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Home My WebLink About0300 PHINNEY'S LANE - Health 300 Phinney's Lane Centerville A = 230 132 Sllll O!CL&D No10259 C_0R �► s''� HASTINGS. YN d Commonwealth of Massachusetts 0230`131rq-1 iR rt Title 5 Official Inspection Form r, X Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / Cla 300 Phinne 's Lane Property Address Wendy& Karen Crocker :Y Owner w Owner's Name information is required for every Centerville MA 02632 4/5/2019 page. City/Town -' State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford key the return Name of Inspector Y Ford Septic Services, LLC r� Company Name P.O. Box 49 Company Address Osterville MA 02655 Cityrrown State Zip Code 508-862-9400 S 12482 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 Furth r E aluation by the Local Approving Authority 4/8/2019 Inspe 's Signature Date The s em inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts �. P Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Phinne 's Lane L Property Address Wendy& Karen Crocker Owner Owner's Name information is required for every Centerville MA 02632 4/5/2019 page. City/Town 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 ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � ,• 300 Phinney's Lane V� Property Address Wendy & Karen Crocker Owner Owners Name information is required for every Centerville MA 02632 4/5/2019 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the.Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts 1- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owners Name information is required for every Centerville MA 02632 4/5/2019 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I , Commonwealth of Massachusetts In P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owners Name information is required for every Centerville MA 02632 4/5/2019 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �•, 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owners Name information is required for every Centerville MA 02632 4/5/2019 page. City/Town 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- per as Number of bedrooms (actual): 3 built DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owners Name information is required for every Centerville MA 02632 4/5/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 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 ems, 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owner's Name information is required for every Centerville MA 02632 4/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts rp Title 5 Official Inspection Form ,S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Phinne 's Lane Property Address Wendy& Karen Crocker Owner Owners Name information is required for every Centerville MA 02632 4/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed date- 3/20/2002 per as-built 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 ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 26"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: 1500 gal. Sludge depth: 2 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�� 300 Phinney's Lane V� Property Address Wendy& Karen Crocker Owner Owner's Name information is required for every Centerville MA 02632 4/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The Tees were present. The liquid level was even with the outlet invert. There was no sign of leakage. The inlet cover was 10" below Grease Trap (locate on site plan): Depth below grade: N/a feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owner's Name information is required for every Centerville MA 02632 4/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/a Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owner's Name information is required for every Centerville MA 02632 4/5/2019 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 even 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 D-box was normal. 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.): N/a * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts jo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.v 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owners Name information is required for every Centerville MA 02632 4/5/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-33x13x2 -4' stone ❑ 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 chambers had 6"of water on the bottom. The cover was to grade. Bottom to grade was 5'. There was no sign of failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/a Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,t 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owner's Name information is required for every Centerville MA 02632 4/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Phinne 's Lane Property Address Wendy& Karen Crocker Owner Owners Name information is required for every Centerville MA 02632 4/5/2019 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 _ A O G4 M a o 3 C3 `! O � Q a s (3 3 60 I `f ,y14 gs t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 c Commonwealth of Massachusetts �. (p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .ems/ 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owners Name ion is required wiredd for every Centerville MA 02632 4/5/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10, feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Topo and water contours map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 e � • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Phinney's Lane Property Address Wendy& Karen Crocker Owner Owner's Name information is required for every Centerville MA 02632 4/5/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 45;z 3% Commdnwealth of Massachusetts Title 5 Official Inspection Form nts�,N OF K Subsurface Sewage Disposal System Form-Not for Voluntary Assess me ,M 300 Phinneys Lane r7'_ 17 AM 10: ?S Property Address Michael Dumas Owner Owner's Name information is -- Centerville, Ma. 02632 required for every page. City/Town State Zip Code Date of'Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information i1 forms on the �$ �0:3 computer, use 1. Inspector: k only the tab key to move your Raymond Dumas cursor-do not Name of Inspector use the return key. Dumas Landscape Const. Inc. Company Name r� 564 Old Stage Rd. Company Address Centerville Ma. 02632 few City/Town State Zip Code 508-778-0249 S 1437 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 11/16/2009 Inspectbe-%tig—haturb 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. �6 I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal Vystem•Page of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System S Conditional) Passes: Y ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 300 Phinneys Lane M Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every page. City/Town 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): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 Y day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville Ma. 02632 11/16/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 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 Form -Not for Voluntary Assessments 300 Phinneys Lane M Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: ' Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 28000 gallons for 2009 , 58000 gallons for 2008 Sump pump? ❑ Yes ® No Last date of occupancy: 10/2009 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 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 300 Phinneys Lane N spay`• Property Address Michael Dumas Owner Owner's Name information is Centerville, Ma. 02632 11/16/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 10/2009Date Other(describe below): General Information Pumping Records: Source of information: owner had tank pumped may 2009 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: maint. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/W2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2004 as per records at board of health Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 32 inches below top of foundation feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: 25 ft. feet Comments (on condition of joints, venting, evidence of leakage, etc.): ok Septic Tank(locate on site plan): Depth below grade: 20 inches 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: 1500 gallon Sludge depth: 0" t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every 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 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): at level Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is Centerville, Ma. 02632 11/16/2009 required for every 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 at level 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 solids 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: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville Ma. 02632 11/16/2009 every page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: plan on record Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leach chambers were dry Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts • m Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every 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, level of ponding, condition of vegetation, etc.): t5ins•09f08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w y 300 Phinneys Lane Property Address _ Michael Dumas Owner Owner's Name information is Centerville, Ma. 02632 11/1612009 required for — every page. City/Town 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 1 i i 1f I r +. f s2� it I c+oy So x 4 7 r t5ins°09= Tift 5 056W k%pectian Form:Suksurfaoe sewage oisposal system°Page is of 17 1 Comn9onwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: loft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ground water contour map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You trust describe how you established the high ground water elevation: no water 7 ft below leach field as per plan on record at board of health Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Phinneys Lane Property Address Michael Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 11/16/2009 every page. Cityrrown State Zip Code Date of Inspedion E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•04100 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION e TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 300 Phinney's Lane Centerville, MA 02632 Owner's Name: Jon Martin ® ND' Owner's Address: I PARCELNO� Date of Inspection: July 7, 2004 Name of Inspector: (Please Print) James M Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: July 13, 2004 The system inspector shall subm 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 300 Phinney's Lane Centerville, MA Owner: Jon Martin Date of Inspection: July 7, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. ` The septic tank is metal and over 20 years old or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with 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 distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 300 Phinney's Lane Centerville, MA Owner: Jon Martin Date of Inspection: July 7, 2004 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. 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 300 Phinney's Lane Centerville, MA Owner: Jon Martin Date of Inspection: July 7, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone I 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 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.] 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 System: 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 300 Phinnev's Lane Centerville, MA Owner: Jon Martin Date of Inspection: July 7, 2004 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)). 5 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 300 Phinnev's Lane Centerville, MA Owner: Jon Martin Date of Inspection: July 7, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Never pumped(new system) Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ 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: Installed 3120102-per as built card Were'sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Phinney's Lane Centerville, MA Owner: Jon Martin Date of Inspection: July 7, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ 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: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tee were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Phinney's Lane Centerville, MA Owner: Jon Martin Date of Inspection: July 7, 2004 TIGHT or HOLDING TANK: None (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 above outlet invert: Even 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 D-box was level and clean. No solids were present. PUMP CHAMBER: None (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.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Phinney's Lane Centerville, M4 Owner: Jon Martin Date of Inspection: July 7, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 33'L x 13'W x 2'T(per as built card) 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 leach field had 2"of water on the bottom and was clean. The scum line was at the same level There did not appear to be any signs offailure. CESSPOOLS: None (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: None (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.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Phinney's Lane Centerville, MA Owner: Jon Martin Date of Inspection: July 7, 2004 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. �k a, A � y`l S� GArQSL a 3 0 - 3 y 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Phinney's Lane Centerville, MA Owner: Jon Martin Date of Inspection: July 7, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 10 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 10'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. II TOWN OF BARNSTABLE LOCATION SEWAGE#2 °III:LAGE `:> I (`�- �� ASSESSOR'S MAP & LOT r D- INSTALLER'S NAME&PHONE NO. G/r— )�a1,�.-, �, i 7 5= > SEPTIC TANK CAPACITY LEACHING FACILITY: (type) -� (size) 3 A 33`4 ,' NO. OF BEDROOMS BUILDER OR OWNER GC,tp� PERMIT DATE: —ao—6 2-- 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 I�_ �Zo r ► TOWN OF BARNSTABLE LOCATION Sol) ?�)AAVM /4AL SEWAGE # V.ILLLAGE lam/►t tt-V►16— ASSESSOR'S MAP & LOT�30 3�-- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY SIJI� LEACHING FACILITY: (type) Ch'4��/S (size) NO.OF BEDROOMS BUELDER OR OWNER -OA^ MA,&' ' 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 leac ng facility) Feet Furnished by:rtI50 ,I o,, FD/� A 3 � CaAlOS� a 3 0 s �o PI y o No. THE COMMONWEALTH OF MASSACHUSETT&, { FEE BOARD OF HEALTH �G APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade (A,�Abandon ( ) - Complete System []Individual Components 3oa Qt41,y1jey-i 1_9•vL4 GG�ev/Zut/'LL� �o/L4� to 6i!-l�L� ocation wner's Name Map/Parcel# Address Lot# Telephone# 6j r L L I r+v-t /L o j c nr S O. JePT L .S L'a V t Le" ��`�° c�o lg!Z s oea� Installer's Name Designer's Name tod'o LL""MJLV1LLE Sig JU IT7-- Jb 0 ; dLVrLLL Address Address Telephone# Telephone# Type of Building: I'ejI yl'r~ram Lot Size Sq.feet Dwelling—No.of Bedrooms .Z Ey-0 16-0'A-3 rC"-nl Z�Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. equ'red) 2 2-0 gpd Calculated design flow 1�80 gpd Design flow provided `y gpd Plan: Date 3 11 o 1 Number of sheets / Revision Date Title f-AS..,Lr-a-C.E 5n-4 Description of Soil(s) 1Ae.3p Soil Evaluator Form No. Name of Soil Evaluator D, J9r`F''3�" ' Date of Evaluation - 7 o-x DESCRIPTION OF REPAIRS OR ALTERATIONS ,LLPL4-C-C Ce7SP'J` ` 1,5Z0 G'+L"-0' J 40n A's"09 A .2f'c.$ /3 sn X�'/� 4e4vd-/t66, ,L CL-j z4 M The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of UvL TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed -- D to J �U `d 9nS e `%-- FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 i T ?W7 TF + 77' h» �• ' °N`y •. :, �..R'u"'R t 4�' '#.1' �°"K....» y. .-�:. ..•l'...�'S•'+1`"��,:fi.k F .Y x- .-.. 1,+� Mir- ,d } - c • ' 1`/ i. ^ a THE COMMONWEALTH OF. ASSACHUSETT�r •` ' '•` FEE J` v lT BOARD OF HEALTH , ( APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade (A j Abandon ( ) - XComplete System ❑Individual Components 3a o Pry/NN 2Y1 C �i �,uv1�++drt(�& [ 644 o-v A,+tee A- ''�-"" ocation gwner's Name Map/Parcel# Address Let G✓rLL/.9-ran A051NSpNeo� 7,2L Se,.d .769/Lcr Z),+,JreL J gZS Installer's Name Designer's Name tod,9 LC "T'tra.-JtLL'L' $oy r�AI� Sit f "re b e757�ri-v�LL� Address Address (soal Sa9.. �7�b ("s-v� �i� -lyo9 Telephone# G Telephone# Type of Building: /tot~lr~r4� Lot Size Sq.feet Dwelling—No.of Bedrooms 2 ?-'-*ts �bC'1/6-r+ A11-3 (CA-]77UL Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. e wired) �20 gpd Calculated design flow _1230 gpd Design flow provided j gpd Plan: Date 3 11,11 1 Number of sheets / Revision Date Title (�OAJ✓4-t=tY -stri-4-s-sY _01Stpalk'L J YfTs" Description of Soil(s) AA er4- G.op,t-,I B' t44-•110 Soil Evaluator Form No. Name of Soil Evaluator 0, J-"''s'"I Date of Evaluation I -7 a1 DESCRIPTION OF REPAIRS OR ALTERATIONS AePL4-me 6'e7spQat. `'(J/Sao Cr4L"✓' JeP?v C C The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of l rvl_ TITLE 5 and further agrees �not �to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed r"" C�w� -r DateU n�'spec ictits 6 V I FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ——— —— ..�mNo• ` i/ THE COMMONWEALTH OF MASSACHUSETTS FEE �� l2Fvs3C� 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 -q 0 Ny 11)t'l� C a (/\J I o /U has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built l� plans relating to application No-0'_ D I1�jdated <��U Approved Design Flow (gpd) Installer 4 77 Designer: Inspector N 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. -I� THE COMMONWEALTH OF MASSACHUSETTS FEEV ' �f7QF� � BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( )�epair ( )Upgrade /!(� Abandon ( ) an individual sewage .disposal system at S C� /\ P ( as described t , in the application for Disposal System Construction Permit No. c� dated Provided: Construction shall be completed within three year's of the date of this p rmit. ll local co .Itions must be-met. Date (��( Board of Health �` (/ v FORM 2 - DSCP DEP APPROVED FORM S/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN'M PUBLISHERS- BOSTON sruiot NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, JD+/Y16-L J't+" .1=,dV , hereby certify that the engineered plan signed by me dated concerning the property located at meets all of the following criteria: -- • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. •- The soil is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable) Please complete the following: A) Top of Ground Surface,Elevation (using GIS information) q 6 B) G.W. Elevation +adjustment for high G.W. 6`4 - DIFFERENCE BETWEEN A and B S Q do Tci r P/r SIGNED/" DATE: NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. a q:health folder.percexmp 1500 GALLON SEPTIC TANK � Lf�N OF SEPTIC- 5 l STES --- - - - MODEL TK•1500(SHEACONCRETE) (OREQUIVALENT) SCALE:: I "=;o' FINISHED GRADE TEST PIT DATA = 24"DIA _ 24"DIA. -9"(MINI 24"DIA Prformed By: Daniel B. Johnson 3„ 3" H 10 6.. 6" Dte: March 7, 2002 To 4"SCH 4o 4!'SCH 40 10' FLOW LINE 14" ZABEL FILTER A-100 . T-1 QEL. = 97.8) SEPTIC TANK TO MEET 0' - 11" A , 10YR4/3 Sand loam 4"SCH 40 TEE 4'LIQUID LEVEL REQUIREMENTS OF P Y GAS BAFFLE 310 CMR 15.226 FOR 1' - 2 6" Bw, 10YR5/8 Loamy sand 4"SCH 40 WATER TIGHTNESS, 97t� 2" -T32" C1, 2.5Y8/2 Medium-coarse sand TEE ETC. 4 N Observed ESHWT ALL WALL SLEEVES/GASKETS a g?� N Observed Groundwater SHALL BE CAST IN PLACE OR 4 6" (MIN•) � MECHANICALLY - -------- INSERTED AT FACTORY. o COMPACTED CRUSHED STONE PERCOLATION *BEST DATA STABLE LEVEL BASE <-3/4'DIA. SEPTIC TANK DIMENSIONS: 10' 6"L X T 8"W X 5'8"H Dte: March 3, 2002 Sil Class: Class I (0.74 G/SF) -- �N� (r3---� �- Dx�u�Eu"s - - DISTRIBUTION BOX x�N1 P:rc Rate: < 2 MPI (TP-1) H•10 Q'Sc d 4 0 1 • 91 I S-•a 1 TT REMOVABLE COVER „ • Dpth of Perc Test: 26 - 44 ! d SCH 40 OUTLET LATERALS b r�97,8 L DISTRIBUTION BOX TO MEET MINIMUM OF THE FIRST ALL BE SET LEVEL OR AO SCHEDULE OF ELEVATIONS REQUIREMENTS F 3110 CMR 15.232(WATERTIGHTNESS, FEET AND CONNECTED TO D-gO� _ �, � •� 98 CONSTRUCTION,ETC). 2�� EACH DISTRIBUTION LINE 98 _ _ r Ilv. Out Foundation (exist/approx) 97 .0 (1) WITH SOLID SCH 40 PVC PIPE Iiv. Out Foundation (exist/a rox) 98 .1 (2) 4"SCH40 6" pp NO. OUTLETS: 2 17' q�s�►Iq° O ° 6" MIN) o MECHANICALLY CRUSHED Il,v. In Septic Tank .5 G,+Ar46rljNev s ,oz3 I)v. Out Septic Tank 96.35 0 0 ( 0 0 0 " rS�IrKftao,,� h.v. In Distribution Box 95.80 STONE(<=3/4 DIA.) r„ic'i Iz� STABLE LEVEL BASE Iiv. Out Distribution Box 95. 63 4''scd 4o a.u�+° SEpr�c TANK Iiv. In Leaching Dry Wells 95.50 s', 1 , A 13- 5.. Bttom of Leaching Dry Wells 93.50 E)ttom(TP-1) No Obs . GW/ESHWT 86.8 LEACHING DRY WELLS-500GALLONS LEGEND "END"CROSS SECTION MODEL: SHOREY PRECAST CONCRETE 99 Fxisting Contour - - - 98 - - - FINAL GRADE TO BE STABILIZED FINISHED GRADE(SLOPE=.02) Eroposed Contour 98 I!I I I I i! 1= I1 I e 611sr11 (f 99tA �ESS�oo4 12"(MIN) M Test ]Pit o H-10 99WELLS: 0 0 0 0 1/4"•1/2"DOUBLE LEACHING DRY 2 o O Finislhed Floor Elevation FFE 4 o 0 0 4' WASH PEA STONE 8'6"LX4'l0"WX2'1"H EYISrINb �{a�§E Basement Floor Elevation BFE OVERALL LEACHING EAWX2GHAREA: 0 0 2'1" o 0 3/4"-111Z'DOU8LE eQ E: oh�'� WASHED STONE t/1 L•a A'� 100,0 0 Ca 0 0 0 o Qb�tu Water Line .--.�,�. W 5 aw' g�JG 'G LEACHING DRY WELLS ' Gas L'Ine —�-� G TO COMPLYWITH THE 8'6"1 REQUIREMENTS OF 310 CMR 15.252 JIT CENTERVILLE . GOp/G LITTLE. „ 1 Gvt4G PO NT tiY as I V GREAT I Est° ,P NOTES POINT a Wgtit W :v r , • ; Py ; o s � � - oA ` 1, All construction methods shall conform to the Title V (310 yANCY'J CMR 15) and the Barnstable Board of Health Regulations. r W ae nu,sscr ,co w �� •' H,pF,' '••e �Q Cq,tE• DR h3 O 'N��l� r 0` �P �REt ao yZ f' e 4 s� �pJcogTTErotiEs 2 . There are no known private or public wells within 100 Ro 4? ?.a Ngr/AN a IW 3 :~ 4�A° RRpFNt 'Cr v RD areafeet/400 feet, respectively, from the proposed leaching t^ (' N°U l CAPE �r'e4cEf—c. �AaRcK T 4 eRE 4P oQ u'I L��Q tFAI �r�V MAID FARMS c ZNER y6 rpa gttNE L°LDS �� 3. Existing cesspool to be pumped and removed prior to rr o 0 BLVESERRY H/LL RD Iv �= o installingthe new septic tank. 23 a�0 6�NA o P O O !EE L 2 � N P p p ICE o cr z V o� 4 I �Pt�pP �¢a tEReu- �/ �/ C L A/o/� , ° ; e° Storrs- "ESr '�}0 �� !`` o eP°�r 4 . No changes are to be made in the field without the approval /lu�G f J a� �P 9 N DALE N P Qr5° RO R MApV a r of the Board of Health and the design engineer. L (J/VG POND s. i sr rE� ', 5. Proposed leaching area is not designed for use with 6tf /vr,A �D tiw o °, s9 4v garbage disposal. Al G «�+ a e Q y! o( f !/ Ter-' V 'F� W G 2 �•Q` 2 W e HILL NNON ( �� °a 0 T 9Pc a I �� J P C�ry�` °Aµ RD LA CP 6. Contractor to notify Dig Safe 72 hours prior to SC�CE`: �5 �lFOM•►/d r v°°��,a • �� a ' `� � � a W 9a � Ao<f�.r..-' o�, Y g o�c e o t,ND'A construction. ( 800) 344-7233. 991 >`�P o Q Pot m x PANE $T 9 y dl fit' CAAL RD z� 7 . Property line information taken from Subdivision Plan Ate= I t e DR ' e�tsrinlo- 6,L4-off ors "��-st J �� o LA; o ? C Q 9�� `BAN `y „RE prepared by Baxter and Nye, dated July 25, 1984 . Reference --... "`"�•.�� \� •�!N 2 3 ? a 4� Q °r orrq AV pp3r _eLA �, 0 Book 389, Page 86. Septic Plan not to be used as a property line survey. CALCULATIONS 2 Bedrooms (Existing) � �'- 110 GPD/Bedroom X 2 Bedrooms = 220 GPD 96- 1'o ��N. �'•`vk Percolation Rate - < 2 MPI (TP-1) s'•O (APJA0Y E,cl.�t� 6,Sn 96.�5 r 4 su .�, r=of-- Soil Class: Class I (0.74 G/SF) 9S Sa 563 Septic System designed for 3 bedrooms per Title V PROPOSED LEACHING AREA: ►t Leaching Dry Wells: 2 at 25' L X 131W X 21H I q `y3so Side Area: 152 SF X 0.74 G/SF = 112. 5 GPD y �rS77t lr�T`[vnl ,Z C�,Qcif�.tl�r Bottom Area: 325 SF X 0.74 G/SF = 240 . 5 GPD box � � wrr«S Total Leaching Capacity: 353. 0 GPD 9z /Soo GA�L�oe�l SEPT[c. TF1nLK ,?5•'L� /'�1�K o,S`hf J J z 69 Z gd N 0 W W z Q -._.....�. .. -.._ IL SUBSURFACE SEWAGE DISPOSAL SYSTEM 0 r 9i.,,,.....•...,,.,4z,^�,,, o p �,.�� )I-tr�.�.L•"� 300 Phinneys Lane, Centerville L�114g�-L Ix LL ___. �` l APPROVED BY DRAWN BY d NO O 95 (p•yN � t ®NJ ` i� SCALE: As Shown w Na ag S Ef 11w r rAy 0.1077 DATE 3/18/02 Daniel B Johnson D.B. Johnson ;• Prepared Gordon Baker For: 300 Phinne s Lana Centerville MA 02632 o+oo c�+Io o+xri D+3 a d+@0 ptso 0+6 o If2 a TA��<�s-' PreparecE DOMESTIC SEPTIC DESIGN, INC. (508) 420-1904 DRAWING NUMBER J Hog, I C/o� 3 f�8/0; BY: 804 Main street, Suite B, Osterville, MA 02655 J-758 ` _ l