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HomeMy WebLinkAbout0020 HEATHER LANE - Health U H65ther Lane A = 1' 9 13U 0 04 f - Marstons Mills v I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 9 p Y rY °M 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 April 7, 2014 required for every p 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. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: r� key to move your I / cursor-do not David B. Mason use the return Name of Inspector key. David Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 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: CD ® Passes ❑ Conditionally Passes ❑ Fails LU ❑ Needs Further Evaluation by the Local Approving Authority U tlu April 9, 2014 a Ibspector's Signature Date — , o health system inspector shall submit a copy of this inspection report to the Approving Authority (Board C,4 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. t5ins-3113 Title 5 Official Inspection rm: bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts F Title 5. Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 April 7, 2014 required for every p page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E l 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 evaluate_d are indicated below. Comments: - This report represents only the condition of the system observed on March 7, 2014 at 11 AM and does not guarentee the continued operation of the system in the future. Increase in use or occupancy may result in hydraulic failure. 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•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 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 Aril 7, 2014 required for every p page. Cityrrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments °wM s 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 April 7 2014 required for every p , 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 '/2 day flow t5ins•3/13 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 °M 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 April 7, 2014 required for every P 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. El ® 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'tributarjr 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 Aril 7, 2014 required for every p 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 god x#of bedrooms): 330 _ t5ins•3113 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 20 Heather Lane, Centerville M Property Address George Sommers Owner Owners Name information is Centerville MA 02632 Aril 7 2014 required for every P , page. City/Town 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? (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 Yes 9 ( Y 9 (gP ))� Detail: 2013; 33,000 Gallons and 2012; 54,000 Gallons Sump pump? ❑ Yes N No Last date of occupancy: current Date CommercialAndustrial 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 wM 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 April 7 required for every p �il , 2014 page. City/Town 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: Barnstable Board of Health 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 PP of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 Aril 7, 2014 required for every p 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: June 17, 2002 Were sewage odors detected when arriving at the site? ❑ Yes E No Building Sewer(locate on site plan): Depth below grade: 2.8 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Observable components appear in working order. Septic Tank(locate on site plan): Depth below grade: .5 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: Typical 1000 Gallon Tank Sludge depth: 311 t5ins•3113 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 M 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 Aril 7, 2014 required for every p page. Cityfrown 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 40" Scum thickness 2„ Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 12" 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.): Observable components appear in working order. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° M 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 Aril 7 2014 required for every p , page. Cityfrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 April 7, 2014 required for every p 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 Effluent level with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box is approx 18" 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 conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•3/13 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 �^M 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 Aril 7, 2014 required for every P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching chambers 45" below grade with 3' risers. No indication of ponding or damp soil. 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 Y 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °,M s 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 Aril 7 2014 required for every p , 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•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 ;M 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 Aril 7 2014 required for every p , page. City/Town 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 April 7, 2014 required for every p page. Citylrown 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: 20 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: 5/14/2002 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Soil logs and Groundwater Contour Map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized documents and resources referenced above. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Heather Lane, Centerville Property Address George Sommers Owner Owner's Name information is Centerville MA 02632 Aril 7, 2014 required for every p 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 Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ti t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 iv y, 07 LOCATION # ac SEWAGE PERMIT NO. VILLAGE M m-, ( Ic INSTALLER'S NAME i ADDRESS on k or S U I L D E R OR OWNER 'G DATE PERMIT ISSUED 7 _� DATE COMPLIANCE ISSUED i7 56- http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=149130004&seq=1 4/15/2014 TOWN OF BARNSTABLE LOCATION 20 Aka 4ker- L.titry¢. SEWAGE # ;200..7-i}®�' VILLAGE ASSESSOR'S MAP & LOTI -/ 0-00 INSTALLER'S NAME&PHONE NO. &6t izL-n Se.Q+� 7 7S-8`776 SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) a .q AJ AR (size)1214 V NO. OF BEDROOMS BUILDER OR OWNER Sor+^tm zC5 PERMITDATE: S-1y-03 COMPLIANCE DATE: (o' 17-pa 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 —aNb� , y 1 O 0 Zl- F t^ t No. 00— 2 Fe%5 0 lTHE CaMMONWEALTH OF MASSACHUSETTS Entered in compute Yes PUBLIC HEALTH DIVISION�JOWN OF BARNSTABLE., MASSACHUSETTS 01pprfcation for Mi0pogat Opotem Com0ruction Verrntt Application for a Permit to Construct( X)Repair( )Upgrade( )Abandon( ) 0 Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No.George Sommer 20 Heather Lane, Centerville 20 Heather Lane, Centerville Assessor's Map/Parcel 02632 02632 Installer's Name,Address,and Tel. o. Designer's Name,Address and Tel.No-Darren Meyer Wm. E. Robinson, Sr. Septic Serv. 43 Vine Street, Duxbury 02332 P.O. Box 1089, Centerville 02632 775-8776 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Title-5 Leaching system to plans of Darren Meyer dated 4-8-02 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 Certifi- cate of Compliance has been issued by t 'g Board of H h. Signed Date Application Approved by Date S'/y'y 2 Application Disapproved for tfie following reasons Permit No. a0 d;Z—20.g— Date Issued f .a... $ S No, Fee S O T OM NWEALTH OF MASSACHUSE17S Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION , TOWN OF BARNSTABLE, MASSi' CHUSETTS Ztpprication for Migpogar 6pgtem/Cong1r uction Permit Application for a Permit to Construct O Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No.George Sonmer j 20 Heather Lane, Centerville 20 Heather Lane, Centerville Assessor's Map/parcel 02632 02632 Installer's Name,Address,and Tel.V.. Designer's Name,Address and Tel.No-Darren Meyer Wm. E. Robinson, Sr. Septic Serv. P.O. Box 1oo 7gggg75 C r�terville 02632 43 Vine Street, Duxbury 02332 =8 5 Type of Building: Dwelling No.of Bedrooms 3 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building - No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Title-5 Leaching system to gala plans of Darren Meyer dated 4-8-02. 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 Certifi- t Cate of Compliance has been issued by t ' Board of Signed _ �; �►-.✓ `r Date �- ` Application Approved by Date_/y'y 2 Application Disapproved for t e following reasons 4 Permit No. rQi 0 0;? --? - Date Issued S 1 y- 0.2- -------------- --------- — ————— �. THE COMMONWEALTH OF MASSACHUSETTS Sommers BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CFgg IFY, that the On-site Sewage Disposal System Constructed( X )Repaired( )Upgraded( ) Abandoned( )by W111iam Robinson Septic. at 20 Heather Lane, Oenterville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2 f�)�'ao f dated Installer William Robinson Sr. Designer Darren Meyer The issuance of t s permit shall not be construed as a guarantee that the sy will nction as esigne . Date Inspector �� --- ----._..,_-- --- --------------- No. yo;— U� Fee S O THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migogal *pgtem Congtruction Permit Permission is here b granted to Construct(X )Repair( )Upgrade( )Abandon( ) System located at 2y0 Heather Lane, Centerville and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co stru tion must be completed within three years of the date of th ermit. Date: .� I U Approved by � 'i LOCATION SEWAGE PERMIT 00. (�Akek LA..,u.e- VILLAGE�f m M-1 t I� I N S T A LLER'S NAME A ADDRESS act -SA OJ ® U I L D E R OR OWNER &QAQ G� h'- V DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �:� _ � ------------- �.l 'L7 x� e; `r 70 41 No.------.. _j.:. •f '', Fns...2 d.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH , pphrattion for Uwvotiaal Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct (P/ or Repair ( ) an Individual Sewage Disposal System at: ........--•••---..................... .. ._._..............•-----•----------... ................................. .�. ............. Local ion-Address r or Lot No. r .l?�/ 4?,���a,��. --1��-�------. /� ._._ ------------------------------- Owner Add ess Wo Installer Address d Type of Building Size I:ot. �.. l. .Sq. feet U Dwelling moo. of Bedrooms____.._ ..............................Expansion Attic ( ) Garbage Grinder (C.� PL4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 114 Other fixtures ................................. W Design Flow.....//6-•.-_--------------------gallons per person per day. Total daily flow-_.r.ZYA'Z?.........................gallons. WSeptic Tank—Liquid capacity/4 Al 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'.0,V+_7_:6_.___`_•-----•-------------- Date....,�� Test Pit No. 1.... ..._.minutes per inch Depth of Test Pit.__/ _._____. Depth to ground water. Q ... Gz, Test Pit No. 2................minutes per inch Depth of Test. Pit.................... Depth to ground water........................ ••-•-•••... ••••...•-•-•......__...-•--- O -•-------•----••------------------••------•--••-------.••-••.................-•---•....------...---••----•-----•r r r Descriptio o Soil.....el--- �.............�^�--c��.�1. G.l�------------- 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 TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is y the ), ard of health. 9 Si d -------•-----•----------- ------ Da ... ... Date 1 - Appliion Approved B Date Application Disapproved for th oll ing reasons- -------------••---....-----------------------------•-••---------------------------------------............----- .................•-••-•------••-•----•••••••••-•••••--••-•-•--•--••-••-----••••••-•-----•--•--•-••.........---•-•-•---•......-•••••......•-•-----...-----------------................................... Date PermitNo......................................................... Issued....................................................... Date No .--...;r .... FEs........................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH rs '� .... OF. i '�r✓�• _ .................................... ,fit lirtt#ion for 13ili ooa�� � l 'rk�s Cnoa�s�.rurtua�t .ermit Application is hereby made for a Permit to Construct (�'") or Repair ( } an Individual Sewage Disposal System at: ................_.....___.......... . ................................. •--•-•--.....• ••-•....._.`.... ..... .=-%.� ....................•-------•••-•-•-•---- / _Loc tionrA7ddress ---•__.... ...t_ rJiC �� ; ram, %?:J . . ' orlLot No ^"" .... ..... Nt" /➢ Owner. - � � � a � •� Address W ,e��� 7 Ge i .. . i tr�r r f r s t c Installer Address U Type of Building Size Lot ° ;a__ ' ..Sq. feet �-, Dwelling moo. of Bedrooms.........._ ..............................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .---••-•••----- -------------••---------------------.-------------------------------•--•---•---..........---•----...-••-••......•---••......-------- W Design Flow_____ 1l4 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 ar ....sq. ft.P ��-------- Z Other Distribution box (. Dosing tank ( ) _- Percolation Test Result Performed by Y` ` fY 7 ,�' Date -----••--- De Depth to ground waterz`� '=�f :.____- Test Pit No. L.._` .....minutes per inch Depth of Test PIt._�_.�<.____._.__. p gr 44 Test Pit No. 2................minutes per inch Depth of Test Pit...........:........ Depth to ground water..............._........ .... •.......---......_•---• •-- ....................-----•-------------------•--------------...------•- O Description of Soil " .. . �� Qk,. �✓�;" y: r r r W U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ........................_............................................................................................................................................................................... 4, Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Q-, �„„s • Signed__ A lic�tion Approved B Date PPPP Y = _ ------- ....................Da-te.............. Date Application Disapproved for th f olg reasons----------------•------------------------------------------__•__ --•-----...__ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...........................................I......................................... fit /w Tntifirtttle of Toutplitturr THIS IJI P°O CERTIFY, That the Individual Sewage Disposal System constructed.-cm Repaired ( ) by .,x? ..I...............-.�' - =--•--...-•--•-----••-----------------------------•----.........----------------------------•-. •• - --•--- at--•---... �-°�-•�------....-•-...•- ---= ... `_ .----.-------------------------•------------------------------------------------------------------•-- has been installed in accordance with the provisions of TItl .�` / Ue State Sanitary Code as described in the application for Disposal Works Construction Permit No...�n...�.:__..__/....................... dated--------------------------.-.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GU ANTEE THAT THE SYSTEM WILL FUNCTION ATISFACTORY. r/J DATE.............................. ------- _ 7`........... Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F..------............................................................................. No..�'..................... ' FEE...`.......................... ;= �is�raa�_ �. rk� �utt��ttr�Uan rruti� e y'granted_....'_.'_.__ "`.Permission is her to Construct ( ,�6r_Repair ( ) an Individual Sewage Disposal System a atNo......................................................................................•-•-----••I---•-------------•-----•-•-••••-----•-------••-•-•................. Street as shown on the application for Disposal Works Construction Permit No. -:; _._...-- , . Dated______________ ____ ___ ____ -------------------------------.-----------------------------------------------------...._.....--•---••- - Board of Health DATE.................••• ! FORM 1255 A. M. SU LKI N, IN@'.. BOSTON AsBuilt Page 1 of 1 LOCATION i # �1c SEWAGE PERMIT NO. VI�LLy AG E / { NS j!"I , l IG INSTALLER'S NAME ADDRESS �r a U I L D E R OR OWNER '% DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 2/ �, L7 7 `f http://issgl2/intra"net/propdata/prebuilt.aspx?mappar=149130004&seq=1 7/20/2010 � y . ASSESSORS MAP: j4q TEST HOLE LOGS ' ._ NOTES: Sc� PARCEL: rR 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOR l/I%I •Yi `` em THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF FLOOD ZONE: C WITNESS : PA_q,�Nk BOARD OF HEALTH REGULATIONS. REFERENCE: db DATE: pP-1 '3 L 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, /log 33 PERCOLATION RATE: (- NG ml SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO 4 CLAc - SOIL, �fy INSTALLATION. TH- I TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION 0 ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE �0 �yF TNig OnLDAm - y . ��,31 DETERMINATION. ` ND� / 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS 6 g �-/g SPECIFIED OTHERWISE) i� LOW LOCAT I ON MAP(Mrs) INF- MfDfum ~l�F. 7 N114 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE DISPOSAL. g2 113� 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) MEr7tU�1-Cps MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A BASE OF 6"OF CRUSHED STONE. 5 � 1N j - I 7 . 3 7 2 -P1 - _PEA- T V. G � rlo OisSa ''J Ra�Nnw 9,, Al y4xm-NG,5 S Tl 7LE d OR-;5&"s 5tQu� SEPTIC SYSTEM DESIGN 9-) FLOW ESTIMATE �G�L1�Q1✓ Po� �C #�hJ ..�__: �_ _� ___ _ _.a.��__..__;.._ _�__. r S'�° 43`o�' BEDROOMS AT 110 GAL/DAY/BEDROOM GAL/DAY SEPTIC TANK !,mil �GA{L/DAY x 2 DAYS - D GAL USE 1 000 GALLON SEPT I C TANK-Fx/97 -)55pcj e w/JScv g4-t, 56-PPIG 1?rp)1,,l E SOIL A3SORPT I ON SYSTEM _. e..a t.�f t 3�.` G S I DE AREA fr2S)2_fyl3)7_Dx2- x 6 75/ BOTTOM AREA:— ZS k l3 x d,7V Zqo. Sb - z 357,R& 4P�, SEPT I SYSTEM SECT I ON �ctsr�rJt� 6 al t � loves w/n G„ � `----•------._ Et_. ZO,`' � a � 10" 1¢" fig/ 4�s Py 77 D4�OX Z �3 L�oVb/G sh I t [Xat� GAL y3 /N57?�'!-�,, �'�,ry�' � 1� © 1=l �r loo � � Eo�� � I 1I�21 �- � SEPTI C TANK -�✓ ��a�l��s �"r�a r.�� --- wLq "//°P/G i 0 U TEES As N6eE sS A vv[l ''t 13 0 j \ or Of SITE AND SEWAGE PLAN IZ' � DA LOCATION : 2-0f Ek —Jo N� Nam° Y" .��n -�e.i/f LLB �►�ig 41140 = P� PREPARED FOR : P _ SCALE:P- ZO l DARREN M. MEYER, R.S. 43 VINE STREET DATE: U a W O DUXBURY, MA 02332 W DATE HEALTH AGENT (781) 585-0293