HomeMy WebLinkAbout0112 NOBADEER ROAD - Health 11.2 Nobadeer Road
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LOCATION Jiy SEWAGE PERMIT NO.
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I N S T A LLER'S NAJAE V ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED C�
DATE COMPLIANCE ISSUED
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THE 0010N1iA'dNWEALTH OF MASSACHUSETTS
ii BOAR® OF !—I_E�TH
.............0 F.. -------------------------•---
Applira#ion for DiSpniial Works Cfnnstrurtinn Frrmit
Application is hereby made for a Permit to Construct k")` or Repair ( ) an Individual-Sewage Disposal
System at:
.. .... .�.— Location---Location-AA •--,/ ..................................: -J.
f
P.�Location- s Lot No yI
------------- /. ��--® - .....
- ..._------ - —Yi —,9z'. o`.! ....1�?�z
� ner "-'— ` Address
oe
Installer Address 1
Type of Building Size' Lot....... ...................Sq. feet
U _Dwelling—No. of Bedrooms.__. ..........................Expansion Attic ( ) Garbage GrinderAw
�-+
`1 Other—T e of Building ._ No. of ersons____________________________ Showers
a YP g -,----------------------------------•-------P--�-- ( ) — Cafeteria ( )
Otherfi es ••••-- -•------------ ------ ---------------------------------------------------------••r.....................
Flow__________________ _
W Design ___.___._ �.. allons per person per day. Total daily flow...... :___„r-....��.-�........gallons.
WSeptic Tank—Liquid capacity__._-__-allons Length_ __._ Width................ Diameter................ Depth.................
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No......../......... Diameter...1.17...Z... Depth below inlet.....................Total leaching area�-.5_/,Zsq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test ResuIt�j Performed by.......................................................................... Date--------------.........................
aTest Pit No. 1<4—minutes per inch Depth of Test Pit..../Z...._.... Depth to ground water.l`�D�.l�
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------
_,-,-_,_--------------------------------
-_...
_............................................................................
0 Description of Soil.......................................................................................................................................................................
W
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
----------------------- --------------------------------------------------------------------------•-------------•-----------------------------------------------------------------------.......---_...--
Agreement:
The undersigned agrees to install the aforedescribed Individual ewage Disposal System in accordance with
the provisions of iiTL is 5 of the State Sanitary Code—The under ed further agrees not to place the system in
operation until a Certificate of Compliance has been i by he b d alth. /C�
k;. Signed------ -- ---------•---•............. _(__... --
; }'�.t t :' - Da
Application"Approved By..................................................................................................
Date
Application Disapproved for the following reasons:.......................--------------------------------------•-----------------------------...................
_.....•••-•••--••----=•••----••••--•••--•--•-•---•-••----•••-•--••••--•••.._...-•••-••--•-•-•--•••••--•---•••-•-••-•••••-•------••--------•-----•--•-•-•••••---••-•-----------••-••---•----•-•-•--•••---
Date
PermitNo....................................................... Issued_.......................................................
Date
h -.ram
No........................ FEz............................_
THE ;;OMMONWEALTH OF MASSACHUSETTS
BOARD, OF HE4 TH'
0F. : . ..:. ,t`j, �1, ...-.•:..................................
Appliratiun for Uhipvnttl Works Tontrurtiun Prrulit .
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage;Disposal
System at: y `•
ihatS�n! A+ddre5§✓' i < ,`�'`ITT• I ,C .......... .N7�.r.........�.........................
Address
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms... ----------------------------------Expansion Attic ( ) Garbage Grinde
Other—T e of Build I No. of persons............................ Showers — Cafeteria
a YP g P ( ) ( )
Otheres -----------------------------••-•-•••••-•..... ----••-••------•-•--•-•---••......••---•--•- _ ....... .
W Design Flow........................... ..�ni 7.q .gallons per persoiA per day. Total daily flow............................................gallons.
R; Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench— o. .................... W! jhtX-_Ii...__.._... Total Length.................... Total leaching sq. ft..
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test I esi is, Performed by........ ..............................i-;;.............................. Date.............. 7.
Test Pit No. I................minutes per inch Depth of Test Pit____.................... Depth to ground wate _..... ... _.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
ODescription of Soil........................................................................................................................................................................
x
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---:............._•-----
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-----------------------------------------------------
•-------------------------------------------
----------
-•-----------------------------------------•------------•--------------------------
Agreement:
The undersigned agrees to install. the aforedescribed Individual ewage Disposal System in accordance with
the provisions of ii:I S of the State Sanitary Code—The under ned further agrees not to place the system in
operation until a Certificate of Compliance has been by the b d f ealth.
Signed . . . ........ ............................. = •-
Date
ApplicationApproved By................................................._...............................................
Date
Application Disapproved for the following reasons:...............................................................................................................
..................................•-••••-••-•--•-•--•-•--------•••-••-••--•-••••--•--•--...._............._
Date
PermitNo......................................................... Issued......-••----•••-•------•--•••.••--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OIL HE .H
-OF...................................:.................................................
Tnrtifir V of Toutplianr
THIS IS TO CERTIFY �, t e Ln" wage Disposal System constructed ( ) or Repaired ( )
by -.
� -G%. `��l_.E�-��• - Instalie�i. . •
at.•-•-••-••----•••••-••---•-•----•--•----•-------•--•---•••-•-......•-••••••-•••••-•--•--•---•---•••-•-------------------------------------------------------------•-•---............................
has been installed in accordance with the provisions of TI 1 -`p?7e State Sanitary CodeSl'e49ed in the
application for Disposal Works Construction Permit No......................................... dated.-.._____._._.__..---__:___.______----------•--.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.`
DATE................................................................................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O &EA1:TH C�
I�� J / ..........................................OF.....................................................................................
+ f'1
No......................... FEE........................
Disposal � #ion Vantit
Permission is hereby granted................................. ---•••-•-•- -••-- .�J- ..........................................................
to Construy<&(d-)Ai &pair% �,�ivi .14e'dage D 9gas"5aVSyst
at No....................................................................... ........ , `�
------- -
Street _ .�...---• �. ._.43. ...
as shown on the application for6sposal Works Construction Permit No........_ -_«,,,�Dat�ed ���_ .........
........................
��' /j•. �
/. Board of Health
DATE--- t . ---. ....................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -`
T
Commonwealth of.Massachusetts
Title 5 Official Inspection Fayp.
- Not for Voluntary Assessments 1IRPIS TABLE
�M Subsurface Sewage Disposal System Form r� M 1 j. 3
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 "AP 1z ISO
computer,use 112 Nobadeer Road, Centerville, MA 02632
only the tab key Property Address
to move your Thomas P. & Helen J. Feeny
cursor-do not -
use the return Owner's Name -
key. 112 Nobadeer Road
Owner's Address
VQ Centerville MA 02632
City/Town State Zip Code
Date of Inspection: 7 November 2004Date
OF
2. Inspector: 61
MgsS9c
Edward L. Pesce, P. E. moo`' EDW SCE L 0
Name of Inspector o CIVIL r;
Pesce Engineering &Associates No 32001
Company Name .09
451 Raymond Road �sT
Company Address
Plymouth MA 02360
City/Town State Zip Code
(508) 743-9206
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
❑ Needs Furth Evalu n the Local A proving Authority G
,L1 ,82
tor'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.
Feeny Title 5 Insp.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State" Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
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:
System components found to be in good condition and functioning properly.
N/A B System Conditional) Passes:
Y Y
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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
structural) unsound exhibits y substantial infiltration or exflltratlan 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:
Feeny Title 5 Insp.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments .
Subsurface Sewage Disposal System Form
A. Certification (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
Owner's Name Date of Inspection
N/A 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:
N/A 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
Feeny Title 5 Insp.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
4M
A. Certification (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. & Helen J. Feeny 7 November 2004
Owner's Name Date of Inspection
N/A 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:
Feeny Title 5 Insp.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
�M
A. Certification (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
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
N/A ❑ ❑ 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.
N/A ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A ❑ ❑ 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.
Feeny Title 5 Insp.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
f
Commonwealth of Massachusetts
Inspection Form
Title 5 Official Ins
_ p
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
CitylTown State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
Owner's Name Date of Inspection
N/A 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—IW PA) 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.
Feeny Title 5 Insp.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
M
B. Checklist
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
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, 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 CM 15.302(3)(b)]
Feeny Title 5 Insp.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
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. & Helen J. Feeny 7 November 2004
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
Number of current residents: 3
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? 0 Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
WA
Last date of occupancy: Presently Occupied Date
N/A 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):
Feeny Title 5 Insp.doc.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
M
C. System Information (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
CitylTown State Zip Code
Thomas P. &Helen J. Feeny 7.November 2004
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: Present occupants/owners
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:
1983, per Town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Feeny Title 5 Insp.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
i4^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 2.0
Feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: N/A(Town water)
Feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Building Sewer is in good conditions
Septic Tank(locate on site plan):
Depth below grade: 1.0
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: 1000 gallon tank
4' 10"X 8'6"
Sludge depth: 2„
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 8.6
Distance from bottom of scum to bottom of outlet tee or baffle 15
How were dimensions determined? Direct measurement(probe)
Feeny Title 5 Insp.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
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.):
Recommend pumping of septic tank this month, and every 2 years (minimum)thereafter. The tank
and piping were structurally sound.
N/A 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.):
N/A 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):
Feeny Title 5 Insp.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
Owner's Name Date of Inspection
Tight or Holding Tank(cont.) WA
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 Liquid level at 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.):
D-Box is level and structurally sound
N/A pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Feeny Title 5 Insp.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.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
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 6' X 8' — 1000 gal number: 1 pit
❑ 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.):
The leaching system seems to be functioning properly; system shows no sign of failure. Liquid
Level in leach pit was measured to be 56" below the invert.
Feeny Title 5 Insp.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection ection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. & Helen J. Feeny 7 November 2004
Owner's Name Date of Inspection
N/A 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.):
N/A 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.):
Feeny Title 5 Insp.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
Subsurface Sewage Disposal System Form
�M
C. System Information (cont.)
112 Nobadeer Road
Pro
perty Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
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.
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Feeny Title 5 Insp.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
112 Nobadeer Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Thomas P. &Helen J. Feeny 7 November 2004
Owner's Name Date of Inspection
Site Exam:
Slope—1-2%
Surface water—none within 300 ft.
Check cellar—no water problems
Shallow wells - N/A
Estimated depth to ground water:-30 ft.
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Consulted USGS Groundwater Map and Town GIS system
You must describe how you established the high ground water elevation:
Existing ground elevation, based on Town GIS is approximately 72 ft(above MSL) The estimated
elevation of the groundwater at this location is 32 ft. (above MSL), based on USGS GW maps- Cape
Cod GW Resources. The depth of the bottom of the leaching system is 10 ft. This yields an
estimated separation distance from the bottom of the leaching area to groundwater of 72— 10—32=
30+ft.
Feeny Title 5 Ins .doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
Sl TE PL A N T YPICAL PROFIL E
SCALE — / " _ , F_L t-L. c-.7 5 NOT TO SCALE
18' STD. LT. WGT. C.l. MH COVER
4"CI. PIPE 4"BIT. FIBER PIPE TIGHT 'DINTS
" OUTLET LEVEL
FLOW LINE 0 J g
J r T
- TO�F 2IRST ✓
-D IN
o - __Ljl1�4DWELLING /o"
c.I. TEE L .77
C.I. TEE -T-
( > ACJ __ —9J STANDARD PRECAST --- - -� T4"-- -------- r_ _
CONCRETE (--IV GAL LON
- SEPTIC TANK `
DlS rRIBL'TION BOX �
_ B TO BE /NS TA L L ED ON
LEVEL , STABLE BASE I
SEPTIC TANK
U Q It t u o 0 4-7 A TO BE INS TA L L ED ON
°2Ep ;L TAut� STD• I-$ZEC_,A`iT CO&.JG• LEVEL , STABLE BASE
— T K L E AL 1-I 1 "G, 0 A'h 1 a-J
r: 2" 1/8" TC 11'2 ' WASHE0 PEA S,cNr. LEACH/IVG P/T
ALL AROUND FREE OF IRONS FINES
BASE TO BE L EVEL
7 d �� b i AND DUS T IN PL ACE
a' r BRICK 8 MORTAR COURES \ 314" TO I-112" WASHED CRUSHE:7
AS REQUIRED TO BRING \ STONE ALL AROUND FREE Cx-
,F 4. 6� COVER TO GRADE 24"C./. MH COVER
.Q s AND FRAME `''. /RCNS, FINES 4NO OUST IN PLACE
O T 4 2 4 T T 8"FLOW _ _ _ _ LEACHING PIT SEC TION/NLE _ _ _ _
PIPE 1. CONCRETE TO BE 4000 PSI 28 DAYS
2. REINFORCED WITH 6" x 6" NO. 6 GA W W M.
3. 2 AND 4 SECTIONS ARE AVAILABLE FOR GREATER
DEPTH REQUIREMENTS.
OPENING WITH 4-118" I I 4 NUMBER OF PITS REQUIRED 1
1 OUTER DAME TER d ! T T S 3,
Q NOTE EXCAVATE TO ELEVATION —�OR LOWER AS
1-314" INSIDE DIAMETER 3„
REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH_
I` S PIT REPLACE EXCAVATED MATERIAL WITH CLEAN
GRAVEL TO DESIGNED GRADE
II 6'N I
o ,
q -O �-�• - - _ ------ ------- - -1
Z MIN.
� EFFEC 7-1 VE DIAME TER
(NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH)
-- -�� WATER TABLE
E ti' CC (-. a•JTtcI2 ED)
IN
SOIL A ND PERC. DA TA GENERA L NOTES
PERC. RATE MIN. /IN . 1 � 7 �5 NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
o
TEST BY: �t�U C f� �W M W t� 12 u./�L L= SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD
l-t �L.D � ;.�h�UG• (!..1 L.
t
PRECAST REINFORCED CONCRETE UNITS
' WITNESSED BY. J O N Q J A L U r"-' ; 1?2 . ►?j • w ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
I Z TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE ,
TEST PIT GR. EL. - DATE ' f �' MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF
TEST PIT NO. I TEST PIT NO. SANITARY SEWAGE EFFECTIVE I JULY 1977,
�,a� 1 •J' Z 7" ��/ 3, TOpIS� /coMP. SA"� 0" ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE
1 .-S�;--.--------
A RS Cr SANp c,aawa� BOARD OF HEALTH.
AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE
M VEDI UNA — BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
29'0& iD h A P PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATED
It1 ` Z�' ��, 21 , E � I ►�I �
12 <,,a- n.I 1::7 EL �,4,�, OTHERWISE.
r'l o c,►zo u�1 I:>wL..' Z'T 4 A,
k1 E0U /-\ 0JF '_F L A KJ E DESIGN DATA
4v' W A Y ) BEDROOMS . DISPOSAL Q o Lj �
EST. TOTAL DAILY EFF. �'� �' GALS.
L EGEND --- SEPTIC TANK I v GAL
SIOEWALL AREA GAL./SO. FT
BOTTOM AREA � 7 L'6-GAL./SO../so. FT SEWAGE DISPOSAL SYSTEM
Ox00 EXISTING GRADE LEACHING REQUIRED_ SO.FT,
ZONE: P �� o F4NI$HED GRADE ACTUAL LEACHING AREA 311)- 07 SOFT. FOR -T
T o � iki ,,�/ /1. 7 I--- tZ 4 Do 1 INVERT ELEVATION %!h'r'/u� �'*,L '` - L J v `l `
DOMESTIC WATER SOURCE (.__ _ LOT 42 _uJ !r 42 v A Q U tw T L ��► tiJ
PROPERTY LINE - �s, 1. t�
for irr�� C kJ T �z' rX%�i LL.!`. 015A R I+J�T /fA
PLAN REFERENCE L G. 40oi�2 - ___----- ': ,� .`` s it " ,, R.,,,��►+• t- SCALE AS INDICATED DATE '
MEAN HIGH WATER ,
L
F r2 o M U `' G` �' -ra r'�' WM. M WARWICK Q ASSOCIATES
BENCH MARK DATUM , MARSH s
F L 0o p Z v Cc tit o u �I /�. z .a• a_ BOX 801 - NORTH FAL MOUTH
IVA SSA CHUSE T TS 02556
1