HomeMy WebLinkAbout0116 KNOTTY PINE LANE - Health 116 KNOTTY PINE, CENTERVILLE
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Commonwealth of Massachusetts
-- - - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
ON ner ON nets Name
forn-stion is
rlequired for every CENTERVILLE. ✓ MA. 02632 12/9/15
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered In any
way. Please see completeness checklist at the end of the form.
`"p°outforrns A. General Information
fillingthe
out forms 6/
on the computer, J
use only the tab 1. Inspector
key to move your
cursor-do not BRIAN S MURPHY
use the return Narne of Inspector
key. B & D SEPTIC INSPECTIONS
VQ Cornpany Narne
P O.BOX 47
Company Address
HULL, MA. 02045
City/Town State Zip Code
(781) 290-9942 S13675
Telephone Number License Number
B. Certification
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 CM 16.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
12/9/15
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
**'"This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ns•3113 Title5Official kispectionFora[Subsurface Savage Disposal Sys tam-Page 1 of 0
p VS
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
Q"ner Owner's Name
information is required for every CENTERVILLE, MA. 02632 12/9/15
page. aty/rown State Zip Code Date of Inspection
B. Certification (coat.)
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.
Check the box for"yes", "no"or"not determined"(Y, N, ND) for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or efiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5i^s-3/13 Tille5Offldal InspectionForar SubsurfaceSeNegeDisposal System-Page 2of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
QN ner Om ner's Name
requiredf revery CENTERVILLE. M G1ty/Town A. 06—��— 12/9/15
page. State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
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
t5rs•3/13 TWe50ftidal Iris pectionForm SubsurfawSevageDisposel System-Page 3of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
ON ner QN ner's Name
infregouiredfor is
every CENTERVILLE, MA. 02632 12/9/15
page. Cityfrown State Zip Code Date of Inspection
B. Certification (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 has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of-the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must Indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than%day flow
t5ns•3%3 riide50f6dallnspectionForm:SubsufaoeSenegeDisposal System-Page 4of17
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
ON ner ON ner's Narre
inquired for every information is
require CENTERVILLE, MA. 02632 12/9/15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool sensing a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fats. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow 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.
Ore•3113 TO 5 0ftidel Ire pection F arm Subsuface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
--- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
ON ner Ow ner's Name
information is required for every �
CENTERVILLE MA. 02632 12/9/15
page. City/town State Zip Code Date of inspection
C. Checklist
Check if the following have been done. You must indicate"Yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelli ng inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 348.5
I
tyre•3M 3 rile 5 Official Ire pacbcn F arm Subsurface Sewage Disposal System-Page 6 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
U
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
Owner Oar ner's Name
information is required for every +CENTERVILLE MA. 02632 12/9/15
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: — 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
2013 = 55,000 gallons = 150.68 gpd
2014 = 103,000 gallons = 282.19 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5�'3113 TitleSOrficiallrupecdonForm SubsufaceSewQe Disposal System-Page 7of17
Commonwealth of Massachusetts
--- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
Cw ner Cw ner's Name
information is CENTERVILLE MA, 2632 12/9/15
required for every �
page. Citylrown State Zip Code Date of Inspection
D. System Information (coat.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Tank last pumped 12/13 - owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)and a copy of latest
inspection of the VA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ns•3(13 Title 5 Official Inspection Form:Subsuface Saw3ge Disposal System•Page 8 of 17
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 KNOTTY PINE LANE
Roperty Address
SEAN MCMULLIN
Cw ner Cw ner s Narm
requ edforevery CENTERVILLE. MA. 02632 12/9/15
page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
Tank = 40+ years. installed 1972, d-box/sa_s = 2 years, installed 12/13
local BOH records.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
"
Depth below grade: 14
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8' X 5' X 4' 1000 gal.
Sludge depth:
1"
t5rs-Y13 Title 5 Official Inspection F am Subsuface Savage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
--_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 KNOTY PINE LANE
Property Address
SEAN MCMULLIN
Ow ner ON ner's Name
information is required for every CENTERVILLE+ MA. 02632 12/9/15
page. Cityf row n State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle . 2819
28" (outlet (.- 49")
Scum thickness 1"
Distance from top of scum to top of outlet tee or baffle 5"
Distance from bottom of scum to bottom of outlet tee or baffle
20°
How were dimensions determined? Measured in field
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank, cement inlet baffle and outlet tee in good condition, outlet tee has
gas baffle in place, liquid level with outlet, tank appears sound no signs
of leakage.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass [polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5irs•Y13 Title5Official Inspection Form Subsurface Sewege0isposal System-Page 10 of 17
Commonwealth of Massachusetts
Title '5 Official Inspection Form
U1WWO Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
Ow nor Ow ner's Name
information is CENTERVILLE MA. 02632 12/9/15
required for every
page. 5R—Tow n State Zip Code Date of Inspection
D. System Information (cunt.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
galons
Design Flow. gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in worldng order. ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3M3 Titte50rficial InspecfionFortrc SubstsfaoeSeNegeDisposal System-Page 11 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address --
SEAN MCMULLIN
U1W
ON ner ON ner's Name
information is
required for every CENTERVILLE, MA. 02632 12/9/15
pa". Otyrrown slate zip Code Date of inspection
D. System Information (coat.)
Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box in like new condition. liquid level with outlets distribution appears
equal. no signs of caM over or leakage. box 23" below grade with
riser to 4" below grade.
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No'
Alarms in working order. ❑ Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
' If pumps or alarms are not in working order, system is a conditionat pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
tSns•31 3 Title5 Official Inspecfion Form:Substsface SewVe Disposal System•Pape 12 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 KNOTTY PINE LANE
Roperty Address
SEAN MCMULLIN
Owner Cw ner's Name
information is required for every CENTERVILLE MA. 02632 12/9/15
page. City/Town State Zip Code Olate of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number.
❑ leaching chambers number.
® leaching galleries number. 10 diffussers
® leaching trenches number, length: 2Q 501
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil conditions normal, no signs of hydraulic failure, vegetation appears
normal.
SAS consists of 2 trenches each with 5 biodifussers
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
tyre•Y13 Title5Oftldal IrepectlonFomt Subsurface Savage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
ON ner Ow ner's Name
requiratfoion is CENTERVILLE MA. 02632 12/9/15
required for every �
page. Otylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15ins•3r13 Title5Official inspection Form Subsurface Seyege Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 KNOTTY PINE LANE
Roperty Address
SEAN MCMULLIN
Orr ner 5;ner's Name
refo for is
required
CENTERVILLE, MA. 02632 12/9/15
page. fo qtyfrown
page State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below.
❑ hand-sketch in the area below
® drawing attached separately
��,3113 Title50fficial kupecbmFum Subsurface SeMageDisposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 KNOTTY PINE LANE
Property Address
SEAN MCMULLIN
ON ner 5;ner's Name
information is CENTERVILLE, MA. 02632 12/9/15
required for every
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water. feet 101+
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: 12/9/13
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:
Groundwater determined from design plan on record at local BOH,
no water encountered (aD 120" on perk test dated 11/8/13.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5irts 3f13 Mfle60fficial InspacfionForm SubsufaceSewegeDisposal System.Page 16 of 17
Commonwealth of Massachusetts
-------- Title 5 Official: Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 KNOTTY PINE LANE
Roperty Address
SEAN MCMULLIN
ON ner Q ner's Name
information is CENTERVILLE, MA. 02632 12/9/15
required for every State Zip Code Date of Inspection
page. City/Town
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Tige50ffidai IrepeclionFomc Subsurface SeNegeDisposal System-Page 17 of 17
t5ins-3r13
AsBuilt Page 1 of 2
TOWN OFWtNSTABLE
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INSTALLER'S NAME$PHONE NOI ,• .t 4 faa&4_ ln+c S[o N to-Y5111
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LEACHING FACUM*(type)"'Aln 7 R tea 11-36 (size) 1 5 U l f i'' PS
NO.OF BEDROOMS
OWNERAr k- U M N
PERMrr DATE: 1 12, COMPIJANCE DATE:
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Maximum Adjusted Groundwater Table to the Bottom of Leaching Facilitp C& or—(CFeet
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 Of airy wetlands exist within
300 feet of leaching facility) Fed
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DearOme p nt of Regulatory Services
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2CO Main Street,Hyannis MA 02601
:Date Scheduled y Time 1J Fee Pd. �`
Soil Suitability Assessment for Se Dlsp a a
Performed By: �!-M_,_ - Witnessed By: 40
LOCATION&.:GENERAL INFORMATION
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Distances from: Open Water Body ft Possible Wet Area OJ/A' • ft prinking Water Well
Drainage Way Tl/'] ft Property Line Vf�ft ,Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
y
h OVA
Parent material(geologic) Si W1r Depth to Bedrock ,
Depthio Groundwater. Standing Water in Hole: �� Weeping from Pit Face
Estimated Seasonal High Groundwater 1 Z-J
DETERMINATION FOR SEASONAL HIGH WATER.TABLE
Method Used:
Depth Observed standing in obs.hole: in, Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index.Welt# Reading Date: Index Well level__�,_--_�, Adj,factor Adj.aroundwater Uvel ,o
PERCOLATION TEST Date . Thne
Observation
Hole# ' I Time at h" / d Z
Depth of Perc �� Z Time at 6"
t
Start Pre-soak Time® �Q • 06 lime(9"•611)
End Pre-soak ! 6.1 zz
Rate MinJlnch. 2
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation testis to,bi conducted within 100' of wetland,you must first notify the
Barnstable ConselrvationsDivision at least one(1) week prior to beginning.
Q:XSEPTICU'ERCFORM.DOC
t.,
DEEP.OBSERVATION HOLE LOG Hole# _!
Depth from Soil Horizon Soil Texture Soil Color Soil. Older
Surface(in.) (USDA) (Munsell) Mottling (Structure;Stoneg;Boulders.
o itoGravel)
13
60 -12a 41
DEEP OBSERVATION HOLE LOG Hole# 2-
Depth from Soil Horizon Soil Texture Soil Color ' Soil' Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. .
Consistency.% rave
l z L S i.� `ta Y/•
z- s 10
-/2 s �� s
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) / (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency. O ve
i
DEEP OBSERVATION HOLE LOG Hole#
Depth.from Soil Horizon Soil Texture SoiI Color Soil Other
Surface{in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
consistency,
Flood Insurance Rate Man:
Above 500 year flood boundary No Yes __
Within 500'year boundary No Yes,...
Within 100 year flood boundary No(\ Yes
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious matenai exist in all areas observed throughout the
area proposed for the soil absorption system? —
If not,what is the depth of naturally occurring pervious material?
Certification /
I certify that on G (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 .
the required tra ,expertise and experience described in M C1v1R 15.017.
Signature Date
Q\SBPTIC�PERCFORM.DOC
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
1 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftphtation for MieposaY 6pstrm ConstCUttion Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1 i La kCA�1• 7 ?%-e Ir Owner's Name,Address,and Tel.No.
C_e vk-2:�vill -e ML/Nv`I�tom+
Assessor's Map/Parcel kci 1 —01
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
<A T' rv,,ot J .A+c 5 019..g005 -7�5y L n►�I"V...t't'.It LOC)r L s
Type of Building:
Dwelling No.of Bedrooms Lot Size 2,&77 70 sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) G gpd Design flow provided 3 y fj' i r gpd
Plan Date 1 1 1 1`t l"Z, Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. 14; ti N' "!2
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction'and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
i C. Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
r
"No. c11 a A" Fee
THE COMMONWEALTH OF`MASSACHUSETTS Entered in computer:
bBLIC,HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplication for Misposal 6pstettt Construction permit
Application for a Permit to Construct( ) Repair(gUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1 I C. nkJ i ,N 6 Owner's Name,Address,and Tel.No. h
Getit-e�v111 �e AL AAjIIi�.► i
Assessor's Map/Parcel h 1 ..pej&
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
A '13rnwa T-"c GOO-L-la0-7i55 r-,vs,.ve�rrtiJ I,t7c�Jk$
Type of Building:
I
Dwelling No.of Bedrooms 3 Lot Size 2 G4 70 sq.ft. Garbage Grinder( ) I
Other Type of Building ko VS r No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required)_ '3 3 O gpd Design flow provided .3 N 0 gpd
Plan Date 1`( � J Number of sheets �--- Revision Date
moo. ;
Title
Size of Septic Tank (0)<lSfrw Type of S.A.S. I y
Description of Soil
_ 4
� 1
Nature of Repairs or Alterations(Answer when applicable) I nl S fY.e h New S. +S w
i
I
Date last inspected: t.
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in f
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. r...
y i n 4 Date /''Z .Ihnr
Application Approved by - f Date
Application Disapp?oved by V Date
for the following reasons ^'
Permit No. Date Issued
- - - I / I---------- - - - -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS.T-O;CCERTIFY,that the On-site Sewage Disposal system Constructed(�H~) Repaired( ' 'Upgraded( )
Abandoned( )b �4 S (du!�.1 ���
at I I G V"Q044 _2t1-4 -e L,J Ce-,J -f o3 has been cons ucted in ce
I; with the provisions of Title 5 and the for Disposal System Construction Permit No. ated
Installer ,hI45 A 3fp�, J Designer
#bedrooms '� Approved design flow gpd
his si The issuan e o permit shall not be construed as guaran2tee that the systemPITyrri ton ased.
h�Inspector
�'1
No-A-0
S �4� Fee
-------------/ �HECOMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal Epstein obstruction Permit
Permission is hereby granted to Construct( ) Repair(1 Upgrade( ) Abandon( )
System located at I I G N4+t -1
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. `
i
Provided:Construction a co pleted within three years of the date of this permit.
Date Approved by IRS
I
s
Town of Barinstable
Regulatory Services
Richard V, Seah, Interim Director
MAM Public Health Division
>�b► c� Thomas McKean,Director
200 Maio Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Imstalle:r & Desizuer Certification Form 11
Date: l 1 j Sewage Permit# _ Assessor's Map1Parcel VA k ~oq ('
c+<Y �1 C=Ew+•pie �•�•Desigmer: Insta)ler: �, � •�''' '�•'� ^ �•1 �
Address: 1 2 .tN0.3�
Address: 4 . x 1`� 5
�es�s S-�,ca lQ 1'��- O 2 6�(�-( �'#,..,1•.e„r,� l�.e C}'z-�. -3 2.
on - ✓' �"`� was issued a permit to i=all a
( te) (installer)
septic system at_ f J4.--0 .L, Cam' used on a design drawn by
clre.r'C-� .n�-cam , (address)—
4ni ; n-ter 1 R r; V4�3 ,.. dated it k t q
(de5i�er)
I certify that the septic system referenced above Was installed substantial_y according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes-
-(i.e-greater than 10' latezal relocation of the SAS or any vertical relocation of any compbnent
of the septic system) but in accordance with State & Loeai Regulations. plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
/were found satisfactory.
i/ I certify that the system referenced above was constru with the terms of
the I1A approval letters (if applicable) PSTER T.
WENTEE
CIVIL
Na 35102 q
St er's Sipatue) T����
s'�lONAL r�t�
(:Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTA13LL PUBLIC ggAkTH DMSION. CERTIFICATE
OF COM AiNCE WILL NOT BE ISSUED UNTIL BOTH TMS FORM AND
BUILT CARD ARE RECEIVED BY THE BA.RNSTABLE PUBLIC HEALTH DMSZON.
THANK YOU.
QAI pt,eOesigner Ceiti3cation Farm Itcv 8'-14-13,doc
Town of Barnstable
WE Tpk�O Regulatory Services
Richard V. Scali, Interim Director
1 BAMSTABLE, Public Health Division
16W.
3 a��� Thomas McKean, Director
rFD MA'S
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Homeowner Certification Form for Alternative Systems
Property Address: rve,
Assessor's Map\Parcel: 111 - o`I
Property Owners Name:
In accordance with Massachusetts DEP alternative system approval letters, the following certification
information is required by the Owner of record. The Owner of record must place an "x" in the
applicable box next to each line certifying the information.
Yes N\A
9 ❑ I have been provided a copy of the Title 5 UA technology Approval,letters.
(15 page Standard Conditions letter and the specific technology letter).
❑ I have been provided with the Owner's Manual
❑ I have been provided with the Operation and Maintenance Manual
❑ ® For Systems installed under a Remedial Use Approval, I agree to fulfill my
responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10)
and the Approval
❑ ® For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to
provide written notification of the Approval to any new Owner, as required by
310 CMR 15.287(5)
® ❑ If the design does not provide for the use of garbage grinders, the restriction is understood
and accepted
❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify
or take any other action as required by the Department or the LAA, if the Department or the
LAA determines the System to be failing to protect public health and safety and the
environment, as defined in 310 CMR 15.303
I UI e'lo�1- AAC MG",(� agree to comply with all terms and conditions above.
Property Owners printed name
Property Owners Signature Date
Note-* This form must be submitted along with the septic system disposal works permit
application for all I\A systems including new construction, repairs\upgrades, with and
without aggregate (stone) and with conventional design criteria or credited design
criteria.
Q:\Septic\IA homeowner certification.doe
TOWN OF BARNSTABLE
LOCATION 1KNc; �, tom- :y I.h) SEWAGE# L
VILLAGE u i 11 ASSESSOR'S MAP&PARCEL 1 q 1-OCI(a
INSTALLER'S NAME&PHONE NO.`�� ;.0 1 CCI�,�r�1 rK: 5ig0-4 20-q S 3V
SEPTIC TANK CAPACITY EX
t 5'F C
LEACHING FACILITY:(type)12,iaLl :sI*A 14-g6 (size) FS
NO.OF BEDROOMS
OWNER A,+l:a 1 I�+I�
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the: °J
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility C .+- Jiftc 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 BYL )au C
A iN r aia ��
OUT - 2; nv'` 3j
T,L bP� - 33 �'�3�S—S2,L1
so
i o, —�� � 12 t� -40
12 d6 p� - 3�,`i
�c�r Ic
i3�tk
Terence McGonagle
J6.16 Kpotty Kne Lane
Centerville ,Mass .
02632
Title Five Septic. CvctPm 7R rodo
1 -1000 gallon tank.
2-1000 gallon precast laching pits .
i
looll
I
D AT E:a/_?jJDD----
PROPERTY ADDRESS: 116 Knotty_ PIne L`ang__
Centerv_illL ,s�j_____
--- 02633----------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon septic tank .
2 . 2-2000 gallon precast leaching
pits packed in stone .
Based on my Inspection, I certify the.following. conditions:
3 . This is a title five septic system. ( 78 Code )
4 . The septic system is in proper working order
at the present time .
5 . PUmped tank and first pit at time of inspection .
6 . Wates water is 30" below the invert pipe to the
second leaching pit .
SIGNATURE.7
Company: Jos92h_P_ Macomber_& Son, Inc.
Address:_ Box_66--
-----------
-_CentervilleL Ma_-02632-0066
Phone:___508 775_3338_______
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools•Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3336 775.6412
COMMONWEALTH OF MASSACHUSETN
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-6600
TRUDY C
Socr
ARGEO PAUL CELLUCCI DAVM B. STR
Governor Corr T
SUBSURFACE SEWAGE DISPOSAL SYSTDA•WSPECTION FORM
PART A
CERTIFICATION
Property Address:116 Knotty Pine Lane Narrw of owswr Terence McGonagle
Centervill I 02632 Address ofOwrw:
rt,Da of inspection: �71�7 8 0 e Name of��Dr: (Pts so pry Jos ph P.Macomber J r .
1 ern a DEP approved ayatam Inspector punwarrt to Section 16.340 of Tkdo 6(310 CUR 15.000)
Cor�Name: J P M a c o m b P r R Ron T ri C
M-'f,ng Address: R^D e-R#p;p'b•'_'-+�-�i-e `r'R-s s )2 6 3 2
Telephone Number:
CERTIFICATION STATEMENT
certify that I have personally Inspected the sewage disposal system at tNs address and that the Information reported below Is true, accurate
and complete ss of the time of Uupection. The Inspection was performed based on my training and experience In the proper function and
maintanance of on-site sewage disposal systems, The system:
ZPasses
Conditionally Passes
Needs Further EvaI stlon By the Local Approving Authority
_ Fails
Inspectors Srtr lgnue: Data: . Z �!//q
�
The System Inspect shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)whNn thirty (30) days
completing tNs Inspection. It the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owt
stall submit the report to the appropriate regional office of the Department offmvironmemid Protection. The original should be.sant to-rev
system owner and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
a
z
5 %10 #
r. N
revised 9/2/98 Patc I of 11
�.�Printed on Rocycld PePer
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continual)
Prop.nyAddress: 116 Knotty Pine Lane Centerville ,Mass .
Owner. Terence McGonagle
Date of Insp.otk-: 2/2 2/0 0
INSPECTION SUMMARY: Check A, B, C, o/ D:
A. SYSTEM PASSES: I
/!LL I have not found any information which Indicates that any of the failure conditions described in 310 CMR 1t.303 exist. Any faik to
criteria not evaluated are Indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
.A�76_ One w 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,u approved by the Board of Health,will pass.
Indicate yesno, or not determined(Y, N, or NO). Describe basis of dater nInation 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 exfiltrst)on, or tank
failure is imminant. The system will pass Inspection If the existing septic tank Is replaced with a complying septic tank as
approved by the Board of Health.
U Sewage backup or breakout or high static water I i observed In th ut)on box due to broken or obstructed pipe(s)
or due to a broken, settled or uneven istrlbutlon bo The system will pass inspection If(with approval of the Board of
Health).
broken pips(s)are replaced
obstruction Is removed
distribution box Is levelled or replaced
• The system fsquired pumping-more than'four-fines-yeardue to broken or obVmcted pipe(:). The system wilfpssr
inspection If(with approval of the Board of Health):
broken pipe(s)are repiacid
obstruction Is removed
revised 9/2/98 Page 2of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 116 Knotty PIne Lane Centerville ,Mass .
owner: Terence McGonagle
Date of Inspection: 2/2 2/0 0
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health In order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH.INILL.PRQTECT THE PUBLIC HEALTRAND SAFETY.AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 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 -40 —(approximation not valid).
3) OTHER
revised 9/2/98 Page 3orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 116 Knotty PIne Lane Centerville ,Mass .
owner: Terence McGonagle
Date of Inspection: 2/2 2/0 0
D. SYSTEM FAILS:
YOUust indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup ofsewege into faciBtryror-"ets+++component due tto an overloaded orvleggsd SAS-or cesspod.
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 th istrib box bove outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth In is less t an 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped J-.
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" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
L/ the system is within 400 feet of a surface drinking water supply
the systemdrwitWn 200 feet of♦44butertr-40a surfso"Ank4ag wetor+urPly --- ..
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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4orii
SUBSURFACE SEWAGE DISPOSAL SYSTE3 4 INSPECTION FORM
PART C
SYSTEM INFORMATION
Prop"Ad&—: 116 Knotty Pine Lane Centerville ,Mass .
Owner. Terence McGonagle
Daft of kWoctto":2
FLOW CONDmONS
RES IDOi MAL:
Design flow: 11d g.p.d.lbadr
Number of bedrooms(deal ): Number of bedrooms(actual):
Total DESIGN flow qv h
Number of current residents,
Garbage grinder(yes or no):
Laundry(separate system) 1 or._; If yea,sepacaialnspectlon.requked
Laundry system Inspected Ve4)or no)
Seasonal use(yes or no):
Water motor readings,If sv Isbls (last two year's usage.(gpd): Idle � � n A
Sump Pump(yes or no), fj ! d lr/`C."
Last date of occupancy
CO M M ER CU1 LAN D U S TR IA L
Type of establishment: �q
Design flow: W,09 oad 1 Based on 15.203)
Basis of design flow
Grosse trap present:(yes or no)
industrial Waste Holding Tank present: (yes or no)431'
Non-sanitary waste discharged to the Title 5 system:(yes of no)144 -
Water motor readings,If available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING�CORDS p�Ba of information: ,
�t
System pumped as part of Inspection:(yes or no)
If yes, volume pumped: /) gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/ ll absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous Inspection records,If any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank o0* Copy of DEP Approval
Other .�
APPROXIMATE,,A�G�E/of all omponents, data�talled.4lf hnown)•ond&ou�r rr
��4*fottation: i�r i iGC i ��I-•-
lv�ewx
Sawage odors detected when-off(ving at the site:(yes or no)All)
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Pr Address
oPertY •116 Knotty Pine Lane Centerville Mass .
Owner: Terence McGonagle
Date of Inspection: 2/2 2/0 0
Check if the following have been done: You must indicate either"Yes" or "No" as to each of the following:
Yes No i
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system eompoaents Isaw&Jmen paa►ped+fw4NtJaast 1Wo'weeks sudtha,aystem hasbaeov*ceimiag queemw flow
rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note If they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
— 1
All system componenta,kluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum.
The size and location of the Soil Absorption System on•the site has been determined based on:
Existing information. For example, 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)
115.302(3)(b))
_ The facility owner.(and.ocrwpants,Jf diffwaW frorn_ownw),ww&proyWad.with Infaignat oann tha pcnparmain•aAaaC&^f
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ProponyAddr—: 116 Knotty Pine Lane Centerville ,Mass .
Ownwar: Terence McGaonagle
Date of Inspection: 2/2 2/0 0
BUILDING SEWER:
(Locate on site plan)
if
Depth below grade::
Material of construction:_L/cast Iron 1-40 PVC jj6thor(explain)
Distance from private water supply well or suction line t
Diameter 40
Comments: (condition of Joints, venting,evidence of feakage,-etc.) - ^-
Joints appear tight No Pyidpnrp of leakage
SEPTIC TANK:,g
(locate on site plan)
Depth below grade:/OG
Material of construction:-L`concrete t1meta0 Fiberglass" Polyethylene_other(explain)
If tank is instal, list age Vf ls.age.confwmad by Certificate of Compliance (Yes/No)
Dimensions: P9Yxp
Sludge depth:_
Distance from top 4 sludge to bottom of outlet tee ortraffi er -'
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: a
Distance from bottom of scum to bolt of outi t tee or baffle: CJ
How dimensions were determined:
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.) rump tank annually , GarhagP di s=ncal i recant
Inlet
sound and shows no Pvi (i,nrp of laaknRe
GREASE TRAP: L
(locate on site plan)
Depth below grade:
Material of constructlonYlJ/�concretelmetal��Fiberglass�APolyethylene7lother(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 baffler
Date of last pumping:
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.)
Grease trap is not present _
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 116 Knotty Pine Lane Centerville ,Mass .
Owner: Terence McGonagle
Date of Inspection: 2/2 2/0 0
TIGHT OR HOLDING TANK:�(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction:l)�concret )&metal,(/2FiberglasPolysthylene{Mother(explain)
A.1h
n1A
Dimensions: AM
Capacity: AA gallons
Design flow Mr gallons/day
Alarm present
Alarm level: Alarm in working order:Yes No,&,'*
Date of previous pumping: *14_
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
'right or holding tanks arp not prpepnt
DISTRIBUTION BOX-,&c CC
(locate on site plan)
Depth of liquid level above outlet invert::_
Comments:
(note if level and distribution is equal, evidenoe of solids carryover, evidence of leakage into or out of box, etc.)Distribution box box is not nrpgpnt
PUMP CHAMBER: .G{,''
(locate on site plan)
Pumps in working order:(Yes or No)AC2
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
ump chamber is not present
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropalyAddiraa: 116 Knotty Pine Lane Centerville ,Mass .
Owns; Terence McGonagle
Data of lnPK : 2/2 2/0 0
SOIL ABSORPTION SYSTEM(SAS)._/
(locate on site plan,if possible:excavation not required,location may be approximated by non-Intrusive methods)
If not located, explain:
Type:
leaching pits,number: + IAI ZIICj
leaching chambers,number:
leaching galleries,number:=
leaching trenches,number, length: _
leaching fields, number, dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology: Title l y e 78 Code
Comments:
tto condition of soil, signs of hydraulic failure,level of ponding, damp soll, condition of vegetation, etc.)
Loamy sand to bonev soil to fine sand . No signs of hydraulic
fai j u -•a or i nndi n$ Cni l c era tirg VPgntnti nn i e nnrmal Wacta
water- is n
Lu
tion box . Pumpe tank and
CESSPOOLS: first pit .
(locate on site plan)
Number and configuration: 0
Depth-top of liquid to Inlet invert AA
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow(cesspool must be pumped as part of Inspection)
Cesspools are not present .
Comments:
(note condition of soil, signs of hydraulic failun,.level of pending,condition of,vegetatlon, etc.)
esspoo s are not present .
PRIVY:
(locate on site plan)
Materjals of construction: /�� Dlme.nslons:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
revised 9/2/98 Page 9of11
► SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(condrwed)
PropertyAd&eis: 116 Knotty Pine Lane Centerville ,Mass .
Owrwr: Terence McGonagle
DaU of 4upecdOn: 2/2 2/0 0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (locate where public water supply comes Into house)
4
J
4 �� 11 �t�c, CQnt�ev�Ile
revised 9/2/98 Page 10of11
" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
P►opertyAddress: 116 Knotty PIne Lane Centerville ,Mass .
Owner: Terence McGonagle
Date of Inspection: 2/2 2/0 0
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater✓YJ Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Site(Abutting property)observation hole, basement sump etc.)
V Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
--.,,,—/Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map .
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page 11of11
nrnT+ —nrrrr-.-I�� rnrarn•nteRllTna7n•.rR1tRT+errrlT'f.T'1en.f.�rw'Y 1�t7R�iAT TT-rr•r-v�+r-...: .r
TOWN OF Barnstable WARD OF HEALTH
SUBSURFACE SEWAGE DISMSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
•.•rr�•r•..•.. —s..��.�r+s�snn•nrnrs+rnrr..aw•xn�'r%-I"tr„Wwwr "M" V I ..-.rrr•s+•-i. —..J
-TYPE OR PRINT C1.EAALY-
PROPERTY INSPECTED
STREET ADDRESS 116 Knotty Pine Lane Centerville ,Mass .
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Terence Mc!Gonagle
w=
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P .Macomber Jr .
COMPANY NAME J. P.Macomber & So'g *Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632.
Street Tovn or City State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 -1578
-
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
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 one :
r
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
hea1Lh or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form,
System FAILED*
The inspection which I have con cicted has found that the system fails to
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 .
Amy
Inspector Signature fWfr�L Dane �O
ee copy of this certification must be provided to the OWNER, the BUYER
On
whre applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner r or""o_ eator shall upgrade pgrede ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 . 305 .
partd .doc
/4 IL41.
Nog�_
THE COMMONWEALTH OF MASSACHUSETTS
�-� BOARD QF HEALTH
-- ----...OF.......6?_Ct.-,e6,-4 7-c-�_
Apphratinn -fur Biipunttt Workii Towitrnrtion Vaniit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System t//:� «�
..._..___-_ .C.�_ �..............�.___...__X.:1....._. =--K:1............. ............ - __ !.':.f.... _ ...........................C Loca' n. ress ^ or Loth
--•-- -------- ,_ *1
wner Address
-----------------------------------------------------------•-••--• --•-----------•-•--••-••••••-•------------•.........•--•---•------••••......--•••--•---------•••--
Installer Address
UType'of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons-.._-_•-__________-_________ Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------------------------------........
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.___----_-._.__..-sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date.........................................
Test Pit No. 1............_---minutes per inch Depth of "Pest Pit.................... Depth to ground water.._.___..___-_._-.-_----
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-------------------
------------------- --------------------------------------------------•-- -------------------------------------------------------------------------- -------
ODescription of Soil--- •-----------------------•-•--•-----•-----........-•---•-----•---•--•----•-•--•-------•-----------------•-•--•-----------------•-•-----•-------------..-.._.._.------
x
U ----------•----•------...--••-•---------•-•----•------...--••---•----•-----•••--•--•••--••-•--•------•-•--•-•--••••--•-•-••--•-•-••--•-------------•-•--------------------------------------------------
x ••--••---------- ............................................................. ••-•------........... ------ - -----
U Nat e,of epairs lteratio s— swer wen applicable-.-. .. ...:...
------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee sued by tly board of health.
1�-----••--•-•---- < a�
------- Sig -- -..... -- Cr✓--•----•=-- •-���"-• --•-•'Date
Application Approved By :/l --••--• _rw - -- X. �...-----•..........:.............................................................._.�...
Date
Application Disapproved for the following reasons_________________________
.......--••-•.....-•---••---.....-••----------------------------------------•-•--•-------•-•-•---•---•---....__......•------•----......-••--•-------------••-------------• ..............................
Date
PermitNo........................................................ Issued.. ' -z ------------..............
Date
L{OCQTION : ` r / 5EWO C-xE PERMIT 1-JO-
IWSTNLL.ER'S ► &ME DDRESS
-Af -
BUILDER 'S Q &MF— ADDRESS
DIaTE PERMIT ISSUED •— �� — —'
DATE COMPLI &t ACE ISSUED : �`c -
,�#
.I `�
�-
Pr,,�j
� �� �� �
r
No......................... Flzs.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.ppliratiun -fur Di,iVuiitt1 Workii Tomitrurtiun Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( L,) an Individual Sewage Disposal
System at:
T t Location:'d`ss �� �o,Lot No. t ., + r f
.'' ....... ................................. ..---...._....................._. ......__...............................
✓�
a .......................... Owner ...............................Address
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.--_-_-_---__--_-_---_.._--- Showers ( ) — Cafeteria ( )
Otherfixtures •-•-----------------•--•-----------•-------------------•---------------------------------------------------------------------•-----------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width------.......... Diameter-------.-------- Depth.-..--_-_.-----
x Disposal Trench—No- -------------------- Width-------------------- Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet__-_____-___-__-_- Total leaching area......-.---_.._---sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by_---------------------------- .......................................... Date------------------...------ ------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit.........._......... Depth to ground water-.-------.------------..
Li. Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•--- ----------- ---------------------•-----------........................................................................................................
ODescription of Soil........................................................................................................................................................................
x
U ------------------------------------------------•-----------------•---------------•-----------•-------....-•--•--•-•-------------•--------------•------------------....------...----•-------------------
------------------------------------------------------------------------------------------------------------------------------------------------------=----------- -------- -- ------- --------------
U Nature of Repairs.or.Alterations—Answer when applicable.-...�___:__�. _�__r....r}.. -
--:------•- =--------------=-----------�----•---....
:. �.-r=�-- --'---- ----- -----•---------------------•---------------•-------••------------------•--•--------------.-•---------•-------------------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health ` o
•
Signed...:.... -----•.... �.-• - .. '
------------------------------------------------------ ................................
Date
Application Approved BY _.-- -r�X�� !-/: ., � .a 6, _...,
---•-- -------------------•--.-•--
Date
Application Disapproved for the following reasons:........................ _------------------------------------------------------------Da-t-e..............
--...-•-•-----•--•--•-----------------------•-------••----------•--••-•-•-------•------•••--....-------•-----•--•-•-------------------------------------•-----------------------•----_-------------•---
Date
PermitNo......................................................... Issued........................................_..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...t""1+ry►..............OF.......Y�.%..F�/1/t i- .--
.................................................
�rrtifirat� of fuumphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
b (_,r g. ( .. .....�...�.1 ---------------------------------•---•-----•-•--------•-•-•----------------:._..-----•-•••.-----•.
V/ /_ .+.Installers
at.......................... ----------------------`----.` .....----'--- '----------t"-- ------!�Jr.�,- ��------------�-- 'f,�(.
....... ...
has been installed in accordan e.with the provisions of/Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.--Q�_--_._.�..":._ "_____________ dated'_. _�_r... ..�.. _�`.........
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 OF� � HEALTH
..........
No. ................ v }�- FEE-2........_"" .......
Bit-iVurittl Wvr4fi T=n5trurttion rl�rmit
Permission is hereby granted {�'! ` ----1 �. ---------- ..........•--•-•--------••-f•-•-
to Constrt}ct7 ) or Repair an n_divi ual Sewag. isposal,/Syitemal
j Ir
( f -
r i
��.--•-- --�•Fl................. ......�-•-- -- - - - �-t.....,--- -- --•--•---------...----�_--ham'.---
Sftreet
as shown on the application for Disposal Works Construct' n Permit No... 9 Dated--- --_ -- .... ...........
7S'
�j Board of Health — i
DATE.1_.. ------------------------------------------------------------• Y
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
l
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL.=97.8
FOR 'A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S.
SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S.
INSTALL RISERS & COVERS OVER INLET & INSTALL WATERTIGHT RISER & INSTALL 2 INSPECTION PORTS (MINIMUM)
T.O.F. OUTLET AND SET TO 6' OF FINISH GRADE COVER. SET TO 6" OF GRADE
EXISTING F.G. EL.=101.0t F.G. EL.=100.8t F.G. EL.=100.8(MAX.)
ff MAINTAIN 2% GRADE (MIN.) OVER S.A.S.
` L = 34' L = 11'(MAX.) INSPECTION PORT
® S=1% (MIN.) ® S=1% (MIN.) (1-MINIMUM)
4"SCH40 PVC 4"SCH40 PVC
6"
19
LLj10"I
1 a" 6 11.3"EXISTING 48' LIQUIDUID
INVERTTO
LEVEL ADD tNV.=97.87 PROPOSED INV.=97.70
GAS BAFFLE 2 TRENCHES WIT 5 UNITS A 6.25'/ NIT = 50'
INV.TING t �� INV.=97.44
oclsnNG SOIL ABSORPT -
EXISTING SEPTIC TANK
ESTABLISH VEGETATIVE COVER
BACKFILL WITH CLEAN
• NATIVE OR PERC SAND
TO TOP OF CHAMBERS
NOTES: BREAKOUT EL.=TOP EL
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP ELEV.
INVERTS, PRIOR TO INSTALLATION. INV. ELEV.=97.44
2) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=96.50 uMIullml I I II
GRADE ON A MECHANICALLY COMPACTED SIX 2 x EEFECnVE WIDTH
INCH CRUSHED STONE BASE, AS SPECIFIED 5' MIN. ABOVE BOTTOM OF 2.83' 5.7'(MIN.) 2.83'
IN 310 CMR 15.221(2). T.P. EXCAVATION OR G.W.
3) INSTALL INLET & OUTLET TEES AS REQUIRED. EXISTING SUITABLE
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM OF TP, EL=90.4 -_ MATERIAL
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL.
2 TRENCHES WITH 8-16" (H-20) ADS BIODIFFUSER UNITS
WITH NO SEPARATION BETWEEN EACH ROW & NO STONE
SEPTIC SYSTEM PROFILE TYPICAL SECTION
GENERAL NOTES:
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER. SOIL. LOG
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DATE: NOVEMBER 8, 2013 REF 14,219
LOCAL RULES AND REGULATIONS. SOIL EVALUATOR: PETER MCENTEE PE(SE1542)
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR WITNESS: DONNA MIORANDI R.S. HEALTH AGENT
INSPECTIONTO ND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER. Eby, TP-1 DEPTH ELEV. TP-2 DEPTH
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 100.7 A 0 100.4 A 0"
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN LOAMY SAND LOAMY SAND '
ENGINEER BEFORE CONSTRUCTION CONTINUES. 99.9 10YR 4/2 10YR 4/2
10
5.'ALL ELEVATIONS BASED ON-ASSUMED DATUM. - �- 10' - - -- _ __ .-
g - ___ g= -- ---
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF SANDY LOAM SANDY LOAM
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 10YR 5/6 10YR 5/6
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 98.2 C1 30 97.7 32'
PERC C1
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. COARSE SAND 30"/42" COARSE SAND
8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 10YR 5/4 10YR 5/4
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS >20% gravel 95 4 >20% gravel 60"
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 95.7 60" C2
DIRECTED BY THE APPROVING AUTHORITIES. C2
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY MED. SAND. MED. SAND
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 2.5Y 6/4 2.5Y 6/4
CONSTRUCTION.
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 90.7 120" 90.4 120"
IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND IN.
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3), NO GROUNDWATER .ENC PERC RATE <2 MIN/IN.
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL.
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. -75"
14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC
SYSTEM COMPONENTS NOT SHOWN ON THE PLAN.
15. OWNER IS RESPONSIBLE FOR REMOVING ANY DECK SUPPORTS FROM
RESTING ON TOP OF THE EXISTING SEPTIC TANK.
DESIGN CRITERIA
NUMBER OF BEDROOMS: 3 BEDROOMS 76„ -�
SOIL TEXTURAL CLASS: CLASS I PROFILE
DESIGN PERCOLATION RATE: <2 MIN./INCH (0.74 GPD/SF)
DAILY FLOW: 330 GPD
DESIGN FLOW: 330 GPD 16
11
GARBAGE GRINDER: NO
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY (VERIFY) 34"
(IF 1000 GALLON AND FOUND TO BE UNSOUND, REPLACE WITH NEW 1500 GALLON TANK) 11.3" TO INVERT �-
PROPOSED DISTRIBUTION BOX: 1 INLET, 3 OUTLET (MIN.) SECTION END CAP
LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 16" HIGH CAPACITY (H-20) BIODIFFUSER UNIT
.74 GPD/SF MODEL 16" HICAP UNITS MUST BE STAMPED H-20
SOIL ABSORPTION SYSTEM
USE ADS 16"HC BIODIFUSSER UNITS IN STONELESS TRENCH CONFIGURATION LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT
(CALCULATIONS BASED ON FULL NOMINAL DIMENSIONS)
EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
EFFECTIVE LEACHING AREA PER FT = (2 x SIDE WA + BOTTTOM SIDE WALL HEIGHT 11.2"
= (2 x 0.94' + 2. 3' 7 771 F/FT OVERALL HEIGHT 16"
LEACHING AREA PROVIDED = 2 TRENCHES x 50' 4.71' SF/ - 471 SF OVERALL WIDTH 34" arcs
4640 TRUEMAN BLVD
13.6 CF ® HIWARD, OHIO 43026
DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.0 S - 348.5 GPD CAPACITY (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC.
Engineering by: SCALE DRAWN JOB. NO. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
Engineering Works, Inc. NTS P.T.M. 250-13
12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. 116 KNOTTY PINE LANE CENTERVILLE MA
(508) 477-5313 11/19/13 P.T.M. 2 of 2 Prepared for: D.A. Brown, Inc. P.O. Box 145, Centerville, MA 02632
4'
t�
r N
0
o Moon Penny
1— 1421 Ln
(LOt 27)o � rn
C m -_4 MB�U 191 -096\
AO Yo 01 5" Mene sho Ln
26,970\S.F. ��,
0
1 r D \ \ \
m PROPOSED S.A.S. \ LOCUS
2 TREKC
�. PROVIDE IN
SP CTION
' PORT/EACH TR NCH Woodvole Ln Co6ek n Ln
33°—� �T so 10 02 \ LOCUS MAP
\� x 99.92 \ NOT TO SCALE
J\ LEGEND
SHED \� `� \ 99,98 — 9$—— EXISTING CONTOUR
2
X 100.98 EXISTING SPOT GRADE
101.61 105 PROPOSED CONTOUR
x W"1.1.�, TP-2 —w EXISTING WATER SERVICE
101.49 rhododendron{ 100.40 —G EXISTING GAS SERVICE
} \ S 60 w —U EXIST. UNDERGROUND WIRES
TP—i a 0 TEST PIT
w 101.48 100,71 C BENCHMARK
BENCHMARK x N N
N M COR./BULKHEAD ~ ~``
�
EL.=101.92 10I, 7+ Oi.00 N
°i.° N EXISTING LEACH PITS
101.57 101,67 , CONTRACTOR SHALL PUMP, FILL
101.33 0`�r� W/ SAND AND ABANDON.
\ - � I
x 101.4 PATIO DECK EXISTING SEPTIC TANK
G C x I (TO REMAIN—SEE NOTE 14)
101.�2 00,19 x TOP OF TANK, EL.=100.50f
1NV.(OUT)=99.17t
.EXISTING
HOUSE(#116) '
7 O.F.=101.9f
101.84 PORCH
C� 101.85 I 8g8 B Sheet 2)
LCC 32
jp
r 77 100.91
GARAGE 1,58 x
yl
Elva I 100.28
pR.l G
101.52' �01.06
o 100,75 '
t�.. 101.19 o
`101.17�0 .. 100%6
X x 100 49
100.85
LAMP
100.26 G
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TKNO
OWNER OF RECORD
McMULLIN, SEAN & MELANIE
116 KNOTTY PINE LANE
PLAN REFERENCE: LAND COURT PLAN 32898 8 (Sheet 2), LOT 27 CENTERVILLE, MA 02632
Engineering by: SCALE DRAWN JOB. NO. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
Engineering Works, Inc. 1"=20' P.T.M. 250-13 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET N0. 116 KNOTTY PINE LANE CENTERVILLE MA
(508) 477-5313 11/19/13 P.T.M. 1 of 2 Prepared for: D.A. Brown, Inc. P.O. Box 145, Centerville, MA 02632