The URL can be used to link to this page

Home My WebLink About0124 LONGVIEW DRIVE - Health 124 Longview Drive, Hyannis A= i I 1 TOWN OF BARNSTABLE LOCA1 I Lay L0ngv:e_-u.) .)R• SEWAGE# �Po 1/ - 00 1 VILLAGE ASSESSOR'S MAP&PARCEL_WSJ - JS INSTALLER'S NAME&PHONE NO. 3 a ,(3 FXea Val►o n �l 7'7 - d G S3 SEPTIC TANK CAPACITY 1500 4cz) LEACHING FACILITY:(type)SoD!a I cka mS z) (size) 3 X Z S X Z. NO.OF BEDROOMS G dc,ry�) Sj OWNER 7cann� c. Ranc�ctl 1 J PERMIT DATE: i-3 -J J 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 Az aG ' gz- a9" A3. 3a ' 63 . 31" 1 1 y A N - f3� - 3y'j, 3 . z I A f3 REAR i�q . 09 , o No. 0'o C l _ y O ` Fee computer: in com THE COMMONWEALTH OF MASSACHUSETTS Enteredp PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21ppliCdtion for �Diooal bpztem Cow6trUCtion 3pPrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. I P y L on c?u i C kJ /9 of Owner's Name,Address,and Tel.No. Assessor's Map/Parcel dSJ /sa IR&I Lon V;C&U .Dr- Cc.n4crV;/JC.. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3 Fr.8 gxca V0k4;0,\ ,Down Cc►pc Enl1� Tca6srr Ltv ForesadQle- y7'7-065 3 s4 1Qr„^ NSy/ Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures : c D^ Design Flow(min.required) 1 gpd Design flow provided ��'��(9 gpd Plan Date e2D Z 010 Number of sheets. 1 Revision Date Title Size of Septic Tank AY00 9CL) Type of S.A.S. �2� SOO 9CL) CAa nn.SCr5' Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7n n K „D .BpX LCa e� n G 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 Health. Signed Date3� J Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. �� (�Q Date Issued -. �:�; -- .. . � .:• .. ��f _ems' .1 n '.$., a:.,i; H. No. e 0oI'I_ �D Fe THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipprication for TBiopooal:*potem Cottotruction Permit Application for a Permit t)Construct( ) Repair( ) Upgrade( )` Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 1 a y L 0Ac U;C kJ R d Owner's Name,Address,and Tel.No. h�� 7cann�c Rend ct 11 Assessor's Map/Parcel ds-1 /.SoZ lay t_ongv�ciJ ./�r• �'�n�crV;llL Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. F. .6 Exca V040/1% ,Down CQ pc En/G Tcct6_ rr 4,n1 Fores4dat k y*7*7-0,/53 93 /na;n 54 36 - 5154// Type of Building: Dwelling No.of Bedrooms �, Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ( Other Fixtures Design Flow(min.required) gpd Design flow provided '�j o d ' `6 t� "' L.t d gP Plan Date ,_V)C c , P O Z 010 Number of sheets ! Revision Date —� a Title Size of Septic Tank /Soo 7cx Type of S.A.S. (z Soo 9cL) c 11a m Scr s Description of Soil ` L ' Nature of Repairs or Alterations(Answer when applicable) M)h, _D BOX Lc-a r-A; 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 Health. �• Signed_ Date Dkin 3- J F Application Approved by Date t Application Disapproved by: ' Date for the following reasons Permit No. �)U f/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( � Repaired ( ) Upgraded ( ) Abandoned( )by i I at 1 _t-( E'4011 has been constructed in accordance with the provisions of-Title 5 and the for Disposal System Construction Permit No. aQ!l`w dated r/ 3-l/ Installer Designer _t)n„),-N c,,o c F_ Ill A #bedrooms Approved design flow( -3-f 7 gpd The issuance of this.ermit shall not be construed as a guarantee that the system wiill func'tiottn as designed. Date l�L/ �� Inspector ti No. awl f 06 ` i Fee /l7l t a • THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS Miopooar �&potem Conotruction Permit Permission is hereby granted to Construct ( ✓) Repair ( ) Upgrade ( ) Abandon ( ) System located at /o)Y Lon 9 u;c w —D r-. C c_n-)c r L,; 11 G 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. Provided: Construction must be completed within three years of the date of thispe�it Date _3— Approved by t[E r. �A Thomi as F Goer, Director BAM-4SPABLE, "S. �� .-Prnb;If .I1��r�trh p6_3 Thomas MeKc an, Director. �200 Main Street,lqy=inmis,IM\ A,02601 Office: 508-862-4644 Fax: 508-790-6304 ,p InstaHeu & Desigger Certification Form Date: 6 'l l Sewa�gge IPermit# OV/Assessor S map\paa eel Dcesignnen a 1wil2 lnsta" Hein U "� CGL✓a D>ti q nn _ Address: 3 Ia, h Address- M A- �� M� On was issued a permit to install a (date) (installer) septic system at Lor)q UI e-0 based on a design drawn by , ( ddress) 11r) 12. P , /0 t-.S dated (dbftnery J certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. . I certify that the septic system referenced above was installed with major changes (i.e.. ;{ greater than IQ' lateral relocation of the SAS or any.vertical relocation of any component of the septic system) but iu accordance with State & Local Regulations. Plan revision or certified as-built'by designer ner to follow. • e ��j, H OF 4f,1,9s q� DANIELA. yam o OJAIA (Installers Signatur ) I CIVIL No.46502 °� FS3/ONAL ENG\ i (Designer's Signature) (Affix Designer's Stamp here) PLEASE RET RTN *TO` BARNS T ABLE PUBLIC. HEALTH J31VIStCIDN. _ CERTIFICATE OF COlea"a,UNCE VdUL i40T BE oSSyR+,D TN-11 BOTH TBIS FORM AND AS-BUILD' CARD ARE ]R_ECEI[VED BY THE BAt NSTABLE PUBLIC HEALTH DMSIGN. -THANK YOU. t. Q:Heal$ilSeptic/Designer Certification Forn 3-26-.04.doc _ r �a - J �v ]Departmont of Regulatory Services Jf Public Health Divisioll Date 9 atS.�-.tip 200 Main Street,Hyanuis MA 02601 i o20 e ]Fee Pd. Da Scheduled_ / ld 1 tm _.... k]crYbnntd By. V. L.f elf, Performed 1 � V! _ _ / ]LOCATION & qENEI RA L I[1VJ[ORIVIIATION Location Address /a 1 0O t�et�) t/, Owner's Name Q // �I av1l/1IS Address Assessor's Map/Parcel: esZc�//�J� Y' engineer's Name d LA)Vti av�C NEW CONSTRUCTION REPAIR Telephone It.�c ()� 36 a Land Use. [a i A41 a-40'C Slopes(%) C/ 4 711L Surface stones �LCJ Distances from: Open Water Body ft Possible Wel Area �,/T�ft Drinking Water Well / t Drainage Way ft Property Line �r, ft .Outer ft b - SKE TCH., (Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands'in pro)[inuty to Boles) 119 Q Parent m3teriei"(g ologic')_t7 'i"`A��l ►�" "_. . .'D�plh ttl13Cdi6l is,'•_ Depth to Groundwater: Standing Water in Hole: �� Weepilig It all)Pit pftce _ Estimated Seasonal High Groundwater ✓d�w� DIC'JcERAUNATION FOR SEASONAL >Fl[>[GH WATER TABLE -- Method Used: _.MLUE,,.< Depth Observed standing in obs.hole: _ In,' Depth to still mold.its: In. Depth to weeping,from side of obs.hole: -__ hL Clroulldwuter Adf uslment.e Index Well Y Reading Date: Index Well leval faetor- Aqj.0Y(t UlldW(lWr Levui z IC'JCI[1'.ICOlL.tATI.ON 7CIL - Observation ! [-tole# Tinie ill 9" Depth of Pere •�y l Tlmp at 6" Start Pre-soak Time @ I r d® Time(9"-6") End Pre-soak LLM�f�n.� Rate Min./Inch ` Site Suitability Assessment: Silt Passed _ Silt~•Failed: Additional Testing Needed(YIN) Original: Public Health Division. Observation Hole Data To Be Completed on Back----------- *'x*If)percolatiou test Is to be conducted Witliil. 100' of wetland, you nwSt first U0 ify tUec. Barnstable Conservation Divlsloll at least olle (1) weelc pricir to beginuing. v Q:\SEPTIC\PERCFORM.DOC DER � ------- Depth from ON HOLE LOG Soil Horizon Scil Texture Surface(in.) Sdil Color Soil(USDA) Other (USDA). (Munsell) Mottling (Structure,Stones;Boulders, Con iste c %• ravel 19 , /�j �. - ---- D1ElCrD De pth from OBSE.RVA IONHOLIC, LOG Soil Horizon Sail T role #�^ Surface(in.) Texture Soil Color (USDA) Soil( Other Munsell) Mottlin /w g (Structure,Stones,Boulders. l/'• I G �v Z/ Consi enc %Gravel 16 SEEP OBSE,RV TrON r1®r_,E Depth from Soil Horizon �®� Role# Surface(in.} Soil Texture Soil Colo[ (USDA; Soil Other (Munsell) Mottling (Structure,Stones,Boulcers. Consistency pnvelt DE]IlD O)SF,R VAT TION r-I®r,� r' Depth from Soil Horizon ®�" 110le# Surface(in.) Soil Tcxtiire Soil Color Soil (USDA) .. (Munsell) Mottlin Other g (Structure,Stones;Boulders Consi 4 Flood Insurance plate Maw Above 500 year flood boundary No Yes Within 500 year boundary No_ yes Within 100 year flood boundary No� Yes _ DeRti>t m_ &� I'�r�ttaral y Occurring,Penviou,s materlal Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system If not, what is the depth of naturally occurring pervious matorial`7 w CeHiffeation I certify that on ac, 4 (date)I have passed the soil evaluator examination approved by the Department of Environmental.Protection and that the above analysis_was performed by me consistent with n °r'P"^t'ite�''•rn:::ng, cxportlse aci s experience described in CIO CMR 15.017. � SignaturDatb e /�7101 Q:\SBP'r[C\PERCFORM.DOC V I {µ Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4 Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated g11512 inspectionforms m y- ♦ a.. . 0rJ0. may naa be'dlacrcd in any ifliay. A. Certification Important: When filling out 1. Property Information: 3�7� forms on the y computer, use oZ only the tab key Property Address S to move your cursor-do not Owner's Name use the return •• key. Owner's Address VQ City/Town State Zip Code Date of Inspection: oto DateI 2. Inspector: \ _�2 Name of Inspector ompany ame Company Address itylrown State Zip Code :.._ —_�-V;_— ,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: XL Passes ❑ Conditionally Passes ❑ Fails ❑ Needs I h v I do the Local Approving Authority L I nspector'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. r , [z il.doe.doc.1 1/2004 pt J Title 5 Official inspection Form:Subsw ace Sewage Disposal Systern Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Insp ection Form Not for Voluntary Assessments w„ r` Subsurface Sewage Disposal System Form A. Certification (cont.) Property Addres`; Cityrrown State Zip Code Owner's Name Date of Inspe t o Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. - Comments: _. B) System Conditionally Passes' ❑ One or more system components'as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent: System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: h a 1 t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) y Property Address City/Town Statef Zip Code Owner's Name Date ofInspection 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 T t5inspi1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System + Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) , roperty Address City/Town State Zip Code Owner's Name Date of he C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fall 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 hass-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: t5ins_p[1].doc.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 Subsurface Sewage Disposal System Form " /GSM A. Certification (cont.) -12LA 1p�,)q�y1 W Property Addres City/Town State ZipCode 0 Owner's Name Date of lnsp;ccttio-n 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 ❑ 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. ❑ A 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.] 4� 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. t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) kltA lo�y��c,c)�T Property Address City/Town State Zip Code 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. i • t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•- Page 6 of 16 . Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal.System Form B. Checklist 1Z�A LoIJc-twv�) Property AddresY City/Town State- Zip Code 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 .K ❑ 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: JA ❑ . 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)] t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information Property Address City/Town State Zip Code Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): �J3� Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 Number of current residents: 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? ElYes No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? - ❑ Yes K No Last date of occupancy: �� ,--- 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? A ❑ 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): — — t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 y Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont) Property Address Cityrrown State Zip Code Owner's Name Date of Ins ecti n� p o General Information Pumping Records: Source of information: S$W-1+ aW Was system pumped as part of the inspection? ❑ Yes TS 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: Were sewage odors detected when arriving at the site? ❑ Yes [ No . f t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts w Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) a Property Address Citylrown State Zip Code Owner's Name Date of Inspecti n Building Sewer(locate on site plan): Depth below grade: feet 4 Material of construction: ❑ cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: N T feet Comments (on condition of joints,'venting, evidence of leakage, etc.): ,. Septic Tank(locate on site plan):' Depth below grade: - i .- 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 ❑ Yes ❑ No certificate) Dimensions: Sludge depth: g r 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 were dimensions determined? — — t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a• .. Page 10 of 16 • Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) UN Lr»c T m w hQ Property Address City/Town State Zip Code . 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.): 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 e c Commonwealth of Massachusetts 4J Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address City/Town State Zip Code Owner's Name Date nlspect, n Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No r 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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp[1].doc.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 M C. System Information (cont.) Property Address City/Town State Zip Code 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: ❑ leaching chambers, number: ❑ leaching galleries number: ❑ leaching trenches r 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.): c zi r �Iy�c3 Q t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System - Page 13 of 16 .e Commonwealth of Massachusetts y.i Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4 C. System Information (cont.) kzw Property Address City/Town State Zip Code Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration t► 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 7No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): � 1 .. Q L S• 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[1].doc.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 ,M s Subsurface Sewage Disposal System Form C. System Information (cone.) Q,y 1nh\3r,q u� Property Addres , City/Town State Zip Code 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. • y t5insp[1].doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 15 of 16 w Commonwealth of Massachusetts 4J Title 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form H C. System Information,(cont.). Property Address City/Town State Zip Code Owner's Name Date of Inspection Site Exam: Slope No Surface water �o Check cellar Shallow wells tom_ Estimated depth to ground water: LkO 1 Please indicate all methods used to determine`the high ground water elevation: ❑ Obtained from system,design plans odrecord If checked, date of design plan reviewed:. Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain:. Checked with local excavators, installers - (attach documentation) Accessed USGS database-explain.- You must describe how you established the high ground water elevation: -t5insp[1].doc.doc 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of,16 COMMONWEALTH OF MASSACHUSETTS ID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI DEPARTMENT OF ENVIRONMENTAL P -TRIO ONE WINTER STREET, BOSTON, MA 02108 617.2 Z11 1 00 rn m WILLIA.M F WELD �V m ,TRL Dl'CO\E Govcmor oLL .,' Sc:roan •ARGEO PAUL CELLUCCI W D:A �ID B STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO �' Commissioner PART A e \ CERTIFICATION /(4MAPjs Michael Don an� Property Address: 124 Longview Drive tMjtUjVtj-je,MasS Address f Owner: 9208 Bayard Place Date of Inspection: (If diffe ent) Fair Fax Virginia Name of Inspector: Joseph P. Macomber Jr. 22032 1 am a DEP approved system inspector pursuant to Section 15.340 of Tit e 5 (310 CMR 15.000) Company Name: Joseph P. Macomber & S ,_i_nc . Mailing Address: Box b Centerville , M 2-0066 Telephone Number: )Ub-775-3338 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority ' Fails / /J�� Inspector's Signature: b � Date: The System Inspector aall'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: AJ SYSTEM PASSES: I 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: _4-QOne 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 04/25/91) Page 1 of 10 DEP on the World Wide Web: http:ltwww.magnet.state.ma.u side p GJ Printed on Recycled Paper all SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:1 24 Longview Drive Centerville Ma Owner: Michael Donovan Date of Inspection: 8/2 5/9 7 BJ SYSTEM CONDITIONALLY PASSES (continued) Ve4le 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 pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation b the Board of Health in order to determine if the system is failing to protect the q Y g 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 X� s'SB o aru u> 'S ,9 (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addrew1 24 Longview Drive Centerville Ma Owner: Michael Donovan Date of Inspection: g/2 5/9 7 D) SYSTEM FAILS: You must indicate ei;•.er "Yes" or "No" as to each of the following: C� I have determined that the system violates one or more of the following failure criteria as defined in 310 CmR 15.303. The bans for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cornea the failure. Yes �'o�r 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. �mNF� 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 -6. 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) LARGE SYSTEM FAILS: You must 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 or greater (Large System) and the system is a significant threat to Y h' 8 gPd g g Y Y g public health and safety and the environment because one or more of the following conditions exist: Yes No qzcr 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 owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Peg* 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 124 Longview Drive Centerville Ma Owner: Michael Donovan Date of Inspection: 8/2 5/9 7 Check if the following have been done: You must indicate either"Yes" or "No" as to each of the following: Yes N 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. ./ plans built b As have been obtained and examined. Note if the P Y are not available with N/A. Y _ 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. r All system components,.kluding the Soil Absorption System, have been located on the site. _,AfdAl4 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 cUfferent 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) [I5.302(3)(b)J (revised 04/25/97) P&ge 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:1 24 Longview Drive Centerville Ma Owner: Michael Donovan Date of Inspection: 8/2 5/9 7 FLOW CONDITIONS RESIDENTIAL: Design flow. ;Z,,W g.p�./bedroom for S.A.S. F/�� tid�L4M Number of bedrooms: Number of current residents: O Garbage grinder (yes or no): Laundry connected to system (yes or no):,e Seasonal use (yes or no):_�#_$ Water meter readings, if available (last two (2) year usage (gpd): /Q� 025 ` eA91 Sump Pump (yes or no):� Last date of occupant),:g� COMMERCIAUINDUSTRIAL: Type of establishment: a Design flow: 4)A allons/day Grease trap present: (yes or no)A)Z� industrial Waste Holding Tank present: (yes or no)&i- Non•sanitary waste discharged to the Title 5 system: (yes or no)- Water meter readings, if available:pVA Last date of occupancy: OTHER: (Describe) AA Last date of occupancy: AV it GENERAL INFORMATION PUMPING RECORDS and Qu c of information: lye System pumped as pan of inspection: (yes or no)� S/�'u 2.S My If yes, volume pumped: __.gallons 9 F-64 fog F1'Y�vI 7'llG r�1�9��J 5� � Reason for pumping: TYPE OF SYSTEM 1A Septic tank/distribution boVsoil 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: aF7LQ skkls —� Sewage odors detected when arriving at the site: (yes or no)lvd (z.vi..d 04/25/97) P.9. 5 of 10 j 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 24 Longview Drive Centerville Ma Owner: Michael Donovan Date of Inspection: g/2 5/9 7 BUILDING SEWER: (Locate on site plan) /1 Depth below grade: Material of constru ion: fast iron _ 40 PVC _other (explain) VWe Distance from private wa er supply well or suction line Diameter _//I" Comments: (condition of joints, enting, evidence of leakage, etc.) SEPTIC TANKA.We- (locate on site plan) Depth below grader Material of construction."concreteO4 metal 44FiberglasW.4 PolyethylenW,4 other(explain) If tank is metal, list aged)-¢ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: �i4 Sludge depth: AJ/9 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness 4--/9 Distance from top of scum to top of outlet tee or baffle: AW Distance from bottom of scum to bottom of outlet tee or baffle: AW How dimensions were determined: VA Comments: trecommendation 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.) �9 9 .G�J GREASE TRAP: ,t1G[1Q� (locate on site plan) Depth below grader Material of construction 4/Aconcret4,NmetaXA/ FiberglasW Polyethylen&V other(explain) A40 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baKle:2/� Distance from bottom of scum to bottom of outlet tee or baffle: IV;# Date of last pumping: W 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.) M)'StV (rovisod 04/25/97) Paq• 6 of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 124 Longview Drive Centerville Ma Owner: Michael Dononvan Date of Inspection: 8/2 5/9 7 TIGHT OR HOLDING TANK: f,�CTank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construct ion-W,'?,concrete4,!&netal QjFiberglassV�Polyethylene.in�6ther(explain) 101 Dimensions: xS 6 Capacity: K)19 gallons Design flow gallons/day Alarm level: Alarm in working orderAA Yes;4?Q No Date of previous pumping: 24 Comments: (conditi of inlet tee,�cpn iup n of alarm and float switches, etc.) DISTRIBUTION BOX: (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.) PUMP CHAMBER:( , (locate on site plan) I� Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (not ondition f pump inharriber� condition of purpps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 124 Longview Drive Centerville Ma Owner: Michael Donovan Date of Inspection: 8/2 5/9 7 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: VA Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition f vegetation, a c. e •�i• � dr. CESSPOOLS: (locate on site plan) Number and configuration: r Depth-top of liquid to inlet invent Depth of solids layer: / Depth of scum layer: Dimensions of cesspool: Materials of construction: 1^ indication of groundwater: infl (cesspo I m st be p ped as an of inspection) Comments: (note condition ppof soil,, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) JAmA J `r l�C P R I VY:&k.d C (locate on site plan) Materials of construction: .(>% Dimensions: Depth of solids: 111W Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revlmed 04/25/97) Page 8 of 10 G ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 124 Longview Drive Centerville Ma Owner: Michael Donovan Date of Inspection: 8/2 5/9 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) �1 /tJV (revised 04/25/97) Pag• 9 of 10 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 124 Longview Drive Centerville Ma Owner: Michael Donovan Date of Inspection: 8/25/97 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abuning property, observation hole, basement sump etc.) �etermine it irom local conditions Check with local Board of health Check FEMA Maps :ZChec pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) 0-40C dW lserNsr�iyrret9 �jd �LjDp £�' �jf'7ter (revised 04/25/97) Page 10 of 10 (•.r+��n•..-T�+'r..'e'�IT'..TT,/'•"•'.+.'R'+.T�:•.T-'Tn/'f:�-�^T.'1 T�'"1L T�f.•91i,'O�I•l, .'fTY.i+^vn'.-v t�'-'T�•r—.— _ I.OHN OF Barnstable WARD OF HEALTH 90I1SURFACE SEWAGE DI Sf USAL SYSTEM I NSHCTI ON FORM - PART D - u1crI F I CAT i O ; -TYPL OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRCSS 124 Longview Drive Centerville,Mass. ASSESSORS MAP , BLOCK AND PARCEL # OWNER ' s NAME Michael Doriova_n �. PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & •ion , Inc . COMPANY ADDRESS Box 66 Centerville , Ma . 02632-0066 Street Town or City Stat• tip COMPANY TELEPHONE (508 ) 775 -3338 FAX ( 508 ) 790 -1 578 CER71 FICATION STATEMENT I certify that I have personally inspected the sewage disposal system n ' this address and that the information reported is true , accurate , and complete as of the time of .inspection , The inspection was performed and anv recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ec System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public lie aILh or the environment as defined in 310 CMR 15 . 303 , Any fai ! � re criteria not evaluated are as stated in the FAILURE CRITERIA sectio:: o : this form . System FAILED* The inspection which I have co\ 4' 0cted has found that the system [ails e protect the }public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . .Inspector Signature Date ✓� �� ')no copy of this certification must be provided to the OWNER , the DUYER ( -here applicable ) and the DOARD OF HEALTH . 1r the Inspection FAILED , the owner or "operator ehall upgrado tho eyote ^ ir.hin one year oC the date of the inspection , unless allowed or requires otherwise as provided in 310 CMR 15 , 305 . partd . ;;c� W U) Z7 P7 ti THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualificatigns as required and is hereby authorized to use the title CERTIFIED TITLE S SYSTEM INSPECTOR as provided M 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection_ lunc 8. 1995 Acung Dircctor of the ion of Walcr Pollution Cootrol r : i ALL SYSTE SYSTEM PROFILE MARKED WITHC MAGNETIC TTAPEALL OR BE NOTES PROVIDE MIN. 20„ DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROX. NGVD ' ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE � �� 2 PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING \ TOP FOU D. EL 73.53' FILTER FABRIC OVER STONE 72.5' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 4. DESIGN LOADING FOR ALL PROPOSED PRECAST a RISERS (IYP jO BLOCKS OR UNITS TO BE AASHO H- Q 3 2'e 4"0SCH40 PVC PRECAST RISERS PIPES LEVEL 1ST 2' MORTAR ALL H-10 5. PIPE JOINTS TO BE MADE WATERTIGHT. 4 COMPONENTS INV' 4'- DES• ENDS (NP) SIDES 69.83 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE o *70.38 " 1500 GAL H-10 " 10 14 �.ar..O TEE SEPTIC TANK TEE °o °°°°°69.75' 0 0 m0m0 DmaO-o -�Oma °o°o°o° cus° ° r� , o000'OOOoO o 0 0a��a O�Or� 0��ODa00a o 000000000000 0000 GAS BAFFLE:.'. o 000 o 0 0 0 o 0 0 0 0�_OOOO,.,O_ >0°0Oaaa0000� []��0�0�0� o°o°000 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND " >°o°o° mmm 1=m oaoao�aoaoa :°o°o°o4' LIQ. LEVEL (ACME OR EQUAL) 69.26 69.09 0 °o °o°o° NOT TO BE USED FOR LOT LINE STAKING OR ANY° ° ° ° ° ° 67.0 OTHER PURPOSE. c° 3 6" MIN. SUMP ° J O•O O 060 O•O O•O O O O O•`O'O•O O O O O O L " V J °000000000000000000000vo 12" MIN. INT. DIM. 00000000000000000000000 M TO SCH. 40-4 PVC. 0000000000000000000000. 8. PIPE FOR SEPTIC SYSTEM _ � 0O 001 ..�_0,.n?o-q 0 O O o °_°_o.o o 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. H-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. ALL AROUND PRECAST STRUCTURES (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR o 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' CONCEALED WITHOUT INSPECTION BY BOARD OFco COMPACTION. (15.221 [2]) o HEALTH AND PERMISSION OBTAINED FROM BOARD o � OF HEALTH. _ ( 7 % SLOPE) ( 1 x SLOPE) LEACHING 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP FOUNDATION 15' SEPTIC TANK 7' D' BOX 11' FACILITY CALLING DIGSAFE (1-888-344-7233) AND 62.0' BOTTOM TH-1&2 VERIFYING THE LOCATION OF ALL UNDERGROUND & NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL WORK' UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS o 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 251 PARCEL 152 PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND SAND. 99- EXISTING CONTOUR X 99.1 EXIST. SPOT ELEV. 99 PROPOSED CONTOUR SYSTEM DESIGN" 198.41 PROPOSED SPOT EL. 71.74 / .08 TH1 GARBAGE DISPOSER IS NOT ALLOWED x TEST HOLE x 71.69 SLOPE OF GROUND /71.51 11 EXISTING DWELLING: 2 BEDROOMS 2� '` \ 1-A.91 9°67 X 9 DESIGN FLOW: 2 BEDROOMS ® 110 GPD = 220 GPD UTILITY POLE 1. 771.91 X z158 X_ USE A 330 GPD DESIGN FLOW FIRE HYDRANT 1-t-97 - _ ��- X (V - -a2;o tiYo - - s.25 _SEPTIC TANK:_-330 GPD '2• -_ 660 i NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING � �S �Z PAVED / ` J 71. 3 � C.-� - 19 71 DRIVE / USE A 1500 GAL. SEPTIC TANK 78072 -Gl'�2. 8 / I SHED / \� \ x72.88 o LEACHING: TEST HOLE LOGS 3 x / x 72.21 _ 7 .12 j / O 3 11 7 - 71.82 SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD ° / o ENGINEER: ARNE H. OJALA, PE, SE 0 0 BOTTOM 25 x 12.83 (.74) = 237 GPD O 21' 16" OAK Z / WITNESS: DAVID W. STANTON, IRS O LOT 26 TH TH 1 �71.73 J 0.8 71.63 12,010 SFf 11 7 2 \x 7 zl TOTAL: 472 S.F. 349 GPD DATE: 12/17/10 ExISTING 73.08 , x 7 . �I USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) PERC. RATE _ < 2 MIN/INCH 158 TOP DWELLING NDN. PAATIC Q 6SP00 wl WITH 4' STONE ALL AROUND ELEV. = 73.53' �I CLASS I SOILS P# 13162 73. 60 x 7 .3 x 7 . 6 0 0I 20' x 7 . 16' 71.40 ELEV. ELEV. / s 73.49 On 72.0' O» 72.0' / ON WIRE ELEC METER 72.7 x 7 3 x 7 . 2 A A / 70 78 x 72.63 7 47 . LS LS �72.5 n71. 71.29 , MA 1OYR 2/1 1OYR 2/1 57 71.08 x' \ APPROVED DATE BOARD OF HEALTH x 6„ 6„ 0.69 tiY k7' S° x 71.25 TITLE 5 SITE PLAN B B 120 56, �`� \ \ Q��/ 1 SL SL OF 10YR 5/6 10YR 5/6 '��° / 7 . 6 x 71.06 36" 69.0 36 69.0 124 LONGVIEW DRIVE 6 71.69 x 71.06 x 71.14 CENTERVILLE EXIST DWELLI NG NG C C BENCHMARK PREPARED FOR PERC COR BULKHEAD ELEV. 73.5' B&B EXCAVATION/RANDALL Cs Cs ° DECEMBER 20, 2010 2.5Y 6/4 2.5Y 6/4 off 508-362-4541 � zN°FMgssgc -. N°��F� ry fax 508-362-9880 oa DAi�IELA. DANJIEL �N , I downcape.com o C7J�,LA A. CIVIL I OJAE_.A down cape engineering, /nC. NO,40980 120" 62.0' 120" 62.0' P. 02 P �� civil engineer's NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 l.l. -,i.c-A'a �VA y V land su/'veyo/'s '^ 939 Main Street ( R to 6A) 0-279 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675