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HomeMy WebLinkAbout0867 SHOOTFLYING HILL RD - Health 867 Shoot Flying Hill Road Centerville A= 192 - 206 UPC 12534 o.2-153LO MAflrq�w h Commonwealth of Massachusetts `9o2—�oc 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name / information is required for every Centerville t/ Ma 02632 7/6/2020 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. Important:When filling out forms A.,Inspector Information on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return key. Company Name P.O.Box 151 4:1 Company Address Forestdale Ma 02644 City/Town State Zip Code + 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property 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 7/6/2020 I ctor ignature Date The system in ector shall submit a cop of thi inspection report to the Approving Authority(Board of Health or D P)within 30 days of co pleti this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector d system owner shall submit the report to the appropriate regional office of the DEP. The origin orm 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Cityrrown 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: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass. ov 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 ❑ N ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Cityrrown 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 ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 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 ❑ ® 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Cityrrown 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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, 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 II 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 ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Citylrown 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? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts !� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information 1. 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 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes Z No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ❑ No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): 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 pumps every 2 years Was system pumped as part of the inspection? . ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �n 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. City/Town 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: tank origanal leaching and Dbox updated in 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 24+feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of poor venting or leaks. Down stairs bathroom has ejector toilet. toilet was cycled to check operations of pump 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 867 Shootfl ing Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) 1000 gal H10 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'6"x5' Sludge depth: 4 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 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tees in place. tank does not require pumping. Recommend pumping in 1 year under normal use 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Cityrrown 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 I79 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .• 867 Shootflying Hill Road Property Address Plumber Owner. Owners Name information is required for every Centerville Ma 02632 7/6/2020 page. CitylTown 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: El yes ❑ NO i 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.): Dbox camera inspected. (AS built measurements not accurate) Dbox is sound with no major decay present. at working level 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owners Name information is required for every Centerville Ma 02632 7/6/2020 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: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts rn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 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.): leaching chamber located cover has riser. Chamber has 4"of water across bottom and no staining over current level to indicate a past failure 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 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 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Cityrrown 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 AI " u Az 30. Ry 3a � G fl evee� ev vex - J, t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Cityrrown 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: no GM at 10' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 2006 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: perc on plan No G/W at 10' bottom of leaching at 66" below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 867 Shootflying Hill Road Property Address Plumber Owner Owner's Name information is required for every Centerville Ma 02632 7/6/2020 page. Cityrrown 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 Town of Barnstable P# I I j Department of Regulatory Services Public Health Division Date � ' L MAM 200 Main Street,Hyannis MA 02601 -Date Time Fee Pd. Scheduled .1 l 60 �0 __ + - W Soil Suitability Assessment for Sewage Di osal Performed By:_,JaV1D D'.- Cou6t-�ANow R t �S Witnessed By:a—�1r-�o�/ LOCATION& GENERAL INFORMATION Location Address 8vC Qopf Flytt 1, Rd ( P—q Owner's Name LD FoZSTC?, f � 6/b �f Address � ���� �Y l YIY t�t 1' C�y�Pn�'� l le, Wllf- D2�3 Assessor's Map/Parcel: 1 t v Engine's Na e � l` /7 60 v/G�qtt i 0c/r,21�S NEW CONSTRUCTION REPAIR y Telephone# Land Use 1 e►� la� Slopes y�y Surface Stones n D ge- Distances from: Open Water Body t o o } ft Possible Wet Area G 0 t ft Drinking Water Well L 00 t ft Drainage Way SD ft Property Line } ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands�n proximity to holes) GROUNDWATER ADJUSTMENT N EXISTING GROUNDWATER LEVEL 31041 FL Z BASED ON TOWN OF BARNSTABLE ' �---- ---�-- -- -- GIS DEPARTMENT RECORDS. O �� INDICATED GW 34.00 ` INDEX WELL SDW-252 ZONE C READING DATE .MA_Y-._.2Z05 READING i47.6 o u� Z ADJUSTMENT 3.4 G1 ADJUSTED GW 37.4 � z0 \ ? 1 PAVED\ DRIVE�S LINE \ O 14 (Gi�lGi t�v'1S1, Depth to Bedrock Parent material(geologic) Depth to Groundwater. Standing Water in Hole: �C5 N,�. Weeping from Pit Face Estimated Seasonal High Groundwater rim P DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Ste° gib&V-e Depth Observed standing in obs.hole: _ —in. Depth to soil mottles: Depth to weeping from side of obs.hole: _ in, •©roundwater Adjustment ft. Index Well# Reading Date: Index Well level Ad),factor, _ Adj.Groundwater Level PERCOLATION TEST D9te alp'tic6 Time,o 6M Observation ' , J c' Hole# time at 4" Depth of Perc 2- ' Time at 6" Start Pre-soak Time @ :Ot�J 'rime(9"-6") ` y End Pre-soak Rate Min./Inch h1P 1 Site Suitability Assessment: Site Passed Site-Failed: Additional Testing Needed(YIN) - Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC NO I TEST PIT I PAARENOTU MATERIAL:EPROGLACIRALD OUTWASH ELEVATION = 66.30 +- PERC AT 62 to 2 MIN/INCH IN C SOILS DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 68.30 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 0-8 Ap SANDY LOAM 10 YR 2/2 NONE FRIABLE 65.55 8-33 B LOAMY SAND 10 YR 4/6 NONE LOOSE 58.13 33-122 C MEDIUM SAND 10 YR 5/4 NONE LOOSE. 5% STONES TEST PIT 2 NO GROUNDWATER ENCOUNTERED PARENT MATERIAL: PROGLACIAL OUTWASH ELEVATION = 68.30 +- 2 MIN/INCH IN C SOILS DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELLI MOTTLING 68.30 0-8 FILL 8-12 A SANDY LOAM 10 YR 3/3 NONE FRIABLE 32-34 B LOAMY SAND 10 YR 4/6 NONE LOOSE 65.47 34-120 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 56.30 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Surface(in.) Soil Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cnitec Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Tonsi tenr Flood Insurance Rate Mae: Above 500 year flood boundary No_ Yes Within 500 year boundary No V' Yes Within 100 year flood boundary No V7 Yes Depth ofNaturally Oceti'Mne Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? tees If not what is the depth p h of naturally occurring pervious material?, • Certification I certify that on Opt l q9 5 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed b me consistent Y Pe y with the required training,expertise and experience described in 310 CMR 15.017' Signature_6' 4e--j• 1(4 Date l O6 Q:ISEPTIMERCFORM.DOC a a TOWN OF BARNSTABLE LnCAI'trd ?Cv �Sool-��y�n� Nell Pal SEWAGE# CC(p - VILLAGE Cenhx,,, I It —ASSES SOR'S MAP&PARCEL 19d-ao(,, INSTALLERS NAME&PHONE NO, iv M- 6. ADbM4 CIA W"?i S,,N,,, Spa- 77S SEPTIC TANK CAPACITY 1000 (9a,1(0As 7 7(© LEACHING FACILITY:(type) a A 5by r Nw[4l s (size) a V X P NO. OF BEDROOMS 3 OWNER PERMIT DATE: Ot� COMPLIANCE DATE: 0. �- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ' �� Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 7-o,3 6iS L hh e--v IL c� l 3 0() J° 1v9,?j i No. "-3 All 00.00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplitattou for Zi.5po5al 6p9tem Cou.5trurttou Verna Application for a Permit to Construct( ) Repair()j Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name Address aa,,��Tel No. 7 71 —51 2 9 867 Sh�yy���/t Flying Hill Rd, Centerville Edwara & Aileen Forster Assessor's ap/Parcell 2 206 867 Shoot Flying Hill Rd eentexVille Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco-Tech PO Box 1089 Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grindern(O ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 leach system to plans of Eco-Tech, #ETE-2373 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He 1th Sign Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued �/ f No. . -3 F10 0.0 0 ` . THE WMM0kWtALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes .2pplication for Oi.5po5ar �&pgtem Cou5truction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. Owner's Name Address d Tel.No. 7 7 -51 2 9 267 SPA Flying Hill Rd, Centerville Edwarc� & l;ileen Forster Assessor's aprnarcel192 206 867 Shoot Flying Hill Rd eentervilit Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 69 4 Wm E Robinson Sr Septic Eco—Tech PO Box 1089, Centerville 43 Triangle Cir, Sandwich -- � Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinderr(o ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 &each y system to plans of Eco-Tech, #ETE-2373 Date last inspected: Agreement: -^--- # The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He lth Sign Date' Application Approved by Date Application Disapproved by: Date for the following reasons oe /l Permit No. Date Issued -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Forster BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (X ) Upgraded ( ) ,w Abandoned( )by Wm E Robinson Sr Septic Service at 867 Shoot Flying Hill Rd, Centerville has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No. ;;�(30 (p -3l a` dated 7 10 Installerr,!� ^�&%Oy-" \�`' d ,.q hot designer C)C rl Or.J #bedrooms 3 Approved design flow ��3 3Q gpd The issuance of this permit shall not be c-o-^n�strued as aa,guarantee that the system wild f n tion a�"d'e igned. Date 1 / 1✓ / Inspector -�'�' ———————————————————————————————————————————— No. aco& ^��� $11QQ•00 THE COMMONWEALTH OF MASSACHUSETTS Forster PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Migoml 6pgtem Corrgtruction Permit Permission is hereby granted to Construct ( ) Repair ( X) Upgrade ( ) Abandon ( ) System located at 867 Shoot Flying Hill Road, CenterVd le and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction ins//t be completed within three years of the dote of this It Date / �� b Approved`by Town of Barnstable Regulatory Services Thomas F. Geiler, Director • BARIMAOLL 9� MASS.tb79. Public Health Division ,� ATED1he�� 'Thomas McKean, Director 200 Main Street,11vannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 2-1 Z-0 6 Sewage Permit# 6b ­5 Assessor's 1`Iap\Parcel 19 2 Designer: Eco-Tech Installe-r:Wm E Robinson Sr Septic Address: 43 Triangle Circle Address:PO Box 1 089 Sandwich Centerville On 3 11-0� Wm E Robinson Sr Sept i(was issued a permit to install a (date) (installer) septic system at 867 Shoot Flying Hill Rd based on a design drawn by (address) Centerville Eco-Tech dated 06-15-06 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the t* distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision Lit* certified as-built by designer to follow. N OF�qss -9 DAVID � M D. COUGHANOWR N Installer's Signature) No. 1093 GISTE��O S�NITARk (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETUMN TO BMUNSTABLE PUBLIC HEALTH DIVISION. CERTIFIC:UE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS F0101 :XiN-D AS-BUILT CUM ARE RECEI«D BY THE B:UZ\STABLE PUBLIC HEALTH DIVISION. TII—.NK YOU Q: Health:Septic:Designer Certification Fom:+ -6-i 11.doc Town of Barnstable F THE 1p� ° o Regulatory Services sAxxsrAB Thomas F. Geiler,Director 9$A 69. •�� Public Health Division lED MA'S A, Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 12, 2006 Mr&Mrs Edward Forster 867 Shoot Flying Hill Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 867 Shoot Flying Hill Road, Centerville, MA, was last inspected on June 6th, 2006 by, David D. Coughanowr, certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: There was conclusive evidence of system failure at leaching pit. Tank should be ecamined for structural integrity. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTAAE HEAL H DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health TOWN OF BARNSTABLE LOCATION v !' SEWAGE # VIIJ AGE ASSESSOR'S MAP & LOT 12A6 "K.4:T A T i rn^��*.,•r��nun rti Tn (/!J!' V13'![.i�..Q�t_ ��fG SEPTIC TANK CAPACITY LEACHING FACII.ITY: (type) (size) I NO.OF BEDROOMS CJ OWNER c►a G-4 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: �® Maximum Adjusted Groundwater ab o the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) - Feet Furnished by TOWN.OF BARNSTABLE - L:6CATI0I i 7 S'Mon7 hkt wo, k i SEWAGE # ' VILLAGE ��We P—Vd LLE ASSESSOR'S MAP & LOT oZ oZQ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1.000 !aqC LEACHING FACILITY: (type) Qf f (size) C®®� 4l NO. OF BEDROOMS_ y� BUILDER OR OWNER lED FOUTEZ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by RC o - T ecy (.rw a- i 8 N- 6w� rd LEACH LOCATIQNS O o-eox o A 8 1 27 FE 15 FE 2 s SEPTIC 2 30.5 FE 12.5 Ft s TANK 3 38 FE 24 FE o i EXISTING DWELLING # 867 r W z � J I W r 3 i 1 'SHOOT FLYING HILL ROAD NOT TO SCALE ; t Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer, use 867 Shoot Flying Hill Road - Centerville only the tab key Property Address to move your Edward and Eileen Forster cursor-do not use the return Owner's Name key. 867 Shoot Flying Hill Road Owner's Address Centerville MA 02632 City/Town State Zip Code Date of Inspection: June 6, 2006Date 2. Inspector: David D. Coughanowr, R.S. c Name of Inspector ; Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA Q2563 City/Town State 3ip Code i7 508 364 0894 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails Need urther Evaluation by the Local Approving Authority [ S June 6, 2006 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. t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System- Page 1 of 16 , Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3of16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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: t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form A. Certification (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection 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 '/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 well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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. t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5of16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM B. Checklist 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection 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, including the SAS, located on site? ❑ ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7of16 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection 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 gpd 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 127 gpd g ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current 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: Last date of occupancy/use: Date Other (describe): t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 22+ years. Certificate of Compliance issued 8/10/83 (Board of Health permit#83-457) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9of16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments GM Subsurface Sewage Disposal System Form C. System Information (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection Building Sewer (locate on site plan): Depth below grade: 2feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 20+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): 1 Depth below grade: 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 El Yes El No certificate) Dimensions: 8.5 ft x 5 ft x 5 ft (1000 gallon) Sludge depth: Not determined Distance from top of sludge to bottom of outlet tee or baffle Not determined Scum thickness Not determined Distance from top of scum to top of outlet tee or baffle Not determined Distance from bottom of scum to bottom of outlet tee or baffle Not determined How were dimensions determined? Permit application t5-2368.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM C. System Information (cont.) 867 Shoot Flying Hill Road Property Address Centerville Ma 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection 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 was not opened because conclusive evidence of system failure was observed at leaching pit. Tank should be pumped dry at time of repair and examined for structural integrity and water tightness. A new PVC tee with a gas baffle should be installed Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete El ❑ metal El 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.): 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): t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments iG M Subsurface Sewage Disposal System Form C. System Information (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Not determined 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.): D-Box was not opened because conclusive evidence of system failure was observed at leaching pit. A new D-box should be installed at time of repair Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM C. System Information (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection 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: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ 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.): Leaching pit was uncovered and found to be full of effluent to within three inches of top t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts • Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection 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.): 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.): t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name 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. LEACH LOCATIONS P • B IT D-BOX o 1 2? Ft 15 f t 2 2 30.5 FL 12.5 F't 6 �o SEPTIC TANK 3 38 F't 24 f t 0 I EXISTING DWELLING # 06F _z J lY W F- 3 SHOOT FLYING HILL ROAD NOT TO SCALE t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form '4M C. System Information (cont.) 867 Shoot Flying Hill Road Property Address Centerville MA 02632 City/Town State Zip Code Edward and Eileen Forster June 6, 2006 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 30+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: 7/20/83 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Design plan on file with the Board of Health shows bottom of system to be 3.3 feet above the bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS Department records indicate that the property is over 30 feet above groundwater table. t5-2368.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 L,O 'C A f,fON 4i� SEWAGE PE MIT NO. o o� &. / g6`�? VILLAGE 1 INSTA LLER' W E i ADDRESS T - e UILDE R OR OWNER DA T E PERMIT ISSUED DAT E COMPLIANCE ISSUED s � � ' ��/ a' �' r � 'f �� J �� �� �� i ..,�J ♦ `���� ` y � ' No .--�. -- Fxs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® F` HEALT� .vN ................OF..... .. ..''A.t.✓....4. . 5� ApplirFattou for Diapaii al Work, Toustrurtton .eruttt V Application is hereby made, fora ermit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys t at: Location-Address or Lot No. ......... .. ...• ._........ ................. ............ a � _ ... G.• _----...-• !� -- ............................. 4 !�' .. ..._ .7..K._ .� N Installer Address Type of Building Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms----- .................................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ---li�t#!t�..... No. of persons........0................. Showers ( ) — Cafeteria ( ) PaOther fi res .............................................................. --••- W Design Flow.....Fi0quid . ..........:.•---•-------•__gallons per person per d Total daily fl w.._..Q��X ___......._...___._._.....gallons./ W Septic Tank— ca acI _/�+oOgallons Length.O" Diameter__ ':.._..... Depth_._.!.1..�.G Width x Disposal Trench—No. ...... Width......�_-------- Total Length___..... /- ... Total leaching area...... .........sq. ft. Seepage Pit No..................... p ....!e....... Total leaching area..3,3_. q. ...... Diameter.__�,�e..... .. Depth below inlet.. _s ft. .. ,z Other Distribution box ( ) Dosing to � ) ` 41 Percolation Test Results Performed by........... ._ ._a 4��.x!'��..�.._ R.�f/� .......... Date........ --�--,P_1...'.-. ...3 ,.� Test Pit No. _._minutes per inch Depth of Test Pit.................... De? to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a 1. - ' �.a...�.... ............................................. U oil ` --- - ----------------- E Description of S _ . ... ,� -------------------------------------- ---- -!n - �- ---_.04*• e..................................................... U Nature of Repairs or Alterations—Answer when-applicable---------------------------------------------------............................................. ------------------------------------•------•--------------------------------.....,--••-••--•-•.•-•••--••••••••-••------------•----•-•••••-•--•-••--•-......----------•--•••••--......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been sued by the I d of health. Signe3�lha., ..... /Date Application Approved By.....•••-•................ . . /n C. ...... ........................................ Date Application.Disapproved for the following reasons: :._. - ` --- ':..............:.......................................................................... .........•-••---•----------•---------•--------------------------------------•••- ------------------ Date PermitNo......................................................... Issued....................................................... Date � I �ii t 4 No..l!.._ _::.! ! - F.Ric ......4.5P............ THE COMMONWEALTH OF MASSACHUSETTS _ BOARD O HEALTH G ......:........OF........ . .. d --- Apli iraation for Uinplinal Works Tons-trnr#iun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System t: 101/(� Lot.Location-Address or Lot No: ......... ?,00 .. ........_. ------•--------- ---------- Own a dd ...... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............... _.:......_......___._..Expansion At c ( ) ' Garbage Grinder aOther—Type of Building ............................ No. of persons........... ...:.......... Showers ( ) — Cafeteria ( ) P- Other tures ..--••-••-•-•-•-•--••-••-••- W Design Flow.....Zqu - gallons per person,'er 4y. Total daily ow___...�•.._�1 .........................gallons. WSeptic Tank— id caPaci y� !!!!!gall Is ength4. ".__...: Width:.�y.�. ._. Diameter.__ ........ Depth.. =_� x Disposal Trench—No. !4..____ Width__ "__..._. �Td"%'V Length_..�'..._ ...... Total,leaching area....r-------------sq. ft. Seepage Pit No._.../........... Dia .ever /Z --- epth below inlet_...._.> i ...........Total leaching area.._.J1...•°.j... sq. ft. Z Other Distribution box r'° Dosing tank ) Percolation Test Res 1-0 °� Performed by....., ,C 11 �...... : /A i ate...._.. .:_�.�- ---_" Test Pit No. 1.. _-_minutes per inch Depth of,.,,Test Pit...............:.... Depth tc/ground water..................... f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - D Description of Soil Q ; ��' t-. ••••• -------... (� ................••..._.._.. -- .•••. _. Q/�Q C rl�,�' ._ lI UW •--••••••--•------------••-••----•......---•••••... Z•. ...••. /nG_....--- Izl ----.. ,A�•............................. Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------------------------------------------------------------•--•-----------------•--------------------------------------•-------------------------•••-••--•-•••••......--...••••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance een ' ued by the b f health. Sig d..... . -----• 4......... ,3. Application Approved By. a� �Q Date -•--•.................... Date Application Disapproved for the following reasons. ..... . ----•----••-•---------------•-••---------•---•---------------•-•-•. •------------- -•-•••••........•••••-••••---•••••-----•--••----....-•••-••...-•-••-•.....-••-•- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.........................................I................... (9rdifirtttr of TnntpliFatta TH_ *4S TO CERTIFY, That the Individual Sewage Disposa System constructed (,., or Repaired ( ) by........ a,1- ........ ;;.. ------ -------------------------------------------•...•...--------------------.. N. i�Z �"` Inst er -- ,- -....... at. .•-� ...... ... .. t. . -. ........................................................ ------••--•- has been installed in accordance with the pr isi of TITIZ 5 o; The State Sanitary Co . as escribed in the application for Disposal Works Construct' n Permit No. r..f��.............. da.ted�. .�./-- ---•-3----_----.-----_------ THE ISSUANCE OF THIS IFICATE SHALT. NOT BE CONSTRUE® AS A UARANTEE THAT THE SYSTEM W14 F NOTION SATISFACTORY. DATE......�loj....................................................... Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF................•---•••-•••••••••-•••.............•-•-•.............................. FE N�`�.•.3................. FeAl-4_................ Map I nrkn Tw.nntrnr$i ntit Permission i reby granted•. ... ... -......... --•------------------ -------•-••••••• ............. to Construc r Repair ( ) a Flu 1 Dispos Street �� as shown on the application for Disposal rks Cq struction Permit No... .__ ._.`Date _.______���JQQQ......................... : ..................•••---.•-••-'... .................................................................. DATE.. •_- / Board of Health - FORM 12 5 HOB & WARREN. INC., PUBLISHERS - •- 3> c � i L �o Zoo s� �tHOF � �y G V loo Z98?4 0 V a00 lb ` 10 io 7•'q,r is /rf.#;`/ N t-- . LNG 5q� ,,• �gVC14 +3Q a 4 z? Zo�E -D I / 11 s; v-/(on-I LEGEND �H OF A14 CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION Ox0 EXISTING CONTOUR —_-- O __.... q yc�, �� 7 G S/ c�0 f-Tv,,/Vr, 171:._� FINISHED SPOT ELEVATION Q. 1//L.L- o RSE- , _�,. _�_._�___�___ FINISHED CONTOUR 0 a No.10951 Q 4. N. APPROVED s BOARD OF HEALTH oFs�+sTE����``` SI0NACE �.1� ,8. 9W� . DATE AGENT SCALE�' .� =" � DATES .DREDGE ENGINEERING CO IN CLIENT . I: CERTIFY THAT THE"'PROPOSED EGISTERE REGISTERED JOB NO. BUILDING. SHOWN "ON THIS PLAN CIVIL LAND CONFORMS TO THE. ZONING LAWS 'ENGINEER SURVE R` _^__._._.. ., OF 'BARNSTABLE , ,.MASS. 712 M A I N STREET CH. 6Yt { H YA W N I S, MASS 5�IE.ET,�L. 4? `, _. DATE F2=EG, _.k AN,D, SURVEYOR 20 FT. Mt/V /YOT.F 7' 5FP7IC TANK 'OR 1E,4C. l/vG P/T A.�tE ..MDRP -TNA."l J2.'•BELD.Jt/ -!O 1 M/A/. r,RAOE, 4 24"17l,1M ETZAP CoNCRET.E COyE.�. :. SWA44 '&,F AP04JGN7" TO GtTAO.E EXr/k -q'PYC PJP< CONCfaETE r i*•jEAV.Y CAST./R®/Y CO✓ER S/��3 L.L L3f USED . COYE/tS M/N. P/TCNAov v J CONCRETE A a C,3�wvE co CLEAM S.4N17. s 2 LAYER �'.. /RONP/PE' ��G D a '�o MIJIf.o/T�C,A/ DIST.G/tL. ,, • • • • .• / > •e' WA5H--D SMNE • • , s s • • •s • s•e • • Ira' E�1•'T: SLEPT/C TAMIUC ®ox 8 • k `. • •iEFfELT'/VC r s • s 3f4" / �2� X s e tooDlaPTj+l •'e e '. •,. WASHED .s OX E ti= ��: b /�$`x <.�' • °• _♦ � p e "'• :T EEC E _ ?y8 .�, �rs4 L f�-i4 9l s a.es. • • s °a: i s-s s :a' a •e. O!T OR4V/t/.jj C�a �A u lit" .1 J6/i/�J$7' &L RVA7/1i140:1� F +� y �. ..t: 2 :1 ,t ��Y7!"�'' i IXYERT .4T R/dlLO/�4tG► PT Y`' a fll1.ArJrJN r dNdrET ,3SED�'/tC T.4AlK S�'3 D(lTL.€TSEP7"IC TANX �.- �/ /9 g �p�p pGROV#V4P itj4rfX TitaLE r II.Ls�Tfr°pIS�R.1,a/�d/./0.V 490;e17 y /± ' - V E��67� ®''�l�i/VA ie'�T�T�u��/ r � p4 � TJON a` L EACHI.J SCALE . % _ /``D d�IME/VslON A 6 JrT. pFSJGAr CNlTENIA :.at�!t: vs/o a Jrr 7Wff arclMe€,� of e�waoo�as •ry�RaRGEDtSPGSALlJXIT N��F SO'I'L 1.0 ` TOTAL ESTIMATED FLON/ 33 '� GAL./DAY SO i L TEST A�! XUMBER Ouw 491.4CN/KG P/73_ { f`E[—,W 96.a .CLI�Y. boo p TE 0*-5 D/L :TEST SIDF LEACHING PER PIT 1 SYrt fT. O !_i Z r r O r�� RESULTS h//T%V1sSSED 9o}"TOMEr t4CN/NG PER P/T 78 $Q. FT PERCOLAT/ON`/l'�4TE / �Ess .1`q!/4 /AtEt 6 Lo�4 r2 L n.t ^'i ' e Fe�tCOZT/ON RATE Ji 2 T:rta r�.MJN I/NC/5( TOTAL LEACH/NG :AREA SQ. FT —7 P Sd 14ESElgV4E EACmiAl6 r4REA 2 L�6 SQ. F; , • �e �rJ.4 o` Cos"RS E ? '�, 5ltrlt>T �7r�NE f/!��' rTc' OF M c,,2 �✓, S P n/Q �. of IN9, o' •�70HM yGin � {'j�'A.. � Jai n�£• - 0 1 '"fVFffd pppRSE v S H o No.10951 �? 4 s Fd.OREDGE E/1IGJNE�R%!VG tO,JNG 29874�0 90 FG 5 7��~J'�`L rG Ff 4.Z- EL', �� : ", 7/2 MAIN S7 N:Yf1KNi3 Mai?S iB� o� FFSSIONA��'t \ ( NO GROVNt7.yyATER ENCOUlVTE� o L'1/EJvT; yr vP,re ' DRTE o sueV� / Q GIi:O tlND Ltr14 TER' r�T ELLS(/ .JOB /VO' 3 f'`S SHEET OF Z tt z CONTOURS.' PLAN REFERENCE v ' { � o ° 4 EXISTING - - - - -f- - 50 PLAN BOOK 222 PAGE 9 -' 'L EGE�ID MINIMAL GRADING PROPOSED ASSESSOR'S MAP: 192 O Focus < 00 EXISTING LOT: 206 m ® / z RO�o m o<w a 1000 GALLON � \ MooNPENNy � _, cD SEPTIC TANK /- ♦ LANE 2 om°c}n m m D-BOX O �/� ♦ Oct /� N --z un TEST PIT ® -� `♦ \ O,� o ' di,I /- mN =W EXISTING ♦ \'� / CENTERVILLE. MA / \J� 'Y r ~ LEACH PIT • ��' ♦;88 L�3 � LOCUS MAP. �w i; >; CD �za ' - \ �'Lj NOT TO SCALE (`z ;ti_;;;. ;; m cooz UTILITY POLE /� 0 EE 0 0 N :.�; OQ NUMBER REFERS TO ' 4�4 DIAMETER IN INCHES. Al /' ; / \♦ -000 L J Z LETTER DENOTES TYPE. *18-p �, J H� 3 O-OAK M-MAPLE P-PINE 3� - / �� Li W 111 z W} / 1 I � � //' N l 16-P / ���/ ♦\ Q Of lJ JII N -/ 0 10-D j �P mQ.0 Z c` ,,� TF I'1W < wvL§j / ® ,( W o ?:: /- TP-2 Lu 70 CD Z1 -<i / 0 l l l U l- tY X 0 L+ � >�_ < ' 6-H \ \\�T \ O LuLj o o O �N (0 J CO Q m L6 \ x� </ GP I ❑ °w ? rhW 24 ft X12�5\ ft x2FL / e o x z� FCDcn_ LEf1GHING f�LLERY / �Z (A _0 W ti �(7L(J O z WC7 / ILI( ~ (n(0 3I W O z Q -'/ m 0 Ww m W Ir o J + O �` " N -/s 66 Ln LOT 2 Z J CD z i \ AREA = 40200 sF +- --�68 SEWAGE DISPOSAL SYSTEM PLAN -1 Z I_ j /-��� -TO SERVE EXISTING DWELLING "m ~ < � --�6�g WARD & EILEEN FDRSTER � Z o � cn � ,� � E D o i, m X 667 SHOOT FLYING HILL ROAD CENTERVILLE. MA o + W W PL A N �"�F"'Ass �G°-r,&C� ECO-TECH ENVIRONMENTAL r- .-� -'/ON DAVID q�yG EST. 43 TRIANGLE CIRCLE O (0 SCALE. 1 1n = 20 f L :- o a SANDWICH MA 02563 z Z �' 70 COUGHANOWR N �` 1995 ,�e 506 3 6 4-0 B 9 4 o z 20 0 20 40 NO. 1093 a- W N X w �F �,�° ON ETE-2373 JUNE 15. 2006 112 x w E L IO w 0 10 20 BENCH MARK ST PIS THIS PLAN IS BASED ON AN INSTRUMENT SURVEY AND IS INTENDED TOF, OF CONC BOUND TA P /y SOLELY FOR INSTALLATION OF THE PROPOSED SEPTIC SYSTEM ELEVATION = 68.78 DEPICTED HEREON. FOR ANY OTHER CHANGES TO PROPERTY INCLUDING USGS DATUM ASSUMED �'v H� 200c PLACEMENT OF ADDITIONS. SHEDS. FENCES OR SWIMMING POOLS, OWNER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. SOIL. TEST LOG-, DESIGN CALCuLAT.IDNS DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD DATE OF TEST: JUNE 14. 2006 SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS SOIL EVALUATOR: DAVID D. COUGHANOWR. R.S. USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL WITNESSED BY: DONALD- DESMARAIS. HEALTH DEPT. CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) NO GROUNDWATER ENCOUNTERED DISTRIBUTION BOX: USE 3 OUTLET D-BOX. TEST PIT 1 PARENT MATERIAL: PROGLACIAL OUTWASH SOIL ABSORBTION SYSTEM: A 24 Ft- x 12.5 Ft x 2 ft.LEACHING GALLERY CAN LEACH ELEVATION = 6B.30 +- PERC AT 62 in :' 2 MIN/INCH IN C SOILS Abut. = ( 24 x 12.5 ) = 300 sf A s d w = ( 24 + 24 + 12.5 + 12.5 ) x 2 = 146 sf ALot = 446 sf DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER Vt 0.74 x 446 = 330.04 GPD (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 68.30 USE A 24 Ft, x 12.5 ft x 2 ft GALLERY. Vt. = 330.04 GPD > 330 GPD REQUIRED 0-8 Ap SANDY LOAM 10 YR 2/2 NONE FRIABLE 65.55 8-33 B LOAMY SAND 10 YR 4/6 NONE LOOSE L EA CHILI G GALLERY SCALE NOT TO 33-122 C MEDIUM SAND 10 YR 5/4 NONE LOOSE. 5% STONES 58.13 USE SHOREY- PRECAST. 500 GALLON LEACHING DRYWELL (H-10 LOADING) NO GROUNDWATER ENCOUNTERED CONSTRUCTION DETAIL 500 GALLON DRYWELL TEST PIT 2 PARENT MATERIAL: PROGLACIAL OUTWASH DIMENSIONS AND DETAIL ELEVATION = 6B.30 +- 2 MIN/INCH IN C SOILS DRYWELL UNIT STON USE H-10 UNIT INSTALL ONE INSPECTION RISER TO WITHIN SIX DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 2a.e ft Q INCHES FINAL GRADE AND INDICCATE LOCATION (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING m ON As-eulL r PLAN 68.30 � � " 0-8 FILL m L' cv �� N F�P � 33 B-12 A SANDY LOAM 10 YR 3/3 NONE FRIABLE m4 000� 0 0in m oo moo Boa 32-34 B LOAMY SAND 10 YR 4/6 NONE LOOSE s5 �t 65 ft 8.5 ft .5 ft �65.4734-120 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 24.0 ft 58.30 102 1� CROSS SECTION VIEW 2 iMr PEASTONE 2 to PEASTONE NOTES 2824 to 3/4 to TO 26 1n EFFECTIVE DEPTH 1-1/2 in GRAVEL 1n 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN - � L 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS 46 58 in 46 to in OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 150 in 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. 5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 61 ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE Zl LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0*' BEFORE PITCHING DOWN GROUNDWATER ADJUSTMENT 8)` ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLA-TION OF LOW FLOW FIXTURES EXISTING GROUNDWATER LEVEL SEWAGE DISPOSAL SYSTEM PLAN AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC, TANK BASED ON TOWN OF BARNSTABLE 9) SYSTEM IS NOT .DESIGNED .TO WITHSTAND VEHICULAR.- LOADING-. ' DO NOT GIS DEPARTMENT RECORDS. -TO SERVE EXISTING DWELLING PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM ,f` `..+:' } INDICATED GW 34.00 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE ST:AR:TING WORK. INDEX WELL SDW-252 EDWARD AND EILEEN FORSTER 11) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND',TRU'E ' TO' GRADE ON A LEVEL ZONE C 867 SHOOT FLYING HILL ROAD CENTERVILLE, MA STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED•�'AND ON TO WHICH READING DATE MAY. 2006 47.6 .4 SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO_'MINIMIZE UNEVEN SETTLING READING ADJUSTMENT 3.4 ECO-TECH ENVIRONMENTAL 12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM JREPAIR -AND CHECKED ADJUSTED GW 37.4 43 TRIANGLE CIRCLE SANDWICH MA 02563 FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE, ETE-2373 JUNE 15. 2006 212