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Home My WebLink About0023 GOLDENROD LANE - Health rGoldenrod Lane, stonhs^j�l'�- orb t\N i Commonwealth of Massachusetts /l1P -0/,o 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Goldenrod Lane Property Address t, Joan Harrell g' Owner Owner's Name iw1F information is ..in required for every Cen yille /� Ma 02632 9-8-15 - page. Ci /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. Important:When A. General Information filling out forms on the computer, � use only the tab 1. Inspector: key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. B&B Excavation L Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 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 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further valuation by the Local Approving Authority 9-8-15 Inspe is 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. Aq# VS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. City/Town 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 (corl ❑ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow 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 an question in Section E the system is considered a significant threat, Y Y Y Y 9 or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 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 dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees material of construction dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 23 Goldenrod Lane Property Address P Y Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 ears usage d see below 9 ( Y 9 (gP ))� Detail: 2013-62,000gallons 2014-75,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: new leaching 2013 with existing tank Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 311" 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): 2'11" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(ccnt.) Distance from tcp of sludge to bottom of outlet tee or baffle 30" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grace: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection D-box is in working order with no sign of back up or carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain wh y: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (2) 2'x3'x43' ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Trenches show no sign of back up. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is Centerville Ma 02632 9-8-15 required for every i page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth.of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. Cityrrown. 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 landmarkszrbenchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: N hand-sketch in the area below ❑ drawing attached separately . '.A C 3. ` F'Ro T A t5ins•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I_ I Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 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: No Gw 132" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design Ian reviewed: July 18 2012 g p 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: Plan on file with BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville Ma 02632 9-8-15 page. Cityrrown State Zip Code Date of Inspection 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 Infcrmation—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION 03 Goldz n Rod L&1 SEWAGE# QOt a - P3 VILLAGE . ,,'-- >> M IUJ ASSESSOR'S MAP,&PARCEL I yq - 130.1G INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY . 1000 LEACHING FACILITY. (type)r.c nckc-S C- :) (size) 2 X 3 x 4/3 NO.OF BEDROOMS I� OWNER tb r r c l l PERMIT DATE: 77-t2 y. 12 COMPLIANCE DATE: 77-30 - I eZ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching,facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED'BY Ai - 1G' BI - zo Az- BZ-25 ' . C3 '331 B4-Sy ' Cy 33 ,6 F'Roa T W A 3 NO. �-o �;t3l THE COMMONWEALTH OF MASSACHUSETTS FEE UU BOARD+ OF HE ALTH Jo o OF AnIl'n"- r h �—e— APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair Upgrade Abandon ❑Complete ete System ❑Individual Components "on Owne's Name 1 -I 2,3 6o1denr�o �n Cen+eau1Il-e Map/Parcel# 5(�j'rp(j r 426 ` 2 0��1 Lot# '( elephone# Do WC) CaZt e i 1 � ns er's D7�e l t, 93 o f S�DeX r Name fyjjoLfhp�G T 509- 11-17` O ress 609 -36-z_ 4,641ddress t Telephone# L� Telephone# Type of Building: / 6(Cj exl-P , . Lot Size Sq.feet Dwelling—No.of Bedrooms It Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. required) gpd Calculated design flow gpd Design flow provided gpd Plan: Da e t U9,11'L Number of sheets Revision Date Title t i-}'�e s I- w l o n Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. SignedI Date62Y21,D IZ Inspection 0 12&vv. 'Z-- FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 '. No. �� l J THE COMMONWEALTH.OF MASSAGHUSETTS FEE AU !' C B O X�-R D O F HIE A LT H /[ of APPLICA�rI N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) ,❑Complete System ❑Individual Components 33 C o�d enr-/)o r-ine.. VV M� cnn fl o(r� 11 Mon Owner's Name !� I � .l �r, l 130-1 23 C�oldr'nroD M �'en�lPrulllf' Map/Parcel# / D 9— 4 ^..`q glsg 1` Lot# J U Teleploone# u &,n vat t l5 n y + �a ��ui�n/�/C�Ci.(�� ce �t �i npr�..ri n(h �, 'he 7 (r !ns l)er's I66 1 4 ( Lr 939 1" I O �1 ((Sf Name i�j Ljh p� 1r T 09" 1-)� l O ,S ,ess 150� µ 3/02.- t4 J 1ddress Telephone# Telephone# Type of Building: Rf uie Lot Size Sq.feet Dwelling—'No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers (' '), .Cafeteria ( ) Other fixtures �jji rr�� Design Flow(min.required) " T"T V gpd Calculated design flow gpd Design flow provided god 7 Plan: Pate 1RI 11- Number of sheets Revision Date Title ► I- e' 05 Sl+d—Onn Description of Soil(s) ✓ / Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has beent issued by the Board of Health. _ Signed ,I Xlt� ,r Date r7 Inspection {� (d vtl 1 l -7- FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ' No. THE COMMONWEALTH OF MASSAC14USETTS FEE (nst(.hIle BOARD OF HEALTH �— CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by:'R yri_l i a at 2 3 �- ®llritnmo Lane. Cf'n-1 e-wilt f has been installed in accordance with the provisions of 31• C R 15.00 (Title 5) and the approved design Tans/as-built plans relating to application No.701 }11 dated 7 2 Approved Design Flow (gpd) Installer 1 lr hC.r+ Q /`ffil-f(ju II-- ' Designer'Dr)�n (h c)e lV Inspector - Date _ I The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 `a a " No. �dl �31 THE COMMONWEALTH OFrMASSACHUSETTS FEE DU 731jIcn,�e5i b( _ BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby grant d to Constj°uct ( ) Repair ( ) Upgrade ('/) Abandon ( ) an individual sewage disposal system at �0//))^ivd as described in the application for Disposal System Construction Permit No. 2 3 dated 7 2— Provided: Constructi n shalllbe completed within three years of the date of thVpet. local co ditions must be met. Date �-- Board of HealthIA er FORM 2 - DSCP DEP APPROVED FORM 5/96 /1/IV3 jC., rVfuu} &-,hLr,4 (,JAO he �a w b. �vivh �' sip f 6 y FORM 1255 (REV 5/96) H&W Ho6m8 WARRENrM —PUBLISHERS- BOSTON ro rrex FROM :down cape engineering inc FAX NO. :15083629880 Aug. 01 2012 1O:29AN P1 fz />�L 3 T 7 �.. \,.�� Mbe�. rr :�T�.I�Y.S�S� .t OIE°�•ll��:�A flDQ4�ilSAa�FY Z. treeq,-ffvz rob,, 16JIA QD•-601 Sia'-tm.11 er Ar 11-n!oller ce rri" idnk iiclta.'Eur'na� }[ ate" W -AAA /1/f, / / �� ! lWf _ R��llirews: l l f Oil _ �>,,issilrrl a T crrxlit Lc,u�sr�.fl � ^(clatc�) (�s1aJ.ler) septic ,tcflJ3.�i � C G 2 1 ``""'� —has(;d On a J,c:Si.(;.0.ch-Li>11 ,1y _ 1 rxrlify that tile, sepdr, ysfi"T i lefo1:P.ilou'd above-w.us instsllud s1:11wL�t1`>L 1111-y Iccarcl nP, t}_ce design., w1li+;b. may iurtide niiT)or apprc��r:d cllang;;s such tts l�Yteral _t:�nc3.tinu of tiic: dist6bidim hox aad./or�c::1lii.r t�llc. _ T c,c:ztify Lhat the ;c-Ptir_ ^y;ILc1LL .CI:fP.'fElrL;k;l3. above: vJLiS jc t .eater than 10' Lateral.ral.ocaEoil of the SAS I)f aLly\ate Cal.re1QCII[011 c�a>`iy ccrrlPCJ.e:rit ��f the tit:•�tir•. �;_y5tr,:1[1) l7i.it in,a.crcird`n1;r.,with. �Li4_e:11r;. ]:.nail R-P�la_l�tli.ous, .f°l�trl revi;;'nu or :;e:.ti ied ari-built by d.r.r.,i.gner Lu ibilnvr. 7tt asr.,,s��c DANIEL A. (IaSra�lFsr'S TfitU.C'C) to QJAL_A �n q No,40R$O„ Rk�SUR`t (1��.,:1;+ L�esis;s:icl's �f.:zi:rlr (it%r�':, H L;�.I.;_t' li.l4'0 ;flcU�I� C .1 9.f6�T�:1'9`t; UJI? f+P411. . Pt�; 1:�`ri!L9!:f.9 411T9p�y rse?oA 'r'f+�.k.°� ()j-.1F�'.Il ,API)) YJ7L6_B' �/21 to ate: fpiD E !1 i�nallYlflrnli[ Lh 5IF!i)Lr Cuh.GC14ior-FoTIT)3 :)U-O'Lde.c FROM :down cape engineering inc FAX NO. :15083629880 Aug. 01 2012 10:29AM P2 \ \ 1 PAVED DRIVE \ `� LOT 8 \ 20,465:LSF \ \ (RE-Usn) \ 0m. ST \ O \ MUM OWILUNO \ TOP MON..A27 _r✓Y \ —O R HEAD(JjU, r PERF.PIPE AND STM SEPTIC AS-BUILT PLAN 12,.,182 PREPARED EXCLUSIVELY FOR THE HEALTH DEPT. LOCATION 23 GOLDENROD LANE, CENTERVILLE SCALE : 1" = 30' DATE : 7/31/12 PREPARED FOR: REFERENCE MAP 149 PARCEL 130-16 B&B EX ATION OANIEL P r A. OJAL,A u �^ �� 4 No.40980� ZW down cape engineering, Inc. sU v C111L ENGINEERS } LAND SURWYORs DATE REG. LAND SURVEYOR 9JB Male Street — YARMou7"AORT, MASS. SENDER: COMPLETETHIS SECTION COMPLETE THIS SEcnON ON DELIVERY.: ■ Complete items1;2,an3.Also complete A. S' ature OZ item 4 if Restricted Delivery is desired.. X ❑Agent • Print your name and address on the reverse ressee .: so that we can;_return the card to you. B. Received by(P'nig Name C. ate of Delivery e Attach this cafd.to the'back of the nailpiece, or on the front_if space permits. s � R '` D. Is delivery address] ren�ftem G�7 Yes 1. Article Addressed to: If YES,enter deliver �Ms..Joan filarrell 23 Goldenrod Lane® Centerville, MA 02632 3. Service Type ❑Certified Mali ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4: Restricted Delivery?(Extra Fee) ❑Yes 2, Article Number t g 7 p 11 t i0:4 7 0 ',0 0 01; 4525 7 2 8 4 �n (Transfer from service labeQ PS Form 3811,February 2004 Domestic Retum!heceipt �oz5 s 0�M t5ai3 UNITED STATES POSTAL SERVICE 1PN3 lass s Paid I I its NQ.GM • Sender: Please print your name, adee-ss 7 "In this"b®x,, I Town of Barnstable Public Health Division I i 200 Main Streety Hyannis, MA 02601 i i I i E +n'G p w� a CO fU f`- Ul ti Ul Postage $ / 4 rl Certified Fee o 0 Return Receipt Fee �e/ Cn Postmark O (Endorsement Required) Here Restricted Fee. r' r%- •(EndorsemeDelivery nt Required) - J fO Total Postage&Fees $ i f ` rt Ms. Joan Harrell 23 Goldenrod Lane 'Centerville, MA 02632 Certified Mail Provides: a A mailing receipt +� a A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. n Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. a For an additional fee, delivery.may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". ® If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT,Save this receipt and present it when.making an inquiry. i PS Form 3800,August 2006(Reverse)PSN 7530-02-000.9047 !7 n i Town of Barnstable Barnstable °F THE f yP °� Regulatory Services Department e;cat RY ■ARN ,ASS. 0• Public Health Division m 9 N ASS �A 1639 .� 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7011 0470 0001 4525 7284 July 2, 2012 Ms. Joan Harrell 23 Goldenrod Lane Marstons Mills, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system located at 23 Goldenrod Lane, Marstons Mills, MA was last, inspected on 6/13/2012,by Ricky Wright, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of the 1995 TITLE 5(3 10 CMR 15.00).. • System is in hydraulic failure You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. PER ORDER OF THE BOARD OF HEALTH QT a�s McKean, R.S. CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future Eval\23 Goldenrod Ln.,Cent.doc � a �� /�� ;/�,,.� I .f Commonwealth of Massachusetts Title 5 Official Inspection Form TS Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M ,a•''r 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. CityfTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your v cursor-do not Ricky Wright use the return Name of Inspector key. B & B Excavation,I nc. rib Company Name 14 Teaberry Lane Company Address r Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S14595 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 pursuato Section 5.340,of Title 5 (310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ®yrFails �y ❑ Needs Further Evaluation by the Local Approving Authority NO 6/14/12 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. T t5ins-11/10 Title 5 Official Inspection Form: bs ce Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (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). 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage n/a ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 3'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 1000 gal Sludge depth: no sludge l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. Cityrrown 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound ,no sign of back-up. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: - - gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owners Name information is required for every Centerville MA 02632 6/13/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): At time of inspection leaching was in hydraulic failure. Water level was over the pipe. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name -- information is required for every Centerville MA 02632 6/13/12 page. Cityrrown 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 1.00 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately L I(D NO � AZ`35' r t5ins•11/10 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 15 of 17 � Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Goldenrod Lane Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. City/Town 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: >12'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 23 Goldenrod Lare Property Address Joan Harrell Owner Owner's Name information is required for every Centerville MA 02632 6/13/12 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D(System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file j t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal P g System•Page 17 of 17 _ I Parcel-Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=9992 • i , �`. ,.}+'wig.�.:�v a-ur�tl„Y,,. Logged In As: Parcel Detail Tuesday,3uly 3 2012 Parcel Lookup Parcel Info Parcel ID 149-130-016 I Developer LOT 9 Lo Location 23 GOLDENROD LANE J Pri Frontage 151 Sec Road I Sec Frontage Village MARSTONS MILLS I Fire District C-O-MM Town sewer exists at this address No I Road Index 0611 Asbuilt Septic Scan: Interactive 149130016_1 Map Owner Info owner HARRELL, JOAN T I Co-owner Streets 23 GOLDENROD LN I Street2 City CENTERVILLE I State MA zip 02632 Country Land Info Acres 0.47 use Single Fam MDL-01 I zoning RF Nghbd 0105 Topography Level I Road Paved utilities Public Water,Gas,Septic I Location Construction Info Building 1 of 1 Year 1984 I Roof Gable/Hip I Ext Wood Shingle Built Struct Wall . Living 3168 I Roof Asph/F GIs/Cmp I AC None I 'a 24. Area Cover Type FEP 12 12 CAT.H&iib G Style Colonial I Int Drywall I Bed 4 Bedrooms I 40 za ons Wall Rooms BMT Int Bath Model Residential I Floor Carpet I Rooms 2 Full + 1 H I rus Heat Total 1B, �4 2 BMT � 24 Grade Average I type Hot Water ( Rooms 8 Rooms 14 Stories 2 Stories I Heat Gas I Found- Poured Conc. I 26, z GAR 2� Fuel ation 24 Gross 5928 Area Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=9992 7/3/2012 I_ Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=9992 IIIssue Date I Purpose Permit# Amount I Insp Date Comments Visit History Date Who Purpose 7/16/2010 12:00:00 AM Nancy Finch Bldg Permit Completed 7/15/2010 12:00:00 AM Mike Keating New Construction 8/3/2007 12:00:00 AM Paul Talbot Cyclical Inspection 1/6/2000 12:00:00 AM Martin Flynn Meas/Listed-Interior Access 2/15/1985 12:00:00 AM IFR Sales History Line Sale Date Owner Book/Page Sale Price 1 1/6/2003 HARRELL,JOAN T 16195/297 $1 2 10/17/2002 HARRELL,THOMAS A&JOAN K 15755/317 $1 3 5/8/2001 HARRELL,JOAN K 13810/231 $1 4 7/15/1987 HARRELL,THOMAS A&JOAN K 5858/283 $210,000 5 5/15/1984 CATERINO, RAYMOND W&CHRISTINA 4108/155 $15,000 6 7/15/1983 1 COMMUNITY PROPERTIES INC 3790/178 $180,000 - Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2012 $242,600 $60,600 $0 $109,300 $412,500 2 2011 $287,000 $3,300 $0 $109,300 $399,600 3 2010 $287,600 $3,700 $0 $109,300 $400,600 4 2009 $326,200 $2,700 $0 $146,300 $475,200 5 2008 $333,300 $2,700 $0 $152,500 $488,500 7 2007 $328,900 $2,700 $0 $152,500 $484,100 8 2006 $290,600 $2,700 $0 $157,900 $451,200 9 2005 $261,900 $2,700 $0 $143,500 $408,100 10 2004 $212,900 $2,700 $0 $143,500 $359,100 11 2003 $190,900 $2,700 $0 $48,000 $241,600 12 2002 $190,900 $2,700 $0 $48,000 $241,600 13 2001 $190,900 $2,900 $0 $48,000 $241,800 14 2000 $143,400 $2,800 $0 $33,200 $179,400 15 1999 $143,400 $2,800 $0 $33,200 $179,400 16 1998 $143,400 $2,800 $0 $33,200 $179,400 17 1997 $155,000 $0 $0 $29,500 $184,500 18 1996 $155,000 $0 $0 $29,500 $184,500 19 1995 $155,000 $0 $0 $29,500 $184,500 20 1994 $136,200 $0 $0 $36,500 $172,700 21 1993 $136,200 $0 $0 $36,500 $172,700 22 1992 $155,200 $0 $0 $40,600 $195,800 23 1991 $156,600 $0 $0 $59,000 $215,600 24 1990 $156,600 $0 $0 $59,000 $215,600 25 1989 $156,600 $0 $0 $59,000 $215,600 26 1988 $117,900 $0 $0 $22,100 $140,000 27 1987 $117,900 $0 $0 $22,100 $140,000 28 1 1986 1 $117,900 $0 $0 $22,1001 $140,00011 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=9992 7/3/2012 G _ FFIC.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH . ...............oF.......... .................:...... . �`130-�I(a Nip iration for Dhip al Warkfi Cnomitrurtion Frrutit Application is hereby made for a Permit to Construct N or Repair ( ) an Individual Sewage Disposal System at• � � � ' et Locatio -Add e s t t� or Lot No. Owner Address W Installer Address ��II// Type of Buildings Size Lot-.9�__`J.�_Y ._.Sq. feet U Dwelling "�No. of Bedrooms.............�_--#-.-_........................Expansion Attic ( Garbage Grinder (� pOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ... .. Design Flow..................... 5........_ gallons per person per day. Total daily flow........... ...............gallons.,, WSeptic Tank—Liquid capacity.l gallons Length................ Width................ Diameter..........--.... Depth.�...�__ x Disposal Trench—No..................... Width.................... Total Length.........:_ _..a.. Total leaching .........sq. ft. Seepage Pit No........` L------. D' meter...........g...... Depth below inlet.......� ..... Total leaching area... ....sq. ft. Z Other Distribution box ( Dosing '-' � &Percolation Test Results Performed by...... ... . . Date......1SJ-- ...... �--- a Test Pit No. 1-....7--.-minutes per inch Depth of Test Pit....-. ......... Depth to ground water---0VC- rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ¢ # ----.-•--• f �° Description of Soil.....--0.=,,_Z--------..�- � .-A.. L- �• ... --------------- .-- ------- !.._.......-. U -------------------------------------•---------------------------.................--------------------•-•--•-••......••--•...-• -••-•••--•--/�-Q---gym... . --...............--•--•.... W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------••-•-•-••••••-•-•----•------•-••••••••••-•••-•-••-•-•--•••--••---•--•--•-•--•--••----------••-•....••---•••-•••-•--••-•--••--•-••---...-•--••-•-•••••••-•............-••---•-•••....... Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of LIT LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b iss by th oa of liealth. Signed.. 7.7 Date ApplicationApproved By.....................................................................••--••...........----•-•---•- ........................................ Date Application Disapproved for the following reasons:................................................................••-•----------------------=------........----•- •-••••••••••-•---••••--••............••••••••••-••-•-------••••--•-••••-••-••-•-••-...---••--••----••--••.......•--••-•-••--•••••••-•••-•••-••--••-•-••••-•-•----•-•••-••••-•---...••••••••••••-••....... Date PermitNo......................................................... Issued-....................................................... Date No �'f� : .. ..... �Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... ..... ... .................OF.......... .-.�.i Appliration for Dtiipotial Work.5 Tonitrnrtion runtit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at p ......................................................... Locatio -Address or Lot No. .....^. !..„ . ri / r3Q.s.... .ki.� --------------------------------------------• ---•-----.............----.................--•- Owner Address W Installer Address U Type of Building Size Lot.. �%;._ 6�Sq. feet .. Dwelling�"'No. of Bedrooms_....._____. .......................Expansion Attic ( Garbage Grinder Other—Type of Building No, of persons............................ Showers Q, YP g ------------------------•-•• P ( ) — Cafeteria ( ) 44 Other fixtures .�............................ W Design Flow......................a:?.:`1._...__._.__gallons per person per day. Total daily flow............ ...................gallons., WSeptic Tank—Liquid capacity..r..Pgallons Length................ Width................ Diameter................ Depth....-G-. Disposal Trench—No. .................... Width.................... Total Length......... _ r... Total leaching area....................sq. ft. x Seepage Pit No........'�-_____- Diameter.......... Depth below inlet.......r ..... Total leaching area...+: n----sq. ft. z Other Distribution box ( � Dosing tt k ( 1 '-' Percolation Test Results Performed by-_..._.l.,Y`- — . _ . �'...... •-•-•...................d6CYf17' Date 1�_.'. ._...� ........ r Test Pit No. 1.......Z.....minutes per inch Depth of Test Pit.��. ..y�......... Depth to ground water..O-Klf.:r--- � Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x � = . ., f..�._......alJf C . of- . �_.:' �fi .escrpton o Soil----•---• ---'5 ..--------- • ' --•---- ----- 4 .---------------- U •-•----------------•----•----•----••--•-----•••-•-•-----•--•-•--•-•------•----••-•-•-•--......-••-••...-•---•-•---------•--••--......-------••• �p.--- • ••---•- w ............................ U ---------------Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------------•---•----•-----------•---•----------------..........--------------....-------------------------------------------------•--•--•--•••...••••-•-........----•-... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... .........................._.... Date ApplicationApproved By-•••-•-•-•---•--•-•--•••••-••--•••••------•-•••••-•----•........................................ Date Application Disapproved for the following reasons-----------------------•-------••----•--•------•------........................................................... -•---•-••-•---•--------------•-------•---•----------•--------•---•--------------••------•----...-•--------•....•••...---•-----••----••-------•-••---••----••••---•-----•---•-•-•--•-•-••-••----•••.-•••- Date PermitNo......................................................... Issued•....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (9rdifiratr of (lontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by... -----------------------------------•-----------...--------------...-----------------•-•......_............. ir42� Installer at --------- -• - -_r'` �. --- --------------------................................................................... ..._...._. .....•--...... has been installed in accordance wfth the provisions of TI LF 5 of The State Sanitary Code desc ed in the application for Disposal Works Construction Permit No. f_":.er!' -••-_------- dated_.-.' :. ... . ... ...•..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® S A GUARA TEE THAT THE SYSTEM WIL FU TON SATISFACTORY. DATE......l!.?��..----------•-••---------•---•---•--•-•--••---. Inspector....... ... ....................................•................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ! ..OF...............................------•--.................--- ................. FEE: .................... Rojimiat Works ion tritrtion rrntit Permissionis he granted --------• --•--.-•--- --••••••-••--•---------••--•.....---•----•-........•-•............................. to Construct r R air )fi divid Se,,a sposal System at No.. �--•---- �- - Street as shown on the application for Disposal Works Construction Permit No�f f,. --- ted... _._. ............ -----•-•----------------•----•--- -••------ ....................................................... --•...............•................ and of Health DATE--------- ----- •--------------•--•--------- , FORM 1255 A. M. SULKIN, INC., BOSTON I� .SEPTiG T4/✓�C� y'7�/� ��•C�J 6�Y. �� J, ti r.: , . :t- I ,3: u�- ♦2 s �.aL _ . lit X Z•S = 7So G.��. p`� 'Tt�TA L I�E..�/C�s�/ = E S06•'t?,� ( j4 ?o?-,�C_ L�•d/L.yFZcti!/� GG'G'�.�-?J.��. m � -f"'T,n. PE2co -ATIC)N RA"TE1 V F/ri �r>Zo� WILLIAM 9r. ' o IN C. E W. AL•AN No. 19334 �}�' JONES I . 25100 ALL T6`�T /D/9/du F.G. % G��• -S -Top FNU = �/ O INS-17-50 1ST. INS G4L. j'.G 5v35o�c_ Z BuX PT�C S7.8 �,EAGI� PIT INV. INV. �4A1Z>. WA�KGD I 5Tuµ6 •S/B cazT1F►CD Pl-oT P"A.W I ' I /3.'�/G,d F'�•U F I L� 1.o C A� ►o N �,4�.�'7�'J�+�CS/�/G.Ls p �P.N Rzr= EN GE CEQT► THAT TNE Poo r�SG"J �rOSNoH(N ►{6•R6.OIJ GOMPL`�5 1rJITN'tHE S I oEL.IN � ,�,p'j 9 AuD S6T�AGK t'L6R�IREM NY> oF -tµ� AOSAL- -To W N O F 13A>111�1 s�A3�-C A N ►S 1�1 oT 'I LOCI.TED WIT ItJ D/�.T>r 1�� B A xT E Q.t P•I Y E I N C. R.E 61'S-T 6 Z Gr D�t.A►•1 D S u Tu15 PLati 15 KiaT E3n5t=p na N o5'rE2.VIl.t..E - 5• , IN5•• ?-UtAENT 5V2V1~"-THE D1=F,SE"T5 5uou,� Nod' (�E �USEDTd �>r'TER/^I►�E �.oT �- INE.S APPLIGA►JT Ca�iylJ.�/7y`'��j/it/G. OCATION �fo SE WAGE PERMIT NO. L /,�,-I- q /s7 � VILLACE I N S T A LLER'S NAME & ADDRESS 00 96 a/,/Iu - ® U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ;1e 35- r' SYSTEM PROFILE NOTES ALL SYSTEM COMPONENTS SHALL BE PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) MARKED WITH MAGNETIC TAPE OR 1. DATUM IS APPROX. NGVD o ACCESS COVERS TO WITHIN 6" OF FIN. GRADE COMPARABLE MEANS FOR FUTURE LOCATION. 2. MUNICIPAL WATER IS EXISTING \ TOP FOUND. EL. 62.0' w 3. MINIMUM PIPE PITCH TO BE 1'/8" PER FOOT. MINIMUM .75' OF COVER OVER PRECAST 2� SLOPE REQUIRED OVER SYSTEM 61 .0' oak Stine PROVIDE INSPECTION PORT TO WITHIN 3" OF NAL GRADE 4. DESIGN LOADING FOR ALL PROPOSED PRECAST PRECAST H-10 RISERS (TYP.) UNITS TO BE AASHO H-10 Ro e Lane Locu 2 0 58.6' 4"0SCH40 PVC PIPES LEVEL 1ST 2' 2" DOUBLE-WASHED PEAS 5. PIPE JOINTS TO BE MADE WATERTIGHT. OR GEOTEXTILE FABRIC TON gshjP 57.05' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE a 10" EXISTING 14" ET TEE SEPTIC TANK** TEE 57 20'f* WITH 310 CMR 15.000 (TITLE 5.) L ° 0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°g °0°0°0°•°0°0°0°070o?- e o 0°000000000° 56.55 0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0 0�0°0°0°0 0°0°0°0° o} r a 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND o GAS BAFFLE °°000°°°° 0°0°° 0°0°0°0°0°0°0°0°0°0°0°0°0°0°0°0° °I>°0°0°0 °°0°0°0°0 54.34' NOT TO BE USED FOR LOT LINE STAKING OR ANY = 77' 60' °4" PVC SET AT .005' ° SLOPE ° ° ° ° OTHER PURPOSE. �o 56. 56. � /' 777� ON 6" DOUBLE WASHED 3/4" - 1 1/2" STONE ' 8. PIPE FOR SEPTIC SYSTEM TO' SCH. 40-4" PVC. 9. COMPONENTS NOT TO BE BACKFILLED OR 6" CRUSHED STONE OR MECHANICAL 3.64'*** 1$'+ CONCEALED WITHOUT INSPECTION BY BOARD OF p io po s COMPACTION. (15.221 [2]) 'HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. ( 1 % SLOPE) ( 1 9; SLOPE) BOTTOM TEST HOLE 1 EL. 50.7'*** 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP LEACHING G-W EXPECTED AT ELEV. 36't PER TOWN MAP VERIFYING THE LOCATION OF ALL UNDERGROUND & FOUNDATION- EXIST. SEPTIC TANK 43' D' BOX 79 FACILITY OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE ***INSTALLER TO CONFIRM SUITABLE SOILS Flo ' MIN WORK. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT BELOW BASE OF SAS PRIOR TO INSTALLATI N OF ASSESSORS MAP 149 PARCEL 130-16 UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE ANY PORTION OF SYSTEM I 11. ANY UNSUITABLE MATERIAL ENCOUNTERED PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE SHALL BE REMOVED 5' BENEATH AND AROUND THE CONDITIONS IF NOT SUITABLE PROPOSED LEACHING FACILITY. 1 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE SAND. IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR '`59.22 BY HEALTH INSPECTOR x 5 .28 PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED 59.02 BY THE BOARD OF HEALTH REVISED DURING A PUBLIC \ HEARING HELD ON AUG. 4, 2009 \ BENCH MARK - TOP OF BRICK \ LANDING ELEV. = 62.2 3) FAILED SYSTEMS ONLY : SOIL ABSORPTION SYSTEM ` SYSTEM DESIGN. INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW 59.60 GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) 59.75 AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS BE LOCATED MORE THAN SIX FEET BELOW GRADE. 1 5 9�. C GARBAGE DISPOSER IS NOT ALLOWED \ ` DESIGN FLOW: 4 BEDROOMS @ 110 GPD = 440 GPD G/60.56 6072 s0 \ � USE A 440 GPD DESIGN FLOW =AvED DRIVE .21 �= SEPTIC TANK: 440 GPD (2) = 880 60.93 �J. 38 \ 0� RE-USE EXISTING SEPTIC TANK** TEST HOLE LOGS ;P, 60`\+ �,� LEACHING: LOT 9 �° 7 \ �i SIDES: 2[2 (43 + 3) 2 (.74)] = 272 GPD ENGINEER: ARNE H. OJALA, PE, SE 20,465±SF / 1. 4 '`59.94 BOTTOM 2[43 x 3 (.74)] = 190 GPD DON DESMARAIS, RS 6' WITNESS: s1'`.ss x 1.�_ � DATE: 7/16/12 TOTAL: 625 S.F. 462 GPD x 1.53 PERC. RATE _ < 2 MIN/INCH I x 60 98 \ USE (2) 43' LONG x 3' WIDE x 2' DEEP x 1 .59 \ LEACH TRENCHES OF PERF. SCH. 40 PVC PIPE AND STONE CLASS I SOILS P# 13696 61 700 ; x\so.o8 62.25 6 7 \ 61.98 EXISTING DWELLING 67 `\ I 1 ELEV. 2 ELEV. TOP FNDN. = 62.0' 12" 9 06 \ WH 001 60.7' 0" 60.8' 61.28 P 61 ' 0 � 60.34 -- -4 MA A A OVER HEAD T1LS. - .68 APPROVED DATE BOARD OF HEALTH - SL SL x 61.11 t 6DAK 1 10YR 3 1 0.84 10YR 3 / TH/ , 8" 8" x 61.07 - ;= x .70 x 60.92 TITLE 5 SITE PLAN B B '�� \ i 1 i OF LS LS ��- ` 6j �.04 10YR 6/6 10YR 6/6 24„ 58.7 24 5-8.8 , .84 ; 23 GOLDENROD LANE CENTERVILLE Jlp le x 60.84 C C �60.23 �° PREPARED FOR PERC - N`Lh B&B/HARRELL MCS MCS PROP. VENT WITH CHARCOAL FILTER J U LY 18, 2012 0.38 AND BUGS'CREEN (FINAL PLACEMENT BY CONTRACTOR WITH HOMEOWNER � � 2.5Y 6/6 2.5Y 6/6 CONSULTATION) wGr ZH OF ki p ASH OF<TAS' .y �� ss� �� O off 508-362-4541 x 60.83 �.�' DANIEL �,� I fax 508-362-9880 downca e.com � DANiELA. �s � •� m . Jo OJALA OJALA m-4� P Na 46CI'V1L � �No.4098 P y� down CQ#Ve engineering, /7C. 120" 50.7' 120" }� r, � ��`"' civil engineers 50.8 Scale: 1"= 20' _ .� �SS�oSAL EN��4 �. a,, suRN 9 NO GROUNDWATER ENCOUNTERED land Surveyors 939 Main Street ( Rte 6A) 12- 182 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675