-Page 14 d 17 Commonwealth of Massachusetts — Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221. Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights CW ner Cw ner's Name requiredfore Westerly RI 02891 .9/27/2014 required for every _ - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage dispotal 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. 2 hehand-sketch in the area below ❑ drawing attached separately VV a I Cal y t5irs-all Titie5 Official Iris pectionForm Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane Centerville MA Property Address Jean E Bliss c/o John Denham 14 Lofty Heights Ow ner Owner's Name information is Westerly RI required for every 02891 9/27/2,0 14 page. City/Town State Zip Code Date of Inspection D. System Information (corn.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. feet Please indicate all methods used to de rmine the high ground water elevation: ❑ Obtained from syste design plans on record If checked, date design plan reviewed: pate ❑ Observed si (abutting property/observation hole within 150 feet of SAS) ❑ Checke th local Board of Health-explain: ❑ C eked with local excavators, installers -(attach documentation) ❑ ccessed USGS database-explain: You m st describe how you established the high ground water elevation: N ,6 4A m/ La di,UP- 7 v✓Lc, Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5ris•Y13 Tft 5 aficWd I s peebon Form Subs Wace Sevage Disposal System•Page 16 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 221 Phinney's Lane. Centerville MA Property Address Jean E Bliss C/o John Denham 14 Lofty Heights Ouv ner Cw ner's Name inforrrration is required for every Westerly R1 02891 9/27/2014 page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist ErInspection Summary: A, B, C, D, or E checked inspection Summary D(System Failure Criteria Applicable to All Systems)completed Ll System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tNns•3113 Title 5 Official Inspection Form Suhsurtace Sevage Disposal system.Page 17 d 17 CATION ;� EWa PERMIT 1J0. VILLAGE IMSTNLLER 5 U&ME ADDRESS 5UILDER 5 1J &V AE QDDRE SS Ifool Dt-\TE PERNA T ISSUED DATE COKAPLI &MCE ISSUED : ' '� / If - lQvo - rr 4P � V , No..-- .l .. ...... ................. THE COMMONWEALTH OF MASSACHUSETTS a� BOARD F HEA TH ....- OF....... ... . . .. . ..................... Appliratio � for Dispon1 Works Tonotrurtion amit Application is hereby de for a Permit to Construct ( ) or Repair �( ) an Individual Sewage Disposal Syst �. :�:. .. . ...._ , � ..... .�. ......................... ................................. ....................._... Volddress or Lot No. -� ..-._ r. a -------------------------------------------- -----------=-•r/ .• ZrAes �` Installer Address U Type of Building Size Lot..):4-?4�1.....Sq. feet Dwelling—No. of Bedrooms. _�? __________________________Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Buildingcs.••--- o. of persons............................. ShowersCafeteria ( ) a' Other fixtures ...... . ..... ........ .:. W Design Flow....... -_.()---.___--------------------gallons per person per day. Total daily flow......... ........................gallons. WSeptic Tank�-Liquid capacity_ .Wgallonsi Length................ Width................ Diameter................ Depth.............. x Disposal Trench—No..................... Width j; �_...V,Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter/-00,.......�Depth below inlet..............--_-- otalglaching area........_.........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ����7�f/ 4 Percolation Test Results Performed by... ----------------------- Date aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit._.................. Depth to ground water........................ -------- -•••__ri....... /-.--.-j.. ........ ................... O Description of Soil `--�••••• . -1 U ---•-------------•----•---.....------......._..._...........---•--..........-----••....--------••-•----••••-•-----•---••--•••----••---•----••••.............••---•-•-•-----•-••-•••-..................•. W VNature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------------------•------------------------------------------------•-------------------•--------•--------------------------------------------------•-.............._....._......•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 f health. h Sign - -- ------ ----- •--• ate Application Approved By . . •---- •..............•. • / Date Application Disapproved for the following reasons:....................... ••-•••••••--••-••--•-•••-•---•--••---------------•---•--•---•••......----••-•--•...... --------------------------•--•-------.........----........---•------------------.......--------.....--••----•---•-----•--------•---------------------------•---•-•••-•••----••-----•.......•---•-------. Date PermitNo......................................................... Issued........................................................ Date No.--- ...... Fimic............................ THE COMMONWEALTH OF MASSACHUSETTS E30ARD OF HEA�TH .....A� OF. *------------------ ...... . ........................ Appliration for Bbspaoal Morks Tonsirurtion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Systems dt: r A,) Location' .......... ----------------------------------------ress --------------------------------------- --------------------------------------------------------- or Lot No. .... ........................................................................... ......................................................Owner .."................................ ' Address, .............. ...... ............................................. ........... ............................................ 4 1 ....................................... M Installer Address 14 Type of Building Size Lot__,U... .....Sq. feet U Dwelling—No. of Bedrooms-----_---3n-----------------_--------Expansion Attic Garbage Grinder PL, Other—Type of Building No. of persons............................ Showers Cafeteria P4 Other Pxtures .......................................W---e........I....................................................... ---------------------------------- Design Flow_....... .............................gallons ej, 14 .. per person per day. Total daily .............gallons. Septic Tank _L'iquid capacity../)._/'-'0' ---------------------- ...gallon Length________________ Width.............___ Diameter..._____........ Depth.___............ No..................... Width'+-L R. ---------- Disposal Trench .... ....... Total Length......._..__........ Total leaching area....................sq. ft. p See age Pit No..................... Diameter.�,_C'Nl,........ Depth below inlet, Total I chi ......sq. ft. Other Distribution box Dosing tank ,,, aching area............ Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit____._...._......... Depth to ground water........................ rXq Test Pit No. 2................minutes per inch Depth of Test Pit.__........._....... Depth to ground water....... ---------- ----------- .................................................... . ........ .............. .2........5.-i------ 0 Description of Soil.--.— . ......................X..t5rt-_- W C, U ........................................................................................................................................................................................................ W ....................................................................................................................................................................................................... M 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 Article XI 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. Sign _10" .............................................................. ............ Application Approved By....,c< at-e....... - ---------- ...... vzr-11 �We Application Disapproved for the following reasons:.......... ................................................Date................ ........................................................................................................................................................................................................ DatePermitNo......................................................... Issued............................................ ....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4. .............0.......... ............. ......(ffrrfifiratr of Toutplitturr TIffIS I4 TO CERTZIFY, III the Individual Sewage Disposal System constructed or Repaired by.. ................... .................... ------- -------------------------------------------------------------------- _ia ....kj at ........�.. ZO v-------- ... ............................................... r`o d i the has been installed i accordance with the pro isions of Article �ZI of The State Sanitary Code as desc application for Disposal Works Construction Permit No..........2..5-..4--------------- dated_'�.� p e in 7,1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....Z 4-7.. ...0 F........... 14111� . ...... .0.-,e 2—:2: .......................................... No ...... FEE...A)........... llifivosal orks str Vamit Permission/*sXreby ranted.. V. —T_' $7 a ............I...... ............................................... ...................... an Individual ewV-a�g System to Construct 14 ) or�JepaZi )6 sposal S . .. ....... ........... ..... a .............y s t,�7� _ ........... ...................................... Street "oo, as shown on the application for Disposal Works/Construction Per-nff*V No. d ........ 0 -- --- ----- ........ DATE................................................................................ Boarl'of a FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ]6 a I � � i. I ,• i a . • 1357 3ILj Chi• - '. ---- _ S%t�� _ r" ter � �,� EXSTINGCONTOUR: ---- SEPTIC SYSTEM DESIGN SEPTIC SYSTEM SECTION 4 F9� PROPOSED CONTOUR: ............. 2�9 EXISTING SPOT ELEVATION: 25.5 FLOW ESTIMATE: 2"PEASTONE OR FILTER FABRIC 'QS PROPOSED SPOT ELEVATION: 25.5 COVERS WITHIN 6" 3/4"-1 1/2" DCUS S,QO TEST HOLE: 3 BEDROOMS AT 110 GAL/DAY= 330 GAL/DAY 102.08 I --1 TOP OF UTILITY POLE: -� FOUNDATION OF FINISHED GRADE WASHED STONE Q, FENCE LINE: °="` INSPECTION PORT SEPTIC TANK: ELEV.=95.83 HYDRANT: 330 GAL/DAY x 2 DAYS= 660 GAL . ' Q� RETAINING WALL: o USE 1000 GALLON SEPTIC TANK (EXISTING) COVER m, ROUTE 28 (1'MIN) LEACHING AREA: 98.5 ELEV. USE 2-500 GALLON CHAMBERS(8.5'x 4.8'x 2'EFF.DEPTH)WITH 98.72 9 5 97.33 LOCATION MAP ELEV. ELEV. 93.0 LOT 4 (21,764 SF) ELEV 1000 GAL. D-BOX H H ELEV. ASSESSORS MAP:230 PARCEL:2 4'OF STONE ALL AROUND (25'x 12.8'x 2'DEEP) (6"STONE UNDER) 4' 4' 25'x 12.8' PLAN BOOK:263, PAGE:51 SIDE AREA: (25'+ 12.8')x 2 x 2= 151 SF (0.74)=112 GAL/DAY SEPTIC TANK TEE SIZES: TO BE CONFIRMED g5.0 2-500 GALLON CHAMBERS WITH BOTTOM AREA: 25'x 12.8'=320 SF (0.74)=237 GAL/DAY ( ) 4'OF STONE ALL AROUND INLET:6"UP, 13"DOWN ELEV. (25'x 12.8'x 2'DEEP) CAPACITY=349 GAL/DAY OUTLET:6"UP, 14"DOWN GAS BAFFLE AT OUTLET TEE N i.p 98.0 TEST HOLE LOGS TH 1 ELEV.97.0 2 ELEV. O/A HORIZON O/A HORIZON DECK ENGINEER: THOMAS McLELLAN,P.E. SANDY LOAM SANDY LOAM 9" 10YR 4/2 96.3 14" 10YR 4/2 96.8 BENCHMARK AT 99 _ bh _ WITNESS: DAVID STANTON,R.S. B HORIZON B HORIZON RIGHT CORNER SANDY LOAM SANDY LOAM OF BULKHEAD S'�a KITCHEN BED DATE: 11-21-14 30" 10YR 6/3 94.5 36" 10YR 6/3 95.0 ELEVATION=101.05 °Fd DINING BATH ROOM PERCOLATION RATE: <5 MIN/IN Cl HORIZON Cl HORIZON FINE SAND FINE SAND P#: 14564 60-- 2.5Y 7/2 92.0 60° 2.5Y 7/2 93.0 C2 HORIZON C2 HORIZON MEDIUM SAND MEDIUM SAND / LIVING BED BED 132" 2.5Y 7/6 86.0 132" 2.5Y 7/6 87.0 / ROOM ROOM ROOM NO GROUND WATER ENCOUNTERED �98 �/ s NOTES: EXISTING FLOOR PLAN \N sQ�'s, 1.VERTICAL DATUM: ASSUMED O ` N00• �/ `\`\ / 100 F 2. MUNICAPAL WATER IS AVAILABLE. 3.SCHEDULE 40-4"PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM. 4.ALL PRECAST UNITS SUBJECT TO TRAFFIC LOADS TO CONFORM WITH AASHTO H-20 SPECIFICATIONS. 96.9 ��� / / ` 5. PIPE PITCH= 1/4" PER FOOT(UNLESS NOTED OTHERWISE). 97 ,� ;� / // 6.FIRST 2'OF PIPE OUT OF D-BOX TO BE SET LEVEL. 12" A/� LP I ' 7.THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE USE OF A GARBAGE DISPOSAL. tree / ��`�-�� r � 8.ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE STATE OF MASS.ENVIRONMENTAL CODE(TITLE FIVE)AND LOCAL HEALTH REGULATIONS. i t1 // / 9.CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. i'p' O O� 00 101 10.GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 3'. 96.8 a�' th-2 ��O 0 ry / Q., / ; \C'4 O' 11.FIELD SURVEY PROVIDED BY TERRY A.WARNER,P.L.S.,HARWICH, MA. 96 ,'� // O�V �+00�a 12.THIS PLAN REQUIRES THE REVIEW AND APPROVAL OF ONE OR MORE TOWN DEPARTMENTS AND 97 O�aQ IS SUBJECT TO CHANGE UNTIL SUCH TIME. 100 13.EXISTING LEACH PIT IS TO BE PUMPED AND FILLED WITH SAND OR REMOVED. 98-� f`�*v I� 14.D-BOX TO BE WATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOW. 101 qq` ^ T 99 \�aQ j r, G 24 cedar pL �d -,� V \ \ W SITE PLAN 101 CO \ 100 LOCATION: 221 PHINNEY'S LN., CENTERVILLE, MA GRAVEL PARKING A PREPARED FOR: a JOHN DENHAM DATE: 11-24-14 SCALE: 1"=20' 2 BASS RIVER ENGINEERING L'HOMA'S J. McLELLAN, P.E. P.O.BOX 1163, EAST DENNIS,MA 02641 M14-49 508-385-3426 OR 508-364-9048