HomeMy WebLinkAbout0315 PINE STREET (HY - Health k315 Pine Street — f
�
Centerville F/R A = 228 k047 ..
0�iford. NO. 1521/3 ORA
10%
i
TOWN OF BARNSTABLE
Gi
LOCATION ' ��"�� SEWAGE #
VILLAGE co--7- ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY le. , �✓®
LEACHING FACILITY: (type) '�"/G`C4 (size)
NO. OF BEDROOMS
BUILDER.OR OWNER
PERMITDATE: COMPLIANCE DATE: J;e-
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 3.00 feet of leaching facility) Feet
Furnished by
ye�s�
A,
,q 17E7
c
. o
GEC � 5"
�� F
1 J A
fa Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
��9 , 6 01pprfcatton for �topaar bpgtetn Conotruction Permit
C,OJ
Application for a Permit to Construct( bl'Repair( 4Jpgrade( )Abandon( ) O Complete System El Individual Components
Location Address or Lot No.r `4'/.v�J�" /-e4A,/, Owner's Name,Address and Tel.No. r
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building �'C'`�' No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ®° gallons per day. Calculated daily flow ® gallons.
Plan Date 0;5�1 Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue�d,4 this Board of Health.
Signed C Date , �d
Application Approved by Date
GO—
Application Disapproved for the following reasons
r
Permit No. Date Issued
TOWN OF BARNSTABLE
LOCATION >''� SEWAGE#
VILLAGE
e:``'°' ASSESSOR'S MAP &LOT
INSTALLER'S NAME-&HONE NO. �r�°"` `' I
SEPTIC TANK CAPACITY ✓ �'9 �' ' '✓`�
LEACHING FACII.IZ'Y: (type) (size)
NO.OF BEDROOMS 't=�Ke< o <-� •� '
BUILDER OR OWNER
PERMIT DATE:
� �'a� COMPLIANCE DATE: " 7✓��
Separation Distance Between the:' P
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 Feet
within 300 feet of leaching facility)
Furnished by
A
c
A '7 o
AG
gD a F
.,e
0 jp y
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN 01�-BARNSTABLEs MASSACHUSETTS
` r� 0.ppfication for Mig;poaf *patent QCongtruction Permit
` Application for a Permit to Construct(lJr epair( L)*tpgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No.� -de/./✓E�lJ� a.►.j_ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�y P 'pj?
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building �PF-r• No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �' y gallons per day. Calculated daily flow 3 O gallons.
Plan Date 4?n>4e-c. -M 9, oSe, Number of sheets _ Revision Date
Title
Size of Septic Tank /�t o� � Type of S.A.S.
Description•of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned on-site agrees to ensure he construction and maintenance of the afore described on site sewage disposal system
in accordance with.he provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Board of Health.
Signed 0 Date
Application Approved by _ ./ :� Date
Application Disapproved for he following reasons r
Permit No. Date Issued l
'
- --- --.----------------------
—a— -----_
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( 1.4 Upgraded{
3 I�Abandoned( )by
at "'T-3 i��'.f? G �'J✓�' has been constru ted in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. r a _ '1 dated L
Installer !! Designer �''�� - _
The issuance of s permit shall not be construed as a guarantee that the7system will function as de i-ned.
Lute inspector .1
NA-Z Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
Migozaf *pztem Congtruction Permit
Permission is hereby granted to Construct( )Repair(j�Upgrade( )Abandon( )
System located at .r' c!!!�
and as described in he above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Constructi /uss b6 completed within three years of the date of this frmi/1.
�
Date: !�/ A roved b !
_ � PP Y
Apr 08 05 10: 12a p. l
ft l
v'1k.
Town of Barnstable
Rory Services
' L Thomas F Ceder.lhrcMr,
was fabric HadthDivision
Imorms McKee,Director
20 Mailm Street;Hyamis,MA 02601
Office: 508.862-4644 Fax. 508-790-6304
Installer&Des' CartWication Form
Date: dD
Resigner: 1.=G0 �� -'" 1 Imstaller -1
Address: ( 2 t ^Lyt A,ddrew:
t
On +' �D 4-5-
was issued a permit to inslv�il a
�/ �(4-,Cg� 1�)
septic system at based on a desipp&t xm by
teas) ✓d9e C
4Q1"datcd
�...o ..,., ``
I cttiify tho the septic systct:n mfermeed above was installed`snbstantially according to
the d�whwb many melnd�e rs m"appt'oved dougm such aS Laiexatl relocation of the
distaffion boat=&or se PM tank.
I cetW that the septic systm referenced above was installed with t *jW chi (i.e.
V+acr than 10'Deal tclocaotkm of tote SAS or any ver ical rdocation of any eoK."nent
of the septic systo n)but ion a&ooardanm with State&Local RegniatiOm Plan revision or
oecti5ed as-built by desiVm to foil".
er's 7mt=)
S S• ) ^— (A�1I DCSlgriet''S$lamp 1'Iere)
PLEASE .A�BtJE usx.nC R�E�A�.'i'I!t>D _ CIER7l7[1HI �
o CoN vtnaa� tvoT soma col A ws-
D —CA"ARIL:RECh�BD UY BAlEt1VSTASLE pUXIIC HEALTH DIVISION.
T9AMIK YO x
Q.HealthtscptfeNesigner Canification Form
COMMONWEALTH OF MASSACHUSETTS S S
kiwi131 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL,PROTECTION
FAILED INSPECTION �'r 1VED
k;nv 1 7 2004
,oe b-tRNSTABLE
TITLE 5 1-iEALTH CREPT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 315 Pine' Street
Centerville PARCEL.
Owner's Name: Anne Palmer
Owner's Address: 20 Ftri arwnorl Lane- LOT
Date of Inspection:(,
Name of Inspector:(please print) Wi 11 i am _ Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
I certify that l have personally inspected the sewage disposal system at this address and that the information reported
below
o is true accurate and as complete of i p 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
Co itionally Passes
eds Further Evaluation by the Local Approving Authority
Fails
Inspector's Sigdature: Date: 6- .-6
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr
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 appro.ving
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.
A Title 5 Inspection Form 6/15/2000 page i
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART,A'a ►, . �. . ._.. a
CERTIFICATION(continued)
Property Address: 315 Pine Street
Centerville
Owner.• Anne Paimer
Date of Inspection: 4-0
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syste Passes:
1 hav not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 3 0 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Co ditionally Passes:
One or ore system components as described in the"Conditional Pass"section need to be replaced or
repaired.The sy tem,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,do r not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The se p is tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,cxhi its substantial infiltration or exftltration or tank failure is imminent.System will pass inspection if the
existing tank s replaced with a complying septic tank as approved by the Board of Health.
•A metal se 'c tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating t the tank is less than 20 years old is available.
ND expla'
O servation of sewage backup or break out or high static water level in the distribution box due to-broken or _
obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approv I of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain.
The s stem required pumping more than 4 tunes a year due to broken or obstrwed pipe(s).The system will
pass inspectio if with approval of the Board( PP of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 315 Pine Street
Centerville
Owner: Anne Palmer
Date of Inspection: .
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 fail' to protect public health,safety or the environment.
1. ystetn will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
s sten::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. Sy tem 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
su face 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 front 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. (her:
3
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 315 Pine Street
Centerville
Owner: Anne Palmer
Date of Inspection: 0L
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
PI 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
_Lb Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool
s _ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
hb Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
,o Any portion of the SAS,cesspool or privy is below high ground water elevation.
_o Any portion of cesspool or privy is within I00.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.
�o Any portion of a cesspool or privy is within 50 feet of a private water supply well.
kO 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.lThis system passes if the well water analysis,
performed at a DEP certified laboratory.,for colfform 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 S ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
J�t:J (YesfNo)The system fails.1 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 +;ill be necessary to correct the failure.
E. Lar a Systems:
To be co idered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd•
You must' dicate either"yes"or"no"to each of the following:
(The follow' g criteria apply to large systems in addition to die criteria above)
yes no
the sy rem is within 400 feet of a surface drinking water supply
the sys cm is within 200 feet of a tributary to a surface drinking water supply
— _ the syst m is located in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)or a mapped
Zone 11 of a public water supply well
if you have answ ed"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section above the large system has failed.The owner or operator of any large system considered a
significant threat rider Section E or failed under Section D shall upgrade the system in accordance with 310CMR
15.304.The sys m 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: 31 5.-Pine Street
Centerville
Owner: Anne Palmer
Date of Inspection:/L G
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
_A::�?.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?
_ JLd Has the system received normal flows in the previous two week period?
Ii-0 Have large volumes of water been introduced to the system recently or as part of this inspection?..
/LU 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?
(J3 _ Was the site inspected for signs of break out?
S— Were all system components,excluding the SAS,located on site?
UlaWere the septic tank:manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles ortees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ 4� 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.
A 5 _ 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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION
Property Address.. 315 Pine Street
en ervi e . .
Owner: Anne Pa mer
Date of inspection: " —0`-
FLOW CONDITIONS
RESIDENTIAIs'
Number of bedrooms(design):. 3 Number of bedrooms(actual): '7
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x i1 of bedrooms): .
Number of current residents: L p
Does residence have a garbage grinder(yes or no): v
Is laundry on a separate sewage system(yes or no) e) [if yes separate inspection required)
Laundry system inspected(yes r no)-
Seasonal use:(yes or no).L4i
Water meter readings,if a ilable(last 2 years usage(gpd)): 2 0 0 3 — 8, 0 0 0
Sump pump(yes or no):Jj�,U 2002 — 12, 000
Last date of occupancy:
COMMERCIAIVINDdSTRIAL
Type of establis ent:
Design flow(bas d on 310 CMR 15.203): gpd
Basis of design w(seats/persons/sgft,etc.):
Grease trap pres t(yes or no):
Industrial waste olding tank present(yes or no):_
Non-sanitary wa to discharged to the Title 5 system(yes or no):_
Water meter rea ings,if available:
Last date of occ ancy/use:
OTHER(descri ):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part the inspection(yes or no):,!!LP n
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping: y
TYPE OF SYSTEM
_ tic 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 c om ponent$,date installed(if kn wn)and source of information:
Were sewage odors detected when arriving at the site(yes or no):/5-6/
6
Paw 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0RA1
PAItT C
SYSTEM INFORMATION(continued)
Properly Address: 315 Pine Street
Centervi le
Owner: Anne Palmer
Date of lnspeetlon: yr—i��
BUILDING S VER(locate on site plan)
Depth below gr de:
Materials of co struction:_cast iron _40 PVC_other(explain):
Distance Gont rivate water supply well or suction lute:
Comments(o condition of jui nts,venting,evidence of leakage,etc.):
SEPTIC TANK:_ locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene
_oUxr(explain) —
If tank is metal list age: Is age confnnned•by a Certificate of Com pliance es or no):
certificate) 1 O' —(attach a copy of
Dimensions:
Sludge depth:
Distance Gorn top of sl dge to bottom of outlet tee or baffle:
Stunt thickness: /�—
Distance from top of s um to top of outlet ice or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
I low µ•ere dimension determined:
Comments(on pum ing recommendations, inlet and outlet tee or Wile condition,structwal integrity,liquid levels
as related to outlet ' vcrt,evidence of leakage,etc.):
GREASE TRAP: (locate on site plan) -
Depth below gra :_
Material of con ction:_concrete metal Fiberglass�iolyethylene__other
(explain): _ —
Dimensions:
Scull)Chic css:
Distance ont top of scum to top of outlet tee or baffle:
Distant from bottom of scum to bottom of outlet ice or baffle:
Date o last pumping:
Con Items(on pumping recommendations,inlet and outlet ice or baffle cunditio:n,structural integrity, liquid levels
as related to outlet invcrl,cvidcncc of leakage,etc.):
7
I - ,
Page 8 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO101
PART C
SYSTEM ►NFORII-IAT►ON(continued)
Property Address: 315 Pine Street
en ervi e
Owner: Anne Palmer
Dole of Inspection:_ --o
TIGIIT or IIOLDING T K: (tank must be pumped at time of ins pection)(locate on site plan)
Depth below grade:
Material of conswctio ___concrete_lnelal_fiberglass__polyethylene other(explaul):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alann present(ye or no):
Alarm level: Alann in working order(yes or no):—
Date of last pu ing:
Corrlments(co dition of alann and float switches,etc.):
DISTRIBUTION BOX: if present must be opcncd)(locatc on site plan)
Depth of liquid level abov outict invert:nti � 49 �
Comments(note if box i evel and distribution to outict/equal,any evil ee oT s Irds carry-over,any evidence of -
leakage into or out of b x,cic.):
IWIP CHAMBER: cats on site plan)
Pumps in working order yes or no):_
Alarms in working or r(ycs or no): _
Comments(note col itloll of l)ulilp cllatllbcr,condltioll of llui11l1S arld al)l)urlcnanccs,ctc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 315 Pine Street
en ervi e
Owner: Anne Palmer
Date of Inspection: ' " " G L
SOIL ABSORPTION SYSTEM(SAS):\ (locate on site plan,excavatiodnot required)
If SAS not located explain why:
Type d
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
� eaching fields,number,dimensions:
r/ overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: i (d
Depth—top of liquid to inlet invert:
Depth of solids layer: j
Depth of scum layer: t,
Dimensions of cesspool: a
Materials of construction: 13/e,
Indication of groundwater inflow(yes or no):
Conan is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (loc eon site plan) _
Materials of con ction:
Dimensions:
Depth of soli
Comments( to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: 315 Pine Street
Centerville
Owner: Anne Palmer
Date of Inspection:/ ^ —P'L
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.
�)
t �1
i
10
Page 1 I of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
Property Address: 315 Pine Street
Centerville
Owner. Anne Palmer
Date;of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water I 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:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
S d S
I1
PLAN REFERENCE CONTOURS o
A � Z �
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( ELEVATION - 551 A9 CLEANOUT PLUG--r
I I I 1 USGS DATUM ASSUMED
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LL 3 <u- co -� c O 20 6 4
0 LL 6 0 u I SEWAGE DISPOSAL SYSTEM PLAN
ry I p F- I I -TO SERVE EXISTING DWELLING
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g AREA - 22436 s f +-
315 PINE STREET CENTERVILLE. MA
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4� tn u) � N; 43 TRIANGLE CIRCLE SANDWICH MA 0256
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88-5 f, 508 364-0894
,Q ETE-1895> DEC 30. 2004 1/2
PLAN1 N THS PLAN IS TO BE CONSIDERED A DRAFT PLAN UNLESS IT
BEARS TFIE STAMP AND SIGNATURE OF THE DESIGN ENGINEER4 SCALE. 1 in - 30 ft ORIGINAL PLANS INTENDED FOR SUBMITTAL TO TIE BOARD
OF HEALTH WLL BE SIGNED N BLUE-AND STAMPED N RED.
SOIL TEST LAG D5*,,SlGN CALCULATIONS
DATE OF TEST: DECEMBER 29. 2004
SOIL EVALUATOR: DAVID D. COUGHANOWR, RS DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD
WITNESS REQUIREMENT WAIVED - NO VARIANCES SOUGHT
SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS
GROUNDWATER
TEST PIT - I PAORENTT MATERIAL: E ROGLACIALDOUTWASH INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED)
PERC AT 74 in : 2 MIN/INCH IN C SOILS
ELEVATION - 55.85 {- DISTRIBUTION BOX: USE 3 OUTLET D-BOX.
DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOIL ABSORBTION SYSTEM: A 24 ft x 12.S ft x 2 ft LEACHING GALLERY CAN LEACH
(INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING
Abot - ( 24 x 12.5 ) - 300 sf
Asdw - ( 24 { 24 12.5 + 12.5 ) x 2 - 146 sf
0-10 Ap SANDY LOAM 10 YR 3/3 NONE FRIABLE A t o t - 446 sf
10-38 B LOAMY SAND 10 YR 4/6 NONE FRIABLE Vt 0.74 x 446 - 330.04 GPD
38-58 CI COARSE SAND 10 YR 4/6 NONE LOOSE USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED
58-144 C2 MEDIUM SAND 10 YR 6/4 1 NONE LOOSE
GROUNDWATER ADJUSTMENT
LEACHING GALLERY
EXISTING GROUNDWATER LEVEL
BASED ON TOWN OF BARBSTABLE CONSTRUCTION DETAIL
GIS DEPARTMENT RECORDS.
I r—DRYWELL UNIT STONE
INDICATED GW 20.0
8'-6'x 4'-10'x 2'-9'
INDEX WELL MIW-29 2 ft EFF. DEPTH
ZONE D 24.0 f t
READING DATE NOV. 2004
READNG 9.2
ADJUSTMENT 5.8
ADJUSTED GW 25.80 r�
ul
r&i"O T E-4,'S "
1) ARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN I 3.s 8.5• 8.5" 3.5'
2) ALL -LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 24 0 ft NOT TO
t 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS SCALE
OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15)
4)- 1N'STALLER TO., VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES
BEFORE EXCAVATING FOR SYSTEM.
5) EXISTING CESSPOOLS TO BE PUMPED. COLLAPSED. AND FILLED, OR REMOVED
6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE
7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-O- BEFORE PITCHING DOWN
8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES SEWAGE DISPOSAL SYSTEM PLAN
AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK -TO SERVE EXISTING DWELLING
9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT
PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. ANNE C . PALMER
10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 315 PINE STREET CENTERVILLE, MA
11) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL
STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH ECO TECH. ENVIRONMENTAL
SIX INCHES OF . CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING
43 TRIANGLE CIRCLE SANDWICH MA 02563
ETE-1895 IDEC 29, 2004 2/2