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HomeMy WebLinkAbout0613 SHOOTFLYING HILL RD - Health E= 193 OTFLYING HILL, CENTERVILL 09 UPC 12543 No. 53LOR HASTINGS, ON { TO Ni+ .4 Fla.. 'ABLE `. f,OCA'FK?I�i �013 � �� k A+OE7777777 ASSESSOWS,if AP _ILOT SBP. C'I`A IK CAF�AC 35ACf G FACII1''1�'{typo} •" .. {s'eze) ____ � ___ PB1I"FF� �.. �C31�r�L�IC��-SATE.' �aparationD�t�nc�B�reon Vie' bra ac u►m Ac pst, Ca n wat''Ua IM the Bat�om of�eachir�Fa ty feet i?nxat�f�fatat St�p1y1�aU andiug Fac�Y £ffany'�( �i�t ottdts�nr an�tb3nOQfdat of Tig377 txiS¢vi IN— and Leaci '� U� Y wctlau3s exist within�Qtl'feet nE:teac6xa�f8s' y � `F t, I �C,-e` 1 A- a - 174 " � .� _37 .6G II r 93f Commonwealth of Massachusetts Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I,t 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville ✓ MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection c "r e�I 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. A. Inspector Information '5bow- Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address East Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);l have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 8-13-2020 inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Ell Title 5 Official Inspection Form i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >¢` 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) . 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: System is in good working order with no sign of failure. 2) 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 El ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. . . 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 El ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form w_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ or Cesspool privy is within 50 feet of a surface water P p Y ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes .' No El ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form h. 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments %i 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® -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 1/2 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 1 of a public water supply 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, t 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ra ,w Title 5 Official Inspection Form i i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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? ® ❑ Wasthe 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ,. Title 5 Official Inspection Form M► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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: Sump pump? ❑ Yes ® No Last date of occupancy: 88-2020 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts ' � ,. Title 5 Official Inspection Form ! i°I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r a 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner----pumped 12-2009 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lb) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12"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.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form F�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 611 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: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,.; Title 5 Official Inspection Form Yl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _� 9 p Y rY :. > 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is Centerville MA 02632 8-13-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °r 613 Shootflying Hill Rd. Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 12-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i� ws F�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrator field in good working order with no sign of back-up into d-box or surrounding stone. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form Ibi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � ,Ya 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of inspection D. System Information (cont.) 14. 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 7 i /7 316 Gr P3 A -J 0-2 '^�` it :16 . a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form i') Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a >` 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is required for every Centerville MA 02632 8-13-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 102" 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 yo u u established the high ground water elevation: Original design plans show groundwater encountered at 102". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form i,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Harold Dean Owner Owner's Name information is Centerville MA 02632 8-13-2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 / O v Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Cityfrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification ;` . C I certify that I have personally inspected the sewage disposal system at this add'(ess and A6t thm 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 mainten a of t site sewage disposal systems. I am a DEP approved system inspector pursuant#o Sectioa15. 0 of Title 5(310 CM 15.000).The system: m ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority XA�� 7-26-11 Inspector's Signature Date The system inspector shall submit,a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,.the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. """"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Lkl� v �( t5ins•11/10 T I AVe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 .0 Commonwealth of MassachLsetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 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: System is in good working order with no sign of failure. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5.1 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. Cityfrown 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): system ElThe y em 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. Citylrown 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 '/day flow t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 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- 1 0,000g pd. ❑ ® 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 of10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes"or"no"to each of the following, in addition to the questions in.Section D. Yes No ❑ ❑ the system is within 400 feet of.a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El he' 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 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 (f 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•11/10 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 �M g 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: I Number of current residents: 2 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: Sump pump? ❑ Yes ® No Last date of occupancy: 7-2011 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 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: N/A 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) (f 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12' 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.): Good condition. Septic Tank (locate on site plan): Depth below grade: 3" 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: 12.. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 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 14" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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-11/10 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 M a 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. Cityfrown 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 worldng 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-11/10 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 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of leakage. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 12-infiltrators ❑ 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.): Infiltrators in good condition with no sign back-up into d-box or surrounding stone. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 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 4 6 Ci A L /3 ---_� 0 E:2 QrOp 6J ' t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated d 102"depth to high ground water. 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 9 you established the high round water elevation: Original design plans show groundwater encountered at 102,.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 613 Shootflying Hill Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 7-26 11 page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 t. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A p CERTIFICATION /gj 00 / Property Address: 613 Shoot Flying Hill Road —o* Centervi e Owner's Name: Todd Picknik Owner's Address: Date of Inspection: � S a D� Name of Inspector:(please print) W i 11 i am E_ . Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA ` Telephone Number: (5081 775-8776_ 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 ction 15340 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: 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 approxing 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. REC Title 5 Inspection Form 6/15/2000 page 1 MAR = 0 ZCC TOWN Or AELE HIiALTH DEPT r — . '1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 613 Shoot Flying Hill Road Centerville Owner: Todd Pieknik Date of Inspection: Z. Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A.rScm Passes: have not found an information which indicates at y 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 exftltration 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 broke or obs>ztKtcd pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is mnoval ND explain: P Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 613 Shoot Flying Hill Road Centerville Owner: Todd P ' knik _ Date of Inspection: $ Roa o G 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(i)(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 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 frond 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 colifonn 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 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 613 Shoot Flying Hill Road Centerville Owner: Todd Pieknik Date of Inspection: S Roold D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/- _ �/ Backu of sewage into facility or stem component due to overloaded or clogged SAS or cesspool P Y g Y P P Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool J Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or /cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _ 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 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(his form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large sys em (he 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 sinfact drinking water supply - the system 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 answered"yes"to any question in Sedion 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.rcgional office of the Department. 4 Page S of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 613 .Shoot Flying Hill. Road Centerville Owner: Todd Picknik Date of Inspection:_ 3 E aoo to Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes �_ 7Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? v _ 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? V _ Were as built plans of the system obtained and examined?(If they were not available note as NIA) V _ Was the facility or dwelling inspected for signs of sewage back up? . v Was the site inspected for signs of break out? P g - Were all system components,excluding the SAS,located on site? v _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of thh baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? v — 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: no Existing information.For example,a plan at the Board of Health. 7— 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: 613 Shoot Flying Hill Road Centerville Owner: Todd Picknik Date of Inspection: 3 i; aoo FLOW CONDITIONS RESIDENTIAL 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 6PtD Number of current residents:_d Does residence have a garbage grinder(yes or no):,^) Is laundry on a separate sewage system(yes or no):No (if yes separate inspection required) Laundry system inspected(yes or no): A/IA Seasonal use:(yes or no): /Jo Water meter readings,if available(last 2 years usage(gpd)): 2005 — 36, 000 Sump pump(yes or no): /VD 2004 — 32, 000 Last date of occupancy: C.r11CA COMMERCIAL/INDUSTRIAL A/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): ry 0 If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: Ty"-OF SYSTEM V 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 ob_tained 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: p 'p Sta.+rCc L)�" -L✓I�'+� Mc.'flu — 1"�G`U ��4N O.v Y �� Gil- �Dw.� Jf /7 tir n5 Were sewage odors detected when arriving at the site(yes or no): Na 6 ]'age 7 of I I OFFICIAL INSPECTION FOR AI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F010.1 PART C SYSTEM INFORMATION(continued) Property Address: 613 Shoot Flying Hill Road Centerville Owner: Todd Picknik Dale of Inspection: 3 S 8a>4- BUILDING SEIVER(locate on site plan) Depdi below grade: Id j 1 Materials of construction:_cast iron ✓ 40 PVC_other(explain): Distance from private water supply well or suction lute: Comments(on condition of joints,venting,evidence of leakage,e1c.): was were IN 4 d Cotic(lkL, IjD ov,d e ve of LPs�cfe SEPTIC TANK: ✓(locate on site plan) Depth below grade: (o 'I Material of construction: v concrete metal fiberglass�,olycOvlene _odur(explain) —' If tank is metal list age:— Is age confirmcd•by a Certificate of Compliance(),es or no):—(attach a copy of certificate) Dimensions:_ /Sbo ("I//o s Sludge depth:_ /o 1 1 Distance from top of sludge to buttom of outlet ice or baffle: 3' Scum thickness: / " Distance from top of scum to top of outlet tee or baffle: y/" Distance Goin bottom of stun,to bottom of outlet Ice or baffle: Id `r I low were dimensions determined:_ pPeoed tv✓,r ,,,d K� /ti'IC45�/'e.neadd. Comments(on pumping recommendations,inlet and outlet ice or baffle condition,structwal integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): oo�,l + ovflc� tte, ;•.�h4c% a-r�( n.tc_i�ru� Iun(.0 Irks S�u�cAgood. . _fin /�ia��neL �7< /ta�afG� lra/ti- /tic/ Sit✓c,l �4/�: GREASE TMI':_(locate on site plan) Depdi below grade:_ Material of construction:_concrete metal ftb.crglass�nolyediylene other (explain): — Dimensions: Scurn thickness: Distance Goin top of scum to lop of outlet tee or baffle: Distance from bottom of scum to bottom of outlet ice or baffle: Date of last pumping: Comments(on pumping reconirnendations,inlet and outlet ice or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 'age 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION F0101 PART C SYSTEM INFORIIIATION(continued) Properly Address: 613 Shoot Flying Hill Road Centerville Owner: Todd Pi kni k Date of inspection: 3�S f 2ooio /A TIGIIT or IIOLDING TANK:IV imik must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:—concrete_rectal fiberglass�wlyethylene other(explaut): Dimensions: Capacity: Rallons J Design Flow: gallons/day Alann present(yes or no): Alarm level: Alarm in working ordcr(yes or no):— Date of last pumping: Comments(condition of alann and float switches,etc.): DISTIUBUTION BOX: " (if present must be opcecd)(locate on site plan) Depth of liquid level above outlet invert: D'r Conunents(note if box is level and distribution to outlets equal, an)-evidence of solids caM,over, any evidence of leakage into or out of box,ctc.): -Qo,- INas level r,,c) q�0cl Co�cli�r�., `N C, So IlG�t CGr��0 ve- AD I S N f LPG j _piSfinbuh V ks eQye l -/-n a Il 7pv! oy ll�lc PUMP CHAMBER: / (locate on site plan) Pumps in working order(yes or no):_ Alarms in working order(yes or no): — Comments(note condition of pump chamber,condilion of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ 613 Shoot Flying Hill Road Centerville Owner: Todd Picknik Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required) If SAS not located explain why: Type leaching pits,number:leaching chambers,numb_er: leaching galleries,number: leaching trenches,number,length: ✓ leaching fields,number,dimensions: d.5,X a5' - l3 Tr�'l .s - �/�o�.� of 3 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.): 44�� Sa, L L-4S prr Np $fig, dF T�rG�fb�lic FJvr� ��� higS Naf c%na ?�G fiJv lief ivO t.+4/. CESSPOOLS: N/(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:�Q"(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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 613 Shoot Flying Hill Road Centerville Owner: Todd Picknik Date of Inspection: 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. L3ACK of Hooc- .i atuc �r I TANS - A-1 :ao' /3_! 1 31' ►7-Q ox A-2 8-P; tob 10 'Page 11 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 613 Shoot Flying Hill Road Centerville Owner. Todd Picknik Date..of Inspection: S 00 SITE EY4M Slope v1 Surface water ✓ Check cellar Shallow wells Estimated depth to groundwater yr+., feet 3etuv 5A.5 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: P'yh e­D+ ,;(w ,kz L-as hecl p dt'Si a Plcw o^ 41e c. %o- -0 12 si- b4e 5os,d or Peal4i. 11 a _ COMMONWEALTH OF MASSACHUSETTS I EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02108 617-292-5500 WILLIAM F.WELD TRUDY COXE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION 613 Shoot Flying Hill Rd c/o Matt Dupuy Property Address: Cerlterville, MA Address of Owner: Shaunna Wharton Date of Inspection: 1 2/31 /9 7 (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Service Mailing Address: PO Box 1 089, Cent ervi 1 1 a, r.'IA 02632 Telephone Number. 308j 7 7 r,-R 7 7 6 /u y 3 - Q Of CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and a tha information reported b is true, accurate and complete as of the time of inspection. The inspection was performed based on my training a proper function and maintenance of on-site sewage disposal systems. The system: � Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: 4* 1, LZ�yla- Date: / dL-3 r-V7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: Al SYSTEM PASSES: &A , have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:ltwww.magnet.state.ma.usldep �J Printed on Recycled Paper r - A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 613 Shoot Flying Hill Rd, Centerville Owner: Wharton Date of Inspection: 1 2/31 /9 7 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or.breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 613 Shoot Flying Hill Rd, Centerville Owner: WW3 F?9 7 Date of Inspection: D] . YSTEM FAILS: You ust indicate eir,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct he failure. Yes o Backup of sewage into facility or system component due to an 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LA GE SYSTEM FAILS: You ust indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The o er or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program require is of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM p PART B CHECKLIST Property Address: 613 Shoot Flying Hill Rd, Centerville Owner: Wharton Date of Inspection: 1 2/3 1 /9 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 613 Shoot Flying Hill Rd, Centerville Owner: I) /t 01n/9 7 Date of Inspection: 3 FLOW CONDITIONS RESIDENTIAL: Design flow: V'/O g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no):_,&:t) Laundry connected to system ( es or no):4.5 Seasonal use (yes or no): Water meter readings, if available (last two (2) year usage (gpd): e} Sump Pump (yes or no): Y d Last date of occupancy: a:3�1-1 7 COMMERCIAL/I N D USTRIAL: Type of establishment: Desi flow: gallons/day Grea trap present: (yes or no)_ Indus rial Waste Holding Tank present: (yes or no)_ Non- anitary waste discharged to the Title 5 system: (yes or no)_ Wat r meter readings, if available: La date of occupant),: OTH R: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: A 114 System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE Q YSTEM ./_ 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) -4^ O (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART C SYSTEM INFORMATION (continued) Property Address: 613 Shoot Flying Hill Rd, Centerville Owner: Wh rton Date of Inspection: 12�31 /97 B LDING SEWER: (Loc to on site plan) Dept below grade: Mater al of construction: _cast iron _40 PVC_other (explain) Dista Ice from private water supply well or suction line Diam ter Com ents: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on bite plan) ii Depth below grade:Material of construction: L. /Oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:-(;G• Sludge depth:_ 3 t Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: © %. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: ti Jwz tJ T-4 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) T��" �� ��✓ ��" ,mil l� I GRE SE TRAP: (local on site plan) Dept below grade: Mater al of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dim nsions: Sc thickness: D tance from top of scum to top of outlet tee or baffle: D tance from bottom of scum to bottom of outlet tee or baffle: Da of last pumping: Y, Com ents (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural inte ity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) Property Address: 613 Shoot Flying Hill Rd, Centerville Owner: Wharton Date of Inspection: 1 2/31 /9 7 TI HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (lo a on site plan) Depth below grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) s Dimen ions: I Capa ty: gallons Desig flow: gallons/day Alarm vel: Alarm in working order _ Yes; _ No Date of revious pumping: Comme ts: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Ll (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) ��LiC/ PU P CHAMBER:_ (loca a on site plan) Pu ps in working order: (Yes or No) AI ms in working order (Yes or No) Co ments: (not condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 613 Shoot Flying Hill Rd, Centerville Owner: Wharton 1 2/ /9 7 Date of Inspection: / SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure level of ponding, condition of vegetation, etc.) 6 CESSPOOLS: (locate on site plan) Number and configuration: �G�►" Depth-top of liquid to inlet i nvert: J� Dept p q � Depth of solids layer: Depth of scum layer: Y Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Co ments: (no a condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) P IVY: _ cate on site plan) Dimensions: Ma erials of construction: De th of solids--- Co ments: (n a condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 613 Shoot FLying Hill Rd, Centerville Owner: Wharton Date of Inspection: 1 2/31 /9 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) W. Y A( b J ) LL ,1J/L7C ry4- (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM p PART C SYSTEM INFORMATION (continued) Property Address: 613 Shoot Flying Hill Rd, Centerville Owner: Wharton Date of Inspection: 1 2/3 1 /9 7 Depth to Groundwater .2 4-Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record V Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 ' TOWN OF BARNSTABLE <bOCATION (�I?� Steno ING '''rlt II Dom.SEWAGE # I7- 761 g VILLAGE. C.eN}C ,*A ASSESSOR'S MAP& LOTM D t) ` STALLER'S.NAME&PHONE NO._b) 1= RbhLn+SbIJ Sr-AL Sf A, & "77S477G :.::SEPTIC TANK CAPACITY I Soo _ LEACHING FACILITY: (type)12►4?;N'�1','o2S (size) aS`VLaS -.iz �:N OF BEDROOMS 3 1 :BuiLDER OR OWNER } PERMUDATE: 12 - S? COMPLIANCE DATE:_ .l 2- ;`Separation Distance Between the: :MA*0um Adjusted Groundwater Table and Bonom of Leaching Facility.; Feet :Nite Water Supply Well and Leaching Facility (If any wells exist :' 'onsite or within 200 feet of leaching facility) Feet ;444c,of Wetland and Leaching Facility(If any wetlands exist '1viiiiin 300 feet of leaching facility) -Feet Ffu7ushed by 4*c k p`r- 20 31 I. a�>< a5 r TOWN OF BARNSTA.BLE AVON 6t 0St�fr��#'1/ A a SEWAGE # nIUAGE _ e ._ A.SSESSORI MAP&LOT NSTAL4EIt'S PHO SEPTIC TANK CAPAcrry ZACHYNG I ACIILnT., (type) �g �(�/b�a✓s (size) �� fO.OF'BEDROOMS _- _ - IUILDER OR OWNER. 'E1 LTDA'TE: COWLIANCB DATE; eparation Distance Between the: Raximum Adjusted.Groundwater Table to the Bottom of Leaching Facility .. .. Feet kivnle Water Supply Well and Leaching Facility (I'any wells exist on site or within 200 feet of leaching facility) �ee4 ,Age of Wedand and Leaching Facility(If any wetlands exist within 300 feet of caching.facility) �, � eet urnished by .a .s �^'�` 6��� .�. � � T . . � � � -c_ ad ` �_c � . R NGTICE. This-Forte Is-To-Be Used For the Rem Of Failed Sept} .-sy-stems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William- 'E--Robinsnn,, Sr ,hereby.certify_that.the_application-for-disposaL,�orks construction permit signed by me dated , concerning the property located-at fi13 Sher of Flying l ilLRoadCpntpr�ille�l A meets all-9f the following criteria: * Ther are no wetlands within 100 feet of the proposed leaching_facility. * T re are no private wells within 150 feet of the proposed septic system. * here is no increase in flow and/or change in use proposed. * There are no variances requested or needed. I * If the proposed leaching-facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SI / G L Ate ;7r`` r LICENSER SEPTIC-SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER j6O 1 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). VV-AICPIV-� TOWN OF BARNSTABLE yQi THE t0 OFFICE OF Dsaa9TeDL : BOARD OF HEALTH Rios 039. `{�' 367 MAIN STREET oM�Yw HYANNIS, MASS.02601 August 8, 1997 Arne Ojala 939 Main Street Route 6A Yarmouthport, MA 02675 RE: 613 Shootflying Hill Road, Centerville Dear Mr. Ojala: You are granted variances on behalf of your clients, M. Dupuy and I. Backstrom, to install a replacement septic system at 613 Shootflying Hill Road, Centerville. The variances granted are as follows: • CMR 15.405 (1) a: To reduce the separation distance between the soil absorption system and the property line to five (5) feet, in lieu of the required ten (10) feet separation distance. • Town of Barnstable Board of Health, Part VUL Section 10.00: To reduce the separation distance between the soil absorption system and the wetland to 68 feet, in lieu of the required 100 feet separation distance. The variances were granted because the existing cesspool is located closer to the wetland and is in all probability, sitting in the groundwater table. Therefore, the proposed replacement system will alleviate a source of pollution to the groundwater in this area. Sincerely yours, /usan G. =ask4, S. Chairman Board of Health Town of Barnstable SGR/bcs shoot o . No. ?7- 70 Fee $5 0 . 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Digozal *pgtem Conotruction Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 7 7 5—3 4 3 3 613 Shoot Flying Hill Rd, Inez Backstrom c/o Atty Matt Dup y Assessor'sMap/Parcel Centerville, MA 25 Mid-Tech Dr, Ste C, W Yarmouth, MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 2—4 5 41 Wm E Robinson Sr Septic Sry Down Cape Engineering PO Box 1089 .Centerville MA 02632 939 Main St Rt 6A Yarmouth port, MA Type of Building: 02675 Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(nd Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Install Title 5 s en t-i c s y s t-e in to the plans of Down Cape Engineering -nb # q7-08 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 issued by th' o of Health Signed Af.-" Date Application Approved by f Date !Z— - 7 Application Disapproved for the following reasons Permit No. l 7-7e f Date Issued 12- P= 1'7 - ----------- - ----------------. ----- No. / 7- 701 Q' � �` Feet$50 a t n If THE COMMONWEALTH OF MASSACHUSETTS Entered in compute£ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Application for Migpo!5ar *pgtem Congtructton j3ermit Application for a Permit to Construct( )Repair('X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components r Location Address or Lot No. Owner's Name,Address and Tel.No. 7 7 5—3 4 3 3 613 Shoot Flying Hill Rd, Inez Backstrom c/o Atty Matt Dup y Assessor'sMap/Parcel Centerville, MA 25 Mid-Tech Dr, Ste C, W Yarmouth, MA Installer's Narne,Address,and.Tel.No. 7 7 5—8 7 7 6 Designer's Name;Address and Tel.No. 3 6 2—4 5 41 Wm E Robinson Sr Septic Sry Down CapW Engineering PO Box 1089, Centerville, MA 02632 939 Main St Rt 6A Yarmouth port MA Type of Building: 02675 Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( n6 Other Type of Building No.of Persons 'Showers( ) Cafeteria( ) Other Fixtures t Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of R pairs or Alterations(Answer when applicable) Install Title 5 Septic system to the plans of Down Cape Engineering j.h # A7 na4 S f 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 issu d by thi oar- of Health. C Signed °t Daie 7 Application Approved by Date 12~.r— 77 Application Disapproved for the following reasons Permit No. 27'7d/ ` Date Issued Z` Sj 12 ~ --- - H�C;OMMONWEAL+TH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(Xl�Upgraded( ) Abandoned(( )by at 613 Shoot Flying Hill Rd, Centerville has been constructed in accordance ~~ with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 a/ dated /2-?' 9 Installer Wm E Robinson Sr Septic Sry Designer Down Cape Engineering The4ssuance of this permit shall not be construed as a guarantee that tife system will function as designed. Date f Z 1 `T Inspector lz�k --------------------------------------- No.97— 70/ Fee $50.00 THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Miopoar bpztem Con5tructton PerPit . Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( System located at 613 Shoot FlyingHill Rd ` Centerville, MA Installer: Wm -&Robinson Sr Septic Srv. and as described in the 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. wj ..Provided: Construction must be completed within three years of the date of thi t Q� f Date: 2 ' 97 Approved by �! /� TOWN OF BARNSTABLEv LOCATION SEWAGE # VILLAGE Cev-Ak-Zvi IIC- ASSESSOR'S MAP & LOTO-3 60 INSTALLER'S NAME&PHONE NO. t.)m G PaWuS J L Swe k 1`754774 SEPTIC TANK CAPACITY I SOO LEACHINd FACILITY: (type)12►N (size) AIL a 5 ' ( 2— NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: f e S? COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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. a 1 / r s s d 95 s� a5 TOWN OF BARNSTABLE I'a, AT10: . li/3 S/ieo� `/yi v f �.!/J SEWAGE # 1���7 VILLAGE ASSESSOR'S MAP&LOT 3 OD INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY' Cd-ts 000V/. LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER E;rrp rfil of 1.1e2 6Ack rre a PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7'`S� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A/'p Feet Edge of Wetland and Leaching Facility(If any wetlands exist , within 300 feet of leachin facility) ,3'0 Feet. Furnished by �Gy �6'hJ I r; r ...:c � ��. J /C�d� QF�'C�l/W I .. .a l� PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 193 009- - Account No: 118713 Parent : Location: HILLSIDE DR CENT Neighborhood: 42AC Fire Dist : CO Devel Lot : Lot Size : .41 Acres Current Own: LAUTERWASSER, I, WHITE, State Class : 101 LOUISE M & GAUTHIER, ANN C No. Bldgs : 1 Area: 1152 47 CHURCHILL DRIVE Year Added: LONGMEADOW MA 1106 Deed Date : 070196 Reference : P1631AD1 January 1st : BACKSTROM, HARRY Deed MMDD: 0000 Deed Ref : 1062/470 Comments : Values : Land: 31900 Buildings : 68600 Extra Features : Road System: 613 Index: 1484 (SHOOTFLYING HILL RD ) Frntg: 110 Index: 718 (HILLSIDE DRIVE ) Frntg: 138 . Control Info: Last Auto Upd: 092097 Status : C Last TAGS Update: 091797 Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : Taken: Account Status : Hold Status : Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [193] [010] [ ] [ ] [ ] SEPTIC PROFILE TEST HOLE LOGS --- ?.0.F. AT EL. 45. - --- ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALID ' ACCESS COVER (WATERTIGHT) To ENGINEER: A+. WITHIN 6" OF FIN. GRADE '� o ` MINIMUM .75' OF COVER OVER PRECAST Z?: SLOPE REQUIRED OVER SYSTEM WITNESS: '� '-' -� K-t C� `''� RUN PIPE LEVEL. ---------- ---- - r DOUBLE WASHED PEASTONE�, --j— �J DATE: 2 - —�j �-FOR FIRS i 2' / I(� PROPOSED ° j ! 3' MAX. PERC. RATE � l! GALLON SEPTIC �z z c LAss SOILS P# (H-- TANK — BAFFLE 41,C, � o0 1 7 3 ; -1 (_ R SLOPE) �6" CRUSHED STONE OR MECHANICAL fy+!� - COMPACTION. (15.221 (21) I 2' - — ft Co -4 t.o+ C1 ELEV. DEPTH OF FLOW = r y SLOPE) r P L - - c T17E SIZES: �� 3;'4" TO 1 1 ;2" DOUBLE WASHED STONE i NLET DEPTH _- OUTLET DEPTH = ! A i i LOCATION MAP SCALE 1" FOUNDATION--- �' SEPTIC TANK D' BOX LEACHING ` � , FAC!_!TY I M I r-�. i ASSESSORS MAP PARCEL 3 ��✓ ''� �iti c.• �,� 1;4•k:. -11 . ; ZONING DISTRICT: j YARD SETBACKS: 41 M FRONT = r.�._ -_ Aa SIDE _ REAR = 2 ;-1 ► .r ' I PLAN REF. - ,� FLOOD ZONE: � L 1 o s� k o� r � i a 'vG cS T : \� �\ SEPTIC DESIGN_ (GARBAGE DISPOSER IS= d.w _) DATUM ISr "w . Et�e.1�►,i;� �t„la_ —_—_-_- -. s ; DESIGN FLOW: BEDROOMS GPO) _ �' ;' G?D L. MUNICIPAL hATER f5 ------ �/J's. USE A GPD DES;G`J FLOW 3. MINIMUM PIPE PITCH TO BE 'j 8" PER FOOT. Jr ' p SEPTIC TANK: �"")o GPO ( _: ) _ ��� 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H--�__ 5. PIPE JOINTS TO BE MADE WATERTIGHT. ) i JSE A 1 500 GALLON SEPTIC j TANK I 6. CONSTRUCTION DETAILS TO BE N ACCORDANCE WITH 1•lA..S. _rA>^wInI ENVIRONMENTAL CODE TITLE V. ,[� 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE SIDES: --- - - -�--- -- J SED FOR LOT LINE STAKING. .� i o .�,^ . `''' <; rf u -'�Lrzn . `�.�-N� 4, 30T OM: Z ; �1S ,� 2-4 --- ) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. TOTAL.: 5'?. S z .F. GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT ;-.� � ..•, J •-,a.�.�,� _ Tr j INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. iL'A QJ e _ ()� , � r' ° L1+ � �• � � ) { r b. r/ (l(�;' /� 1 / I :c ..1 a .S rb�.14. a-'T 1Ei SITE ND SEWAGE PLAN 100.0 PROPOSED SPOT ELEVATION — f `L -_—J OF CY 100x0 EXISTING SPOT ELE`rATiON - 9 N THE TOWN OF: is 1070 — PRO-'OSED CONTOUR — — i 00 — -- EXISTING CONTOUR PREPARED FOR: I _ O e. tic-jG . f {�r,e ! 1•-� aO J ! 'Sa5 -�� v�{�� y�rl✓� BOARD OF HEALTH -- _ ___ - ------ --- ---------DATE MA SCALE. DATE: -•-•-.__ APPRCYED f Ic o� . i on W&-W2-4541 tm 5W M2-NW I I down cape engineering, inc. ,r x ►, A ►�� A"to CIVIL ENGINEERS t�w�► t LAND SURVEYORS JOB -.- 939 main st. yarmouth, ma 02675 :x' ,, ,�, 4 w . DATE