HomeMy WebLinkAbout0062 BUNNY RUN - Health 62 Bunny Run
Barnstable
A = 234 - 033
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TOWN OF BARNSTABLE
LOCATION K; SEWAGE
'VILLAGE •B,4G gr ASSESSOR'S MAP.&PARCEL J"�/� A.�3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) C— -ems e,,94 size) I�r jet Roz
NO.OF BEDROOMS oZ
OWNER 11,re
PERMIT DATE: ® —��` COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ��' S Feet
Private Water Supply Well and Leaching Facility(If any wells exist orr
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 �J�✓ �� '®��✓�
CA
41
moo.
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o I l
No. �gtq
_ g Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYitatiou f r bisposar 6pstem Construction Permit
Application for a Permit to Construct( Repair( ) Upgrade 44'Abandon( ) Pf/complete System ❑Individual Components
Location Address or Lot No.U:j ggg,vray Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel .6Z lam/ ® 33 Iy Gp r/A
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
07 �� 3� 7 0 7.2 7
Type of Building:
Dwelling No.of Bedrooms Z11 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) } gpd Design flow provided -��9 gpd
Plan Date Number of sheets .� Revision Date
Title
Size of Septic Tank>y *&I /.9"® Type of S.A.S.
Description of Soil _ f->
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed "�' Date
Application Approved by Date �—�° /y
Application Disapproved by Date
for the following reasons
Permit No. C�f Date Issued y
���0
d.
No. G( _ Fee /Ov
x. THE COMMONWEALTH`"OF MASSACHUSETTS Entered in computer: Yes
+. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application f r Disposal 6pstem Construction Permit
Application for a Permit to Construct( Repair( ) Upgrade a) -AAbandon( ) �omplete System ❑Individual Components
Location Address or Lot No.U �vr.�y Qll/.✓ Owner's Name Address,and Tell.No.
4 G � l'tf'� 0
Assessor's Map/Parcel S% 3-4 'e i //O
Installer's Name,Address,and Tel.No. ( Designer's Name,Address,and Tel.No.
v7 9 0 7.J 7
Type of Building:
'~ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No'of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
gpd
Plan Date y -1 R-/f/ Number of sheets J Revision Date
Title
Size of Septic Tank�Rw /�"O ���� Type of S.A.S.
Description of Soil _J_-
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
w
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o ealth.
-...z47 J�
Signed �G "�' Date
Application Approved by 1f , Date ��2° IV
Application Disapproved by Date
for the following reasons
� I
Permit No. C) - L f Date Issued
------------- _ - = =-=-----_---- = = ==-=--- = = -- - --------------- ---------- -------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
I THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(� Repaired( ) Upgraded(�
'! Abandoned( )by
at dS 46U'+'A-/l �'U� has been constructed/in accordance'
with the provisions of Title 5 and the for Disposal System Construction Permit No. o 7 - �� dated
Installer y'! l��O�t"U, Designer JU w LAW^"(-d".✓ ,
#bedrooms oZ Approved design floA o� ® gpd
The issuance f thi permit shall not be construed as a guarantee that the system wi fu tiff a desi d.
P g Y � ,�^
Date a Inspector ` V ,•
QS
No. 7 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
iB�ID Y *pstem �ConstrUCtiD hermit
Permission is hereby granted to Construct(PRepair( ) Upgrade( Aband ( )
System located at 6--J 118?4' &Z
v�
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
n
Provided:Consttructio must be completed within three years of the date of this permit.
Date / o 7( Approved by
f
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i
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Town of Barnstable
do Regulatory Services
Richard`V.Scali,Interim-Director
�$ MASS, Public Health Division
Thomas Mc Kean D',_.ireetor
200 Main.,Street,Hyannis,MA 02601
Office: 508462-4644
Fax 508-790-6304
Installer& Desi:ner Certification Form
Date: %` .-y Suva a Perm t# c.�p' �'r�s�' � psi v 3�
Designer: cT� ' �—4'
Assessor s-1M_ ap\Parcel
�o •S'o,X/ yam _ .
Installer:
Address: Address; Z5 Q
On �"."� o_�'y' . �.�� 1. �'�'c�c.,..�
(date) was issued a permit to install a.
(installer)`
septic system at 6 _ ' -.�-�-_V ✓E' �-
(address) based on a design drawn;by
dated -� ,P—
I/' (designer)
Y ,
I certafj that the septic system referenced above was installed_substantially'according'to
the design, Mich may include minor'approvved changes such as lateral relocation in the
distribution box and/or, septic tank. Strip out (if required) was inspected and the,soils
were found.satisfactory,
I certify that the septic system referenced above was installed.=with,major changes (i.e.
greater than 10' lateral relocation•of the SAS or any vertical.relocation of any component of the septic system) but in accordance with State>&Local.Regulations. Plan revision or
certified as built by designer to folloW- Strip out:(;if required)was inspected and:the soils
were found satisfactory;
I certify that the system,referenced above was constructed in compliance with the terms
of the 11Aapproval.letters(if applicable)
SAMUELJ.P.cyG
( nsta,er's Signature) JENSEN
o CML N
No.46058
Q
�90�FG�S7Ep�.<j E� •
(Deli' Signature) F
(Affix er s Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEAL;TIi DIVTSIOId`.: CERTI<FI.CATE B CUIIPLIAIVCE.W1LL NOT BE ISSiTED tTNTIL BOTH=T.HiS FORM AND AS-
B>J?LT
HARK
ARE RECEIVED By
BARt\STABLE PI7BL1<C HEALTH.D:iVISION.TiVK YOU.
Oseptiemesigner Certification Form Rev 8-:14-.13.doc
VE Town of Barns fable P#
Dep>artineut of Regulatory 00ervices
nnnrterner� Public 11calth Division M Date 2 .AB& -
a'699 200 Main Street,Hyannis MA 02601
PAD IMI.`I
Date Scheduled
Time Fee Pa. d
'®oil Suitability Assessment for Se e Dis ®s� �
Performed By:
Witnessed By:
LOCATION GENE = O1�A ON
Location Address ti1 n 's Name / / �Z�`�'L. _
ss SV`
Assessor's Map/Parcel: +�u_7 l d ® Eng leer' ame
NEW CONSTRUCTION REPAIR eplione# �� ? �� 7
Land Usc' `jtLCPtt�,llj Slopes - �
Surface Stones
Distances from: Open Walser Body ft Possible Wet Area ft Drinking Water Weli 7�'�(] ft
Drainage Way. ft Property Line I %ft Other
It
1�r—"TC11:(Street lame,dimensions of lot,exact locations of test holes&perc tests,locate wetlands ht proximity to boles)
LIJ
t Cf, r
Odd.t mal.crial�gekotogic) p k
Depth to Bedrock
C) D-Wh to Ground r-.. Standing Water in Hole: Weeping from Plt l4pee i11 Q�
Estimated Seasonal High Groundwater 7/*3—A �e_L ppt
DET t R1VlQ t�T1O OR SPA,�'O A1, GT1 WATER'1'Aa]�L,
Method Used: 5 r
�gC�atytb��s..cab f�, ?;
Depth Observed standing in obs.hole: ? lo, Depth to soil lllottles;-^�� _.In.
De r to weeping from side of s.hole: T/2S2) Ill, Groundwater AdjoAlmenl ([-
Index Well# cading Date: Index Well level Adj.thctor.:�_ Atu.01,01111dwater Level
PERCOLATION TEST Time
Observation
Hole#
Time at 9" �•-�----
- n—_ --
Depth of Pere 7 Time at 6"
Start Pre-soak Time @ Time(9"-6") .>Q;
End Pre-soak
Rate Min./Inch Mt g
Site Suitability Assessment•' Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Heath Division Observation Hole Data To Be Completed on Back----------
*"If percolation test is to be conducted within 100' of wetland,you must first notify tile.
Barnstable Conservation Division at least one (1) weep:prior to beginning.
c�:�s errlc�rnlzcroRM.Doc
DEEP-OBSERVATION HOLE LOG Hole# /
Depth from Soil Horizon Soil Texture Sdil Color Soil . Other
Surface(in.) (USDA) (Munsell) Motlliug (Stnuchire,Stones;Boulders.
onsistency,96 Oravel)
�— " A 112 3 How
3 �'`
n
/ r
e
ham, l
� 9
tef
ICJ% ��trni.v.l
DEEP OBSERVATION HOLE LOG Hole# �
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
onsis en `Yo r vel
- lam
DEEP OBSERVATION HOLE LOG- Mole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stoncs,Boulders.
Consistenov.%Oraycl)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,
Consistency, 6 Qtaypll
w -
no.
IT',.(�t
K
Flood Insurance hate Mau:
- Above 500 year flood boundary No- Yes V '_
Within 500 year boundary No Y Yes
Within 100 year flood boundary No T_ Yes r _�
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environ ental Protection and that the above analysis was performed by me consistent with
the required trai ' ,ex rtise and perience described in 10 CUR 15.017.
Signature Date 14�
QAS EPTIC\PERCPORM.DOC
OF BARNSTABLE 1
LQCATION � SEWAGE
VILLAGE ASSESSOR'S MAP
INSTALLER'S NAI&P�NO. —c—
SEPTIC TANK CAPACITY c c( C
LEACHING FACELrPY: (type) ( � ` (size) ,
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: DA
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
•t
AA r7
CA
�-� COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAULCELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A `
CERTIFICATION
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17 ,
Name of Owner GENTRY /
Address of Owner: C/O OF LINDA HUTTON STRAWBERRY HILL REAL ESTATE
c O
Date of Inspection: 312199 ti
Name of Inspector:(Please Print)JOHN GRACI 19
1 am a DEP approved system inspector pursuant to Secdon 15.340 of Tide 5(310 CMR 15.000)
Company Name: John Graci Title V Septic Inspection
Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636 t
Telephone Number: (608)664-6813
CERTIFICATION STATEMENT
I certify that I have personalty Inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The Inpection is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:3/2/99
The System Inspector sha I submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE.THE
SYSTEM WAS NOT INSPECTED UNDER NORMAL USE.THE OVERLOW CESSPOOL WAS EMPTY AT THE TIME OF THE INSPECTION;IT SHOWS
SIGNS OF HAVING 4'OF WATER IN IT. RECOMMEND REMOVING THE TREE NEAR THE OVERFLOW TO PREVENT ROOT DAMAGE AND
RECOMMEND RAISING COVER TO THE OVERFLOW.
revised 912198 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:3/2/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
NO The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is Imminent.The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
ND Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
NO The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:3/2/99
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nLa_(approximation not valid).
3) OTHER
n&
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:3/2199
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nla.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located Ina nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:3/2/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with NIA,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:312/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow'.-M g.p.d./bedroom
Number of bedrooms(design): 2 Number of bedrooms(actual):nLa
Total DESIGN flow: A
Number of current residents:A
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NQ If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):M
Water meter readings,if available(last two year's usage(gpd): Wit
Sump Pump(yes or no): NQ
Last date of occupancy: 11/1198
COM M ERCIALIINDLISTRIAL
Type of establishment: nta
Design flow: Wit gpd(Based on 15.203)
Basis of design flow: Wa
Grease trap present:(yes or no):JM
Industrial Waste Holding Tank present:(yes or no): KQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:Wa
Last date of occupancy: nta
OTHER: (Describe)
n&
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped nla. gallons
Reason for pumping: nLa
TYPE OF SYSTEM
X 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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
SYSTEM"IS APPROXIMATELY 35 YEARS OLD
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:312199
BUILDING SEWER:
(Locate on site plan)
Depth below grade: V r
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
Wa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: V
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
Wa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
nta
Dimensions: 6X6'BLOCK CESSPOOL-EMPTY
Sludge depth: nfa
Distance from top of sludge to bottom of outlet tee or baffle: nla
Scum thickness:-n&
Distance from top of scum to top of outlet tee or baffle:_n(a
Distance from bottom of scum to bottom of outlet tee or baffle: n&
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation.to outlet invert,structural integrity,evidence of leakage,
etc.)
MAIN CESSPOOL AND ALL COMPONENT ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM FOR MAINTENANCE EVER YEAR
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
D&
Dimensions: nLa
Scum thickness: nLa
Distance from top of scum to top of outlet tee or baffle:l]La
Distance from bottom of scum to bottom of outlet tee or baffle n&
Date of last pumping: n&
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
Wa
revised 9098 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:312/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n&
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n[a
Dimensions: nla
Capacity: n& gallons
Design flow: n/a gallons/day
Alarm present: NQ
Alarm level:.ila_ Alarm in working order:Yes_No_ NQ
Date of previous pumping: n(a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nLa .
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:n!a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
Wa
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n1a
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:3/2/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: n&
leaching chambers,number: _n&
leaching galleries,number: 1]LA
leaching trenches,number,length: Wit
leaching fields,number,dimensions: Wa
overflow cesspool,number: 676'BLOCK CESSPOOL
Alternative system: n&
Name of Technology: -nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE OVERFLOW"!IS STRUCTURALLY SOUND,THE CESSPOOL WAS EMPTY AT THE TIME OF THE INSPECTION RECOMMEND MOVING TREE
NEAR SYSTEM TO P
CESSPOOLS: _
(locate on site plan)
Number and configuration: n&
Depth-top of liquid to inlet invert: n&
Depth of solids layer: nta
Depth of scum layer. Wit
Dimensions of cesspool: n&
Materials of construction: n&
Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n!a
PRIVY: _
(locate on site plan)
Materials of construction:n(A Dimensions:n/A
Depth of solids: nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
revised 9/2198 Page 9 of 11
J • '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:3/2199
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
C4geor
j�n Rco�lh
C>
AA i"7
A 4 3S
r>A ,3
as Yi
G �
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 62 BUNNY RUN CENTERVILLE MAP 234 PAR 033 L 17
Owner: GENTRY
Date of Inspection:3/2199
NRCS Report name: n&
Soil Type: nla
Typical depth to groundwater: nla
USGS Date website visited: Wa
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
�000 oroluo
632
� o p
1po�o f S�N,�P �N LOCUS
�0 5977'00 �p> .1��i� l G' -N QRAIIIDERRYw> �
p�2 167,70'
1vQ ,pP 5 Hedge
10 PROPOSED $00 GAL.
C fin... � CHAMBER(TYP.) _
o / �p1p� Q� ' TP 1 gip&�� PROPOSED SOIL
�S\ _ I ABSORPTION SYSTEM 6 ,
[� BENCHMARK SET o �" . « ,
c� ORANGE PAINT ON SONOTUBE �T 10 NYV
`l EL.=101.18{ASSUMED) O £�Q1ta
tip 1po�� Gp! Epp 10112 ,•� �j°l 052�
o 1p3 oP� 1o�1a LOCUS MAP
Paved Drive tiOp6. Of �� Z
.o a e ' NOT TO SCALE
REMOVE&STACK STONE
MP 22 �� 10'MIN. �� o WALLAS REQUIRED rn �� SAMU
o6 p 5 °(f� o } ;V o J EL J.P. `yam LEGEND
� 1p . R° I
10`MIN. �Q �`� nZ�'� c ��L — 50 — EXISTING CONTOUR
:t o { '3; y PROPOSED o cn a N°.46(tS8
#62 { �t� 1p3. pR� DISTRIBUTION BOX
Z MAP 234 EXISTING P o�etsl �" �pR P �� �'/STEP� 50 PROPOSED CONTOUR
� 2 ��� AI
9 PARCEL 33 . DWELLING tP tioF �o _ ' — Emic — ELEC.UTILITIES
op63 =15,271t S.F. 5� 1pa �f
TOF=101.62 + O$ lk2 Gl —'w — WATERLINE
\ 0.35t AC. / (ASSUMED) K �25 �p1� E�9wn�V Sred Lp
—."GAS— GASLINE
a� TEST PIT LOCATION
(EXISTING CESSPOOLS TO BE \ pIS�
> �ti PUMPED AND BACKFILLED �Q IF3� O O O SEPTIC TANK '
9 ��` �p1 tipl PROPOSED 1500-GAL. WITH CLEAN SAND OR 'Pik"
m R1 G Zn' �" REMOVED AS REQUIRED SEPTIC TANK 4"SOLID SCHED.40_PVC PIPE
O 1pti; �p2' k
f 1 63.00' 2
' 10 •® •DISTRIBUTION BOX
N 64 27'0 W
. , �3 —————— 4"PERFORATED SCHED.40 PVC
oFF02 INSPECTION' NOTE:
y �o DISPOSAL SYSTEM INSTALLER TO COORDINATE ALLf REQUIRED 0 500-GAL CHAMBER
A 2 INSPECTIONS BY BOARD OF HEALTH AGENT AND DESIGN ENGINEER
rn
0
PRIOR TO BACKFILLING SYSTEM COMPONENTS. A MINIMUM OF
' u" p 99 SITE PLAN 48-HOURS ADVANCED NOTICE SHALL BE PROVIDED FOR INSPECTIONS. -
, . ��9' ` c9 • i. BOARD OF HEALTH AGENT AND. DESIGN .ENGINEER:APPROVALS. ARE PROPOSED SEPTIC ,,
g3 0 - 10 20 40 FEET REQUIRED PRIOR TO- BACKFILLING SYSTEM-COMPONENTS.
b, -
,
UPGRADE
GENERAL NOTES: U Located at:
1. ALL SEPTIC SYSTEM COMPONENTS.AND CONSTRUCTION. METHODS.SHALL BE IN ACCORDANCE 7. LOCUS ASSESSOR'S PARCEL ID: 234-033 ('J 62 BUNNY RUN
H W T TITLE 5 OF THE STATE ENVIRONMENTAL CODE, 310 C.M.R.. 15.000, AND ALL APPLICABLE 8: OWNER OF RECORD: MCCORMACK, DAVID W. & MEGHAN E., 62 BUNNY RUN, CENTERVILLE, MA S
LOCAL BOARD OF HEALTH RULES AND REGULATIONS. -02632. DEED: BK.�15364 PG. 118 PLAN: BK. 172' PG. 51.
2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE 9. THE LOCUS IS LOCATED 1N'FLOOD ZONE C 'AS SHOWN ON F.I.R.M. COMMUNITY PANEL NUMBER Prepared for:
DESIGN ENGINEER PRIOR TO INSTALLATION. 250001 0005 C REVISED 19 AUGUST. 1985. DAVID &MEGHAN MCCORMACK�
3. EXISTING CONDITIONS SURVEY AND PROPERTY BOUNDARY PROVIDED BY TERRY WARNER, P.L.S., 10. NO PUBLIC SURFACE WATER SUPPLY OR PUBLIC GRAVEL PACKED WELLS WERE FOUND WITHIN
62 BUNNY RUN
HARWICH, MA. ELEVATIONS BASED ON ASSUMED DATUM OBTAINED FROM A BENCHMARK AS 400 OF THE PROPOSED SEWAGE DISPOSAL SYSTEM. NO TUBULAR PUBLIC WELLS WERE
NOTED ON PLAN. CENTERVILLE, MA02632
4. THIS PLAN IS INTENDED FOR THE SEPTIC SYSTEM WORK DEPICTED ONLY AND IS NOT FOUND WITHIN 250, OF THE PROPOSED .SEWAGE DISPOSAL SYSTEM.
11. NO PRIVATE POTABLE WELLS 'WERE FOUND WITHIN 150' OF THE PROPOSED SEWAGE DISPOSAL Prepared b
INTENDED FOR ANY OTHER PURPOSE. PROPERTY LINE INFORMATION IS APPROXIMATE ONLY. P y
THE DESIGN ENGINEER WILL NOT ASSUME ANY LIABILITY FOR USES OF THIS PLAN OTHER.THAN SYSTEM. SAMUEL JENSEN, P.E.
ITS INTENDED PURPOSE. 12. CHANGES .TO EFFLUENT FLOW OR CHARACTERISTICS,. GRADING OR LANDSCAPING EITHER
. ZONE: RESIDENTIAL — RF-1, WP WELLHEAD PROTECTION OVERLAY DISTRICT. ON—SITE OR ADJACENT TO THE SITE OR FAILING TO 'PROPERLY INSPECTOR-PUMP THE SEPTIC P.O. Box 1141, Forestdale,.MA 02644
5 ICT.. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED IC ZONING TANK MAY 'DETRIMENTALLY AFFECT THE FUNCTION OF THE SOIL ABSORPTION SYSTEM. 774-327-0727
13. THE OWNER SHALL' INSPECT AND PUMP THE SEPTIC TANK ,EVERY 2 YEARS.
REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE 14. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. Scale:AS NOTED Date:APRIL 29, 2014
AUTHORITY. ,
� .. Sheet No. 1 of 2 Rev.
THREE 20" MIN. COVERS TYP. FINISHED. G _ 1 -
( ) aGRADE..OVER CHAMBERS 015 102 0 '
2 SLOPE AT 2% MIN. OVER SYSTEM
TOP OF FINISHED GRADE OVER TOP OF S.A.S. \ I
OF TO DOUBLE WASHED STONE
.' -- COVERS SHALL BE SET TO D-BOX - 101.30 �� •, PROVIDE RISERS ON ALL
FINISHED GRADE OVER
FOUND. SEPTIC TANK = WITHIN 6" OF FINISHED GRADE J" TO 1-1/2" DOUBLE',WASHED CHAMBERS TO«WITHIN 6" OF
EL.=101.62 101.15 - 101.25 6ROOFDFINALEGRADEWITHIN EL. 99.25
WITH RISERS. " STONE TO CROWN OF PIPE ' FINAL GRADE
BREAKOUT,EL`:
//
„ INLET INVERT INLET INVERT 9". MIN.
3 MIN. sn'..., .g 3 MIN. EL. = 98.65 OUTLET INVERT.; EL. = 98.25 36" 'MAX
99.37 13fl
"2" MIN EL. = 98.48
o a0 DopQp ao d0 0® oo c'o
3" MAX 14 \�-OUTLET INVERT. �, ": 00=0 00000 00 0 O0 '0 0 2 0 0
1 _ . .
J EL. = 98.69 6 OF CRUSHED . 2 00 00 00000 00 0 00
INLET INVERT 48" OD DO 00000 O0 0 00 C3 O O
EL. 98.90 , , GAS STONE 96_25
10' MIN. BAFFLE 6 OF UNDISTURBED EARTH OR 4, .T� 8'-6"--�1 �=�--4' 4' F 4'-10"-1 _4'
CRUSHED COMPACTED BACKFILL 5,. ,.
r 25 12 -10
p H 0 O �L�L STONE UNIT SHALL BE 5 OUTLET. MIN.
cV w�cV n.M�iA ��i�v 2. 500-GAL. CHAMBERS GROUNDWATER.. 2 500-GAL: CHAMBERS
PROPOSED 1500 GAL CONCRETE SEPTIC TANK? INSTALL FIRST TWO FEET OF PROFILE` EL. = 90.1 END VIEW
LENGTH 10'-6" WIDTH 5'=8" HEIGHT 5'-8" OUTLET PIPES LEVEL. °
SEPTIC ,TANK DISTRIBUTION BOX SOIL ABSORPTION SYSTEM
NQT TO SCALE NOT TO SCALE NOT TO SCALE
• TEST PI . . .• ,-
T . DATA:
SOIL EVALUATOR: Samuel 'Jensen: SE 1928 TOWN WITNESS: Do- nna Miorandi
CONSTRUCTION NOTES: DATE: March 17, 2014 PERC. RATE: <2 min./in., CLASS:_1 EXCAVATOR: J. LeBouf
1: ALL SEPTIC' SYSTEM' COMPONENTS- AND CONSTRUCTION METHODSSAAAUELJ'F' J'
TEST PIT ,1� -, TEST PIT 2 JENSEN
SHALL BE IN ACCORDANCE 'WITH' TITLE 5 OF THE STATE 0 103.8 0 102.6 o CAVIL
ENVIRONMENTAL' CODE, 310 C.M.R. 15.000, AND ALL APPLICABLE Sandy Loam 110YR•3/4 Sandy' Loam 10YR. 3/4 No. VIL :
LOCAL BOARD OF HEALTH RULES AND;REGULATIONS. A Massive; Very`'Friable A Massive; Very Friable e
2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 13" _ 102.7' 12 101.6'
BOARD OF HEALTH AND THE DESIGN `ENGINEER PRIOR TO Sandy Loam 17OYR 6/8 :.Sandy, Loam*10YR 6/8
INSTALLATION. B. 6
Ve . Friable;
3. THE: DISPOSAL SYSTEM .INSTALLER SHALL VERIFY ALL UTILITY ve;, Very 'Friable; Massive, Very
29" ' 101.4' 30" / 1001' € < •�. ,
Massa
'LOCATIONS PRIOR TO CONSTRUCTION THROUGH DIG-SAFE AT LEAST 'Med. 'Sand 2.5Y 7/4 Med. Sand 2.5Y 7 4 w`
72 HOURS PRIOR TO COMMENCING'WORK ON SITE AT C Loose; Single Grain C Loose; Single Grain
1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. 39 5 - 10% Gravel 5 10% Gravel
4. THE DISPOSAL SYSTEM INSTALLER SHALL NOTIFY-THE DESIGN PERC.
ENGINEER OF ANY DISCREPANCIES FOUND IN SITE CONDITIONS FROM 57�� No, Mottling Observed No Mottling Observed
THOSE.SHOWN .ON PLAN PRIOR TO CONTINUATION OF WORK. No. Standing Water No Standing Water
5. PIPING`SHALL CONSIST OF SOLID 4" SCHEDULE 40 PVC, PIPE WITH No Weeping, No Weeping
.'WATER-TIGHT JOINTS UNLESS OTHERWISE NOTED. 138" 92.3.' 150"
6. `'SLOPE ALL SOLID PIPE AT 1.0% MINIMUM UNLESS OTHERWISE 'NOTED.
7. ALL JOINTS WHERE PIPE ENTERS-AND EXITS CONCRETE STRUCTURES
SHALL BE MADE"WATERTIGHT WITH NON-SHRINK GROUT OR. AS
APPROVED BY THE DESIGN ENGINEER. DESIGN DATA:
-8. :ALL-STONE TO BE DOUBLE WASHED AND FREE OF ALL DIRT,, DUST NUMBER: OF -BEDROOMS: 2
AND FINES. DESIGN FLOW+ RATE: 110 GPD/BEDROOM PR
9. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL CALCULATED FLOW: 2 X 110 = 220 GPD OPOSED SEPTIC
AND UNSUITABLE MATERIAL IN AREA .BENEATH AND FOR 5 'FT. ON DESIGN FLOW: 330 GPD (CODE MIN.) UPGRADE
ALL SIDES OF LEACHING FACILITY. REPLACE'ALL UNSUITABLE MATERIAL
WITH CLEAN- :COARSE SAND FREE FROM CLAY, FINES- OR OTHER SEPTIC TANK NEW 1500-GALLON SEPTIC TANK Located at:
UNSUITABLE MATERIAL IN ACCORDANCE WITH .310 CMR 15.255(3)-. REQUIRED =;J200% OF DESIGN: FLOW; 2 X'330 ;660 GAL r�Pry 62'BUNNY RUN
10. ALL SEPTIC SYSTEM COMPONENTS SHALL'BE CONSTRUCTED TO , • PROVIDED: 1500-GAL -C ASS.
WITHSTAND H-10 LOADING UNLESS LOCATED UNDER PAVEMENT, -
DRIVES OR TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND SOIL ABSORPTION SYSTEM- TWO 500-GAL. CHAMBERS Prepared for:
H-20 LOADING UNLESS OTHERWISE NOTED.,_ WITH 4-FT OF STONE AROUND DAVID &MEGHAN'MCCORMACK
11. FINISHED GRADES SHALL NOT BE LESS-THAN NOTED BREAKOUT T $2 BUNNY RUN
ELEVATION FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE REQUIRED S.A.S. CAPACITY: 330 GPD CEN'62 BUNNY
MA 02632
SAS. UNLESS A 40 MIL GEOMEMBRANE LINER, IS PLACED AT LEAST I
FIVE FEET FROM S.A.S. AND THE TOP OF THE LINER IS NOT LESS SIDEWALL AREA = (LENGTH° + WIDTH) (2 SIDES) (EFF. HEIGHT) Prepared by:
THAN THE BREAKOUT ELEVATION IN ACCORDANCE WITH 310 CMR ! _ (25'+12°83')(2)(2') = 151.3 SF
15.255(2) AND LOCAL REQUIREMENTS: SAMUEL JENSEN, P.E.
�- 12. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION'. BOTTOM AREA (LENGTH) (WIDTH) _ (25')(12.83') 320.8 SF P.O. Box 1.141, Forestdale, MA02644
`"774-327-0727
PROVIDED S.A.S. CAPACITY = (BOTTOM + SIDEWALL) (L.T.A.R.) Scale:AS NOTED Date:APRIL 29;2014
_ (151.3 + 320.8) X 0.74 = 349 GPD
[SheetN
o. 2 of 2Rev. -