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HomeMy WebLinkAbout0185 INDIAN HILL ROAD - Health 185.llndian,!,Iill Road arstnble A31B8 - 03 i f P removed down to t12e (•2 ,'lctyer- ur1C[ 1-Cj✓lac:c rrl tll C:1G granular sand per 310 CMR 15.255 (3), (4), (5). Title 5 a.nd (6). rrface � 011 0355y A.M. 318 Z PAR. 38 gh 107. w 00 s88'14'20" 44 i 44. FENCE � FENCE a ¢!2 `REPLACE EXISTING TANK SEE GEN. l WITH 1500 GAL. 21.5 PINE. I f1ln O O NOTE #8 l PLASTIC'SEPTIC X \ 44.3' TANK 44 - x No W __ FENCE OT 31 A cri ;44. location 38 3 0 7.4 - A.M. 318 U csible for 1 ;; ' PAR. 39 o is BL"D i; AREA=1'2.533t S.F. M 72 slope. SILL EL=46.7 jz p 15 :.. ii (G.I.S. f} �� I J44. 27.5i ` '- Pvc i grades I .� CLEANOUr HOUSE ' pies, A.M. 318 PAR. 41_ I I DECK is #185 1.i 45.2' w : w 1 .. ., x _ 144. CEDAR :.' :ASPHALT.-"' .; 38 I ` TP I Iv 45.1 CA x •28.8 ! 2' Eff/Depth 4� �s>0- 46 200 sf 40 >ign Flow 86'35'1031W 59.00 42 WOODS o � - EDGE OF 46 q 437;.. r4 ROAD NOT CONSTRUCTED II Commonwealth of Massachusetts Y F Title 5 Official Ins ecti®n Form c' 3 p _ a Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments L 3 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ: ' 08807 G January 5,`2010 required for every 9 y 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. N Important:When filling out forms A. General Information - :•"" on the computer, O P � use only the tab 1. Inspector: O key to move your cursor-do not Troy Williams use the return —�--- - key. Name of Inspector ' Troy Williams Septic Inspections ICI Company Name 19 Hummel Drive` f' Company Address �•� South Dennis MA 02660 Cityrrown State Zip Code 508) 385-1300 S1682' y4 Telephone Number License Number. B. Certification 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 e sewage disposal systems. I am a DEP approved system:inspector pursuant to,,---Section 15 340 pf, Title 5 (310 CMR 15.000).The system: -� ® Passes ElConditionally Passes _' ❑ Fails ❑ Needs Further Evaluation by the Local Approving.Authority January 5, 2010 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 regionol office of the DEP.The original.should be sent to the system owner and copies sent to the-buyer, if alipplicable, 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 dtbs not address how the system will perform in the future under , the same or different conditioriis of use. 185 Indian Hill Road,Cummequld•03108 Tule 5 Official Inspection Form:Subsurface Sewage Disposer Sy§lam•Page 1 of 15 r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 'January 5, 2010 required for every 9 ry 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 Sectiom:D A) System Passes: ® I have-not found any information which indicates that any'of.the failure'criteria'described in 310 CMR 15.3,03 or in 310 CMR 15.304 exist.Any failure'criteria not evaivated:are indicated below. Comments: System meets minimum standards set by MassDEP,at the time of inspection only. This inspection is: not a guarantee or.warranty on the future working conditions of leaching,-pipesor components: B) System Conditionally Passes: El One or more system components as described in the"Conditional Pass". section need to be replaced or repaired. The system, upon completion of the replacement or'repair, as approved by the Board of Health,,will pass. Answer yes, no or not determined (Y, N,.ND)'in the El-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;exfiltrationor 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.Mructurally sound, not leaking and if a Certificate. of Compliance indicating that the tank is less than 20 years old is°available., ND Explain: N/A _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 r ❑ obstruction is removed 185 Indian Hill Road,Cummaquid•03r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System .Page 2 of 15 i i .r Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 'c 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 required for every g January 5,2010 page. City/Town State Zip Code Date of Inspection ' B. Certification (coat.) B) System Conditionally Passes (cont.) Q distribution'box is leveled or replaced ND Explain: N/Ati` 9 The system required pumping more than 4 times;a year due to broken or-obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health) ❑ broken pipe(s) are replaced obstruction is removed ND Explain: ` N/A C) Further Evaluation is Required by the Boardof 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 mannerwhich will protect•public health, safety and the environment; ElCesspool or privy is within 50 feet,of a surface water 4 y ❑ 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, safety and environment. ❑ The system has.a septic tank and+soil absorption'system;{SAS) and the SAS; within 100 feet of a surface water supply or tributary to a surface`water supply. ElThe system has a septic tank and SAS and the.SAS is within aIone ,of a`Public water supply. ❑ The system has a septic tank and SAS and the SAS is within.50'feet ota private water supply well. 185 Indian Hill Road,Cummaquid•03108 Title.5 Official Inspection Form:Subsurface-Sewage Disposal System Page_3of 15- 1' s. - . Commonwealth of Massachusetts = Title 5 Official ins ecti®n Form 'l Subsurface Sewage Disposal System Firm Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid- Property Address John Levitt Owner Owner's Name information is 46 Fuller Port;Bridgewater, NJ .>` 08807 -,January 5 2010 required for every 9 _ ry page. City/Town State Zip Code Date,of Inspection '- B. Certification (cont.) ; C) Further Evaluation is Required'by_the Board of Hea th.(cont) , ❑ The system has a septic tank and SAS and the SAS.is less than 100`feet but 50 feet or more from a private water supply well*" Method used to determine,distance.; *"This system passes if the well water analysis;,performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate,nitragerris"equal to or less than 5 ppm, provided that.no otherfailure criteria ate triggered. A;copyof the analysis mustbe attached to this form. 41 3. Other: N/A t xY 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 tlue"to an overloaded or clogged SAS or cesspool, Static liquid level in the distribution box above outlet invert due to an.overlo_aded Ela ® or clogged SAS or,cesspool 0 Liquid depth in cesspool is_aess than 6 below'invert or available volume is less than'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged,or ' obstructed pipe(s). Number.of times pumped: " ❑ - JE Any portion of the SAS, cesspool orprivy 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. 185 Indian Hill Road,Cummaquid•03108 Title 5.01ficial Inspection Form:Subsurface Sewage DisposalSyslem Page 4 of 15 Commonwealth of Massachusetts , Title 5 Official Inspection Form" Subsurface Sewage Disposal System Form -Not for Voluntary-Assessments. 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owners Name information is 46 Fuller Port, Brid ewater. NJ 08807 January 5, 201.0 required for every g ry page. Citylrown. State Zip.Code Date,ofInspection 71, B. Certification'(cont.) D) System Failure Criteria Applicable to All Systems (cont.): `~ Yes No ❑ ® Any portion of a cesspool or privy is within a..Zone 1 of a public well: ❑. Z' Any portion of a cesspool or privy is.within:50 feet of a private.water supply well. ❑ M '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,:ana.lysis ..and chain of custody must be attached to.this form] Q 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.. J questions in.Section D. Yes No ❑ M the sy.stem.is within 400 feet of'a surface drinking water supply ❑ ® the system is within 200 feet of a;tributarylto a4surface drinking water supply the Systerq is located in a nitrogen sensitive area (Interim Wellhead Protection ❑ Area IWPA) or a mapped Zone Il of a public.water supply well . If you have answered"yes"'.to anyquestion 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. s 185 Indian Hill Road,Cummaquid•03(08 . Title 5 Official Inspecii66 Form:Subsurface Sewage Disposal System•Page 5 of 15 x , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " w 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name Information is required for every 4§ Fuller Port, Bridgewater' NJ;' 08807 January 5",,2010. page. CityrFown State Zip Code Date of Inspection C. Checklist t Check if the following have been done You must indicate"yes'or"no as to.each of the following: . �u Yes No ® ❑ ` Pumping information was provided by the;"owner;occupant',,or Board ofiHealth ❑, ` ® Were any of the system components pumped out in the previous.two weeks? ' ❑ ® Has the system received normalflows in the previous two week period? Have large volumes of water been introduced to the system recently'4or as part of ❑ ® this inspection? t ® Were as built plans of the system obtained and examined? (,If they were not available note as N/A) ❑ Was the facility or dwellinginspected forslgns of sewage back up? � El Was the site inspected for signs of break,outs ® ❑ Were all system-components, excludin-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, de th ofslud9a and-de th of.scum?dimensions, de th of II uid ' Was the facility owner(and occupants if different from owner).provided with' information onthe 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 . ® -❑ 7 bete'ermined in the.field (if any of the failure criteria related to Part C is at issue. `approximation of distance is unacceptable),[3:10.CMR1:6302(5)] ♦ 185 Indian Hill Road,Cummaquid-03108 Title 5 Official Inspection Forma Subsurface Sewage Disposal-System•Page 6f of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Substirface Sewage Disposal System Form- Not for Voluntary Assessments-, r 185 Indian Hill Road, Cummaquid Property Address L.' John Levitt Owner Owner's Name-- ' information is Fuller or, Bridgewater required fofevery 46 Pt id 9 NJ` u,` 08807, ` January,5; 2010 page. CitylTown _¢ �" �, State Zip Code Date.of Inspection a �j 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 gpd Number of current residents 0 Does'residence have a garbage grinder? ❑ Yes, IM No Is laundry on a separate sewage system. [if yes separate inspectiori required] ❑ Yes _® No Laundry system inspected? .Yes ❑ No Seasonal use? {4ri r, , ❑ 'Yes No Water meter readin s, if available last 2 ears usage d 09=12,000gals g ( y 9- (gP 08=41:,000gals t Sump pump? N 41 ❑ Yes ® No Last date of occupancy x w} s, Occasional use . Date Commercialllndustrial Flow Conditions Type of.Establishment: N/A N/A Design flow(based on 310 CMR 15 203): Gauons perday'(gPd) Basis of design.flow seats/ e s rson /s . ft. etc N/A _ Grease trap present? ❑ Yes ®•.No >. Industrial waste holding tank present? ❑ Yes [A No ` Non-sanitary waste.discharged to the Title 5 system? ❑ Yes No Water meter readings, if available: N/A. Last date of occupancy/use: N/A Date Other(describe); N/A kr. 185 Indian Hill Road,Cummaquid•03/08 Title 5;`Official Inspection Form:Subsurface Sewage Disposal System Page 7`of Or 15 P , Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary'Assessments y 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 Janua J'5, 2010 required for every 9 - ry_ page. City/Town State: Zip Code Date of Inspection D. System Information (cont.) General.Information.- - e s Pumping Records: Source of information: No pumping info since new irr06. Was system pumped as part of the inspection? ❑: Yes ® No If yes, volume pumped:: N/A gallons How was quantity pumped determined? _N/A a Reason for pumping: — . - Type of System: ® Septic tank, distribution box; soil absorption system h ❑ Single cesspool ` [ IQ 3 f ❑ Overflow cesspool El 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 systern owner),and a copy of latest inspection of the I/A system bysystem operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other.(describe):; { Iq 41,s , Approximate age of all components, date installed (If known) and source of information. Tank,d-box& leaching were installed on 6/1/06 per compliance. Were sewage odors detected arriving at the site? 9 9 ❑ Yes ..� No gyp. 185 Indian Hill Road,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 8 of 15 , Commonwealth of Massachusetts ` W Tifle 5 Official Inspection corm a Subsurface Sewage Disposal System corm -Not forVoiuntary Assessments 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is P Ful ler Port, Bridgewater NJ 08807 x- required for every 46 F 9 k January 5,2010 ' page. Citylrown State Zip Code ;i Date of Inspection D. System Information (cont) Building Sewer'(locate on:site plan):, z . Y Depth below grade: feet Material of construction: t ❑ cast iron ® 40 PVC' ❑ other(explain) ', c Distance from private water supply well or suction line: N/A feet. Comments (on.condition ofjoints,venting, evidence of leakage, etc:): Lines were found clear at the time.of inspection.' Septic Tank(locate on site plan):` ' Depth below grade: -feet' Material of construction:' ❑ concrete ❑ metal ❑fiberglass polyethylene ❑other(explain) If tank is metal,-list age. N/A Years Is age confirmed by a Certificate of Compliance?,(attach a copy of certificate) ❑ :Yes ❑.. No ----------- ------ --- -— --- --- --- - -- r. -- ----- - -. Dimensions `6'X 10.5'X 6' 1500 gallon 4" Sludge depth: 2' 8" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Thin'Layer Gi,r, Distance from to of.scum to to of outlet V p p. tlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle" Y How were dimensions determined? Probe/.Measured 185 Indian Hill Road,Cummaquid•03/68' z= Title 5 Official Inslpection F06:`Subsudace Sewage Disposal System.Page 9 of 15 .. ,i, ' f Commonwealth of Massachusetts 77 Title 5 Official 8ns`pection;0=orm Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments �M 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port; Br d 'ewater NJ ' 08807' Januar 5, 2010` required for every _�_ Y page. Citylrown 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)' Pvc inlet and outlet tee's were present. No evidence of leakage or damage,was found:Tank was not in need of-pumping at this time. Grease.Trap (locate on site plan): N/A Depth below grade: , , feet Material of construction: [I concrete 0 metal Q fiberglass` [] polyethylene other(explain); N/A .. , X N/A Dimensions: Scum thickness N/A Distance from top.of scum to top of outlettee or baffle. r � f Distance from bottom.of scum to _bottom of outlettee or.baffle; N/A Date of last pumping: N/A Date Comments (on pumping recommendations., inlet and outlet teeor baffle condition, structural integrity,` liquid levels as related to outlet invert, evidence of leakage, etc) N/A Tight or Holding Tank (tank must be pumped,at time of inspection)'(locate;on site plan): Depth below grade: N/A Material of construction: ❑ concrete_ ;❑ metal berolass polyethylene other(explain) N/A y V. 185 Indian Hill Road,Cummaquid-.03/08 " r :i: Title 5 Ofrcial Inspection Form Subsurface$swage Disposal System r Page 10 of 15 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disorbsal System Form -Not for Voluntary Assessments y 165 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is required for every 46 Fuller Port, Bridgewater NJ 08801 January 5,`2010 page. Cityrrown 'State Zip Code Date of Inspection D. System Information (cont.):. Tight or.Holding Tank (cont.) Dimensions: N?A . t Capacity: N/A gallons N/A Design Flow: gauons per day Alarm present: ❑.Yes ❑ No Alarm level: N/A Alarm in working order °' ❑ -Yes El No Date of last pumping: NIA Date Comments (condition of alarm and float switches, etc.) N/A a . Fi, S. *Attach copy of current pumping contract(required). Is copy'attached� ❑ _Yes El No Distribution Box(if present must be opened)'(locate on site plan). : Depth of liquid level above outlet invert Level with 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 was found level and,in.working.order with equal distribution'to outlet lines. No evidence of solid carryover or backup in the past was found present at the time of.inspection:` Pump Chamber(locate on.site plan): Pumps in working order: ❑ Yes ❑ No . Alarms in working order'. d t 4 ❑ .Yes ❑ No 185 Indian Hill Road,Cummaquid r 03/08 Title 50fficial Inspection Form:Subsurface Sewage Disposal System Page 11 of 15 -t H ,s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 185 Indian Hill Road, Cummaguid Property Address John Levitt Owner Owner's Name i information is 46 Fuller Port, Bridgewater NJ ; 08807 January 5;2010 required for every 9 ry page. Citylrown State -..Zip Code Date of Inspection D. System Information (cont.)'' Comments(note condition. of pump chamber, condition'of pumps and appurtenances etc.): N/A Soil Absorption System (SAS) (locate on site plan excavation not required) If SAS not located, explain why. z:- N/A Type: .: ❑ leaching pits. number. ib 4 500 gallon ® leaching chambers number. w/3'stone ❑ leaching galleries number -T . . 40`X 10'`X 2' El leaching trenches number,nlength: Teaching fields number; dimensions. overflow cesspool number ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of,0.hdmg, damp soil, condition of vegetation, etc.): Soil was sandy.Chambers were dry on inspection. Checked stone and found:dry and.clean with no, evidence of hydraulic failure or.problems in the past found at the time of inspection. 1851ndian Hill Road u C 1 ma Wd•03I08 q Title 5 Offiaal Inspection form.Subsurfaiie Sewa a9.pis osal System•Page 12 of 15.- P Y 9 a Commonwealth of Massachusetts'' Title 5 Official Inspection' Fornn. 0 Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments. 185 Indian Hill Road,Cummaquid - Property Address John Levitt Owner Owner's Name information is 46 Fuller Port,.Brid Bridgewater NJ'° 08807 Janua ;5, 2010 required for every _ 9 _ ry page. City/Town State .r Zip Code Date of Inspection', D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site`plan)`., Number and configuration N/A. Depth —top of liquid to inlet invert N/A° , Depth of solids layer N/Ai Depth of scum layer N/A Dimensions of cesspool N/A: MateriA of construction z , Indication of groundwater.inflow ❑:Yes ® :No Comments (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, - etc.): ;a N/A k ` Privy (locate on site plan):. Materials of.construction: N/A N/A. Dimensions — N/A Depth of solids — Comments(note condition of soil, signs of hydraulic failure".level of poriding, condition of.vegetation, etc.): N/A . .•' N s 'z 185 Indian Hill Road,Cummaquid 03/08. Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection F.®rr,n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'r 185 Indian Hill Road, Cumma -d --- — Property Address John Levitt_ Owner Owner's Name — — - — information is required for every 46 fuller Port 'Bridgewater - NJ 08807 , January 5, 20��Q page. City/Town State . Zip Code Date of Inspection D. System.,Information (cont.) - Sketch Of Sewage Disposal System:Provide a.sketch of the sewage'disposal system icluding ties to at least two permanent reference landmarks or.benchmarks. Locate all;wells within "00 feet. Locate where public water supply enters the building. .. a% .. .. Y . _ Al `� _ �"� r' ( �3 ram'•^.� '>,.I 1' 185 Indian Hill Road,Cummaquid•03/08 I _ + 5�� , sw 0 7ille 5 Official hspeGion Fonn:Subsurface Sewage Disposal y-slam•Page 14 of 15 �a�f Commonwealth of Massachusetts Title 5 Official Inspection Form., Subsurface Sewage Disposal System Form -Not for.Voluntary Assessrttents 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owners Name . .: information is , required for every 46 Fuller Port, Bridgewater NJ - 08807. January'5, 2010 page. Cityrrown State Zip Code ;-Date of Inspection D. System Information (cont.) ;. Site Exam: ® Check Slope ❑ Surface water Check cellar El Shallow wells- 44 t Estimated depth to high ground water: 30'+ feet Please.indicate all.methods used to determine the high groundwater elevation. F ® Obtained from system design plans on.record `4. " If.checked, date of design plan reviewed: 1/19/06 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 texplain SDW 252 Zone A . 46.6' T adjustment You must describe how you established the high ground water elevation 4 Soil was sandy. Test hole 10' below bottom of:leaching with no water found at 16`5'. Groundwater adjustment in area at the time of inspection was. T: Bottom of leaching:at 6.5'.was found not.to be located in the high roundwater elevation at the time of ins e�ction.' 185 Indian Hill Road,Cummaquid-03/08 Title 5 OffiGal Inspection Form:subsurface Sewage'DisposaI System•page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection I`or�i ` 3 p LL Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments . 185 Indian Hill Road,Cummaquid Property Address John Levitt Owner Owner's Name information is required for every -46 Fuller Port, Bridgewater NJ 08807 January 5, 2009 pager Cityfrown `State Zip Code ". Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any Way. Important:When A. General Information filling out forms on the computer, use only the tab 9.' Inspector: key to move your cursor-do not Troy Williams use the return Name of Inspector y - . ke - Troy Williams Septic Inspections ICI Company Name 19.Hummel Drive Company Address South Dennis MA 02660 Cityrrown State .,:Zip Code (508) 385-1300 S1682 a Telephone Number . License Number s }, B. Certifications 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. Thee Insp stion was performed based on my training and experience in the proper function and maintenanceof on site. sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1"40 of title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ' ❑s Fails ❑ Needs Further Evaluation by the Local Approving Authority .. F January 5, 2009 Inspector's Sign Pure 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. 185 Indian Hill Road,CtAmaquid•03108, Title 5 Of.cial Inspection Fonn:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts = T Title e 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid Property Address _ John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 January 5,2009 required for every g ry page. Cityrrown 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: System meets minimum standards set by Mass DEP at the time of inspection only. This inspection is not a guarantee or warranty on the future working conditions of leaching pipes or components. 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: x, Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not " determined," please explain. •-, ❑ The septic tank is metal and over20 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: ND Explain: . N/A ❑ Observation of sewage backup orbreak out or high,static waterlevel 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 `r obstruction is removed 185 Indian Hill Road,Cummaquid•03/08 -a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Dorm o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 . January 5, 2009 required for every 9 ry page. Cityrrown State Zip Code Date of inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: N/A ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of:Health in order to determine if the system is failing to protect public health, safety or the environment.. , 1. System will pass unless Board of Health determines in accordance with 310 CMR ; 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ' ❑ Cesspool or privy is within 50 feet of a bordering vegetated we 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, 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 septictank 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: 185 Indian Hill Road,Cummaquid•03/08 Title 5.Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 . i , Commonwealth of Massachusetts r=' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 January 5, 2009 required for every 9 rY page. City1rown State Zip Code Date of Inspection B. Certification (cont.) k" C) Further Evaluation is Required'by the Board of Health(cont): - ❑ 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 vice►I". _ s Method used to determine distance: N/A " This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: N/A t' 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 or 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'nveri or available volume is less than Y day flow ❑ ® Required pumping more than 4 times in the last year NOT due.to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation: ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ; 185 Indian Hill Road,Cummaquid-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 a Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ^M '( 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 January5, 2009 required for eve 9 . 9 every Cit /Town page. Y State Zip Code Date of Inspection, B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Ari portion of a cesspool or privy is within a Zone 1 of a public well. YP p P Y ❑ ® 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: a ® 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 F ❑ ® 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 El ® 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. 185 Indian Hill Road,Cummaquid•63108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name - information is 46 Fuller Port, Bridgewater NJ 08807 January 5, 2009 required for every 9 ry page, Cityfrown 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? El MIHave large volumes of water been introduced to the system recently or as part of this inspection? ® ElWere 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? ® El 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)] { ..e- 185 Indian Hill Road,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 January 5, 2009 required for every g rY page. Citylrown State• Zip Code Date of Inspection. 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 exam le: 110 d x#of bedrooms yF 440 god ( P 9P ) Number of current residents: 0 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usa +e (god))-. 09=12,000gals 9 ( Y g., 08=41,000gals Sump pump? ❑ Yes ® No Last date of occupancy: Occasional use Date Commercial/Industrial Flow Conditions: 7r Type of Establishment: N/A Design flow(based on 310,CMR 15 203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.):' N/A 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: N/A N/A` ` Last date of occupancy/user . Date Other(describe): N/A 185 Indian Hill Road,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 official Inspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid a Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ' 08807 January 5, 2009 required for every g ry page. Citylrown State Zip Code " Date of Inspection D. System Information (cont.) General Information Pumping Records: P g Source of information: - No pumping info since new in 06. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity,pumped determined? N/At Reason for pumping: N/A Type of System: - 3 ® Septic tank, distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool ❑ Privy w El 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): K Approximate age of all components, date installed (if known) and source of information: Tank,d-box.& leaching were installed on 6/1/06 per compliance. Were sewage odors detected when arriving at the site?.. ; ❑ .Yes ® '-No 185 Indian Hill Road,Cummaquid•03/08 Title 5 OffiGal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 Z 'Janus 5, 2009 required for every 9 _ rY page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan):, Depth below grade: 18„+ > feet Material of construction: ~ ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line:: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection: Septic Tank(locate on site plan): 4 Depth below grade: feet y. 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 q. Dimensions: 6'X 10.5'X 6' 1500 gallon , Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle; 2, 8„ Scum thickness Thin Layer Distance from top of scum to top of outlet tee or baffle 6s c . .. Distance from bottom of scum to bottom of outlet tee or baffle - 14" How were dimensions determined? Probe'/Measured 185 Indian Hill Road,Cummaquid•03108 ' Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ' 08807 January 5, 2009 required for everyry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ,A Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and outlet tee's were present. No evidence of leakage ordamage-was found. Tank was not in need of pumping at this time. t Grease Trap(locate on site plan): Depth below grade: N/A Meet Material of construction: µ . El El metal ❑fiberglass Elpolyethylene ❑ other(explain): N/A -N/A Dimensions: OL Scum thickness _N/A' 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' NIA Date of last pumping: N/A Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A ,Tight or Holding Tank(tank must be pumped at time of.inspection) (locate on site plan): * Depth below grade:-; r j N/A Material of construction: ` concrete" , ❑ metal , . ❑fiberglass ❑ polyethylene Elother(explain): ` N/A 185 Indian Hill Road,Cummaquid.03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f _ 185 Indian Hill Road, Cummaquid Property Address John Levitt t Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 January required for every g 5, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t . Tight or Holding Tank(cont:) Dimensions: N/A Capacity: N/A . gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes' ❑ No ,r Alarm level: N/A _ Alarm in working order: El Yes ❑ No Date of last pumping: N/A Date .. Comments(condition of alarm and float switches,etc.): . N/A ' "Attach copy of current pumping contract(required): :Is copy attached?. { . ❑ Yes F ❑,No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with 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 was found level and in working order with equal distribution to outlet lines. No evidence of solid. carryover or backup in the past was found present at the time of inspection. f ` Pump Chamber(locate on site plan): Pumps in working order:' ' ❑ .Yes ❑ No Y Alarms in working order: ❑ Yes ❑ No 185 Indian Hill Road,Cummaquid•03I08 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid Property Address f John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 January 5, 2009 required for every 9 rY' page. City/Town State -.Zip Code Date of Inspection D. System Information (cont:) - Comments (note condition of pump chamber, condition of pumps.and appurtenances, etc.): N/A #, k Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A Type: ❑ leaching pits number:y ® leaching.chambers number: 4-500 gallon w/3'stone Elleaching galleries number: 40'X 10'X 2' El leaching trenches , a�,' : number, length: _ ti ❑ leaching fields number;;dimensions: ❑ overflow cesspool a number:" ❑ innovative/alternative system, Type/name of technology: y Comments (note condition of soil, signs of hydraulic failure, level of.ponding, damp soil, condition of vegetation, etc.)': a Soil was sandy. Chambers were dry on inspection. Checked stone and found dry and clean with no evidence:of:hydraulic failure or problems in the past found at the time of inspection:- 185 Indian Hill Road,Cummaquid•03/08 ,Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 P Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 185 Indian Hill Road, Cummaquid Property Address John Levitt f Owner Owner's Name information is 46 Fuller Port, Brid ewater NJ 08807. January 5, 2009 required for every 9 .. ry page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer r s N/A Depth of scum layer N/A" Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow O.Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): ' e Materials of construction; NIA b Dimensions N/A ` Depth of solids N/A Comments(note condition of soil,signs of hydraulic failure,glevel of ponding, condition of vegetation, etc.): N/A . .w A., _ y. 185 Indian Hill Road,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 185 Indian Hill Road,Cummaguid v Property Address John Levitt Owner Owner's Name ` information is 46 Fuller Port, Bridgewater NJ 08807 January 5 2009 required for every 9 rY page. Cityfrown State Zip Code Date of Inspection e D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Cj _CD 3 16 0 0 • you I ,2 J .� �.7 C_ 3 1 S Lt l ` 3i b WC,.1hi'p 17 185 Indian Hill Road,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal ystem-Page 14 of 15 �i� Commonwealth of Massachusetts Title 5 Official Inspection Forte 1 Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments 185 Indian Hill Road, Cummaquid Property Address John Levitt Owner Owner's Name information is 46 Fuller Port, Bridgewater NJ 08807 January 5 2009 required for every 9 _ ry page. Cityrrown State Zip Code Date of Inspection . D. System Information (cont.) Site Exam: ® Check.Slope ' ❑ Surface water t b F ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 30+ 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 1/19/06 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: SDW 252 Zone A 46.6' _:7'adjustment You must describe how you established the high ground water elevation: . Soil was sandy. Test hole 10' below bottom of leaching with no water found at 16.5'. Groundwater adjustment in area at the time of inspection was 7. Bottom of leaching at 6.5'was found not to be located.in the'high rog undwater elevation at the time of inspection.. 185 Indian Hill Road,Cummaquid 03/08 , Tide 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of 156 i 'own of Barnstable Pit -� Department of Regulatory Services Public Health Division Ddte 200 Main Street.Hyannis MA 02601 . Date Scheduled _ Time FeePd. ,soil Suitability Assessment for Sewage Dis sal Witnessed By: Performed By: LOCATION& GENERAL INFORMATION Location Addr t R 01� jy I l 2A Owner's e Address �S,-pV1Z Assessor's Map/Parcel: •3 1 ® Engineer's Name, NEW CONSTRU�iION REPAIR ! Telephone# Z _ , Surface Stones Land Use `— ' Vt'- lam' Slopes(4'0) Distances from: Open Water Bod y G ft Possible Wei Arca --ft Drinking Water Well t �U It -_ft Other fr Drainage Way. � .'� J ft Property Line sions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) SI{ETCI�:($tree[name,dimen 1 A— L j Depth to Bedrock Parent material(gedlOgic) W eeping from Pit Face Depth to Grouadwakdr: Standing Water in Holey bA A Estimated Seasonal:High Groundwater L1'iL \Y• Di DtTERARNATION FOR SEASONAL HIGH WATER TABLB Method Used: ._.`„21r1��.' _ in. Depth tv-SaG tnoRlcs:�..�....-�.�:..-r..-T-------f[ Depth Observed standing in obs.hole: -- - ^-- . Groundwater Adjustment r, Adj.�t�undwatet Level Depth to;weeping from side of obs.hole: Adj.faClo ..� Index Well# - Reading Date: Index Well leVC] .- PERCOLATION TEST vale. ' -- Observation TWO at 9" Hole# Time at Depth of Perc ^-- k ,time(9"-V) ------~— Start Pre-soak Time.(o? End Pre-soak Rate Min./Inch L2 Site Failed; Additional Testing Needed(Y/N) Site Suitability Assessment: Site Passed_ n Original: tion Hole Data To B Public Hot h Division Observa e Completed on Back--------- (�" n test is to be conducted within 100' of wetland,you must first notify the ***If percolaltb prior to beginning. Barnstable C41jiservation Division at least one (1)Week p DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil ther Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders. CnitenGravel) p L,5 -4,.1.`-V 1 o y 2 V 1%t-L t t—L q I'j� G V _ r4A k yr L o r` -i G 2 Yt-1 r saw 7.•7.� DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture SoiI Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ra el a DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Ora 1 'DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. =no Flood Insuranje Rate Map: �� Above 500 year flood boundary No— Yes AZ Within 500 year boundary No— Within 100 year flood boundary No____ Yes Depth of NatuislIV Occurring Pervious Material Does at least fo r feet of naturally occurring pervious material exist in all areas observed throughout the area proposed f�r 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 I nvironmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 310 CNM 15.017. Signature Q:IS.EFnC%PERCFbRM.DOC { Town of Barnstable P�oftra,,o Regulatory.Services ` Thomas F. Geiler, Director H XAm E Public Health Division 'y ,anss. Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax:'508-790-6304 Installer &Designer Certification Form Date: Sewage Permit# Z 0 01,-1k Assessor's MaplParcel '7 si er: Installer: O '� De gn STEPHEN I DON LE.AND ASSOCLATES Address: 42 CANTERBURY LANE Address: s3s 5081540-2534 on (p ��- IP ,� �� was issued a permit to install a (date) (installer) septic system at 8i-1 y V\kL, Jri, based on a design drawn by (address) u e. -'z � .® dated e,— -A ._o Cn eesipe I certify that the septic system referenced above Was installed substantially according to the design, which may include minor approved changes such as lateral`relocation of the distribution box and/or septic tank. - 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 & Focal Regulations. Plan revision or certified as-built by designer to-follow. . - ,' YrR ' CHRISTINc' Ova �G\S fAiR:l�tJY i PSTEPHEN a (Installer's Si a e d No 926 # s J.YL_ . DOt esigner's Si afore) (Affix Designer's Stamp Here PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE 'OF p COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer.Certification Form 3-26-04.doc. Christopher C®sta & Associates, Inc. (Land Sureveyors a C1,01 Eny"inee:'S a Environmental Consulta-nts � 465 East Falmouth Highway/ P.O. Box 128, East Falmouth, MA 02536 Phone: 508-548-6424 Fax:..508-548-0350 . e-mail.iean(cDcostaassociates.com Christopher Costa,P.L.S. N.Douglas Schneider,RE: February 14, 2006 Mr. Stephen P. Doyle Doyle Associates 42 Canterbury Lane East Falmouth, MA 02536 RE: Sieve Analysis of Samples Taken From 185 Indian Hill Road, Cummaquid, MA 02637 - Helen Thauer Dear.Mr. Doyle: _ A total of three random samples were collected into one:container from the above referenced property. The contents of the container were air-dried and the sieve analysis is as follows. t Sieve# % Passing % Allowed % Remained (+l-0.5%) Pass/Fail 4 27.3 45 62.7 PASS 50 100 -10-100 0 PASS 100 0 0-20 0 PASS 200 1 0 0-5 0 z. PASS The results indicate the soil is suitable under MGL 310 CMR 15.255 "Fill - Material"for a Title 5 Soil Absorption System. z F r . If you have any questions, please-feel free to contact me. Sincerely, Crlhnh stopher Costa, P.L.S., President Christopher Costa &Associates, Inc. DEP Certified'Soils Evaluator ®��, OF A�1qS CHRISTOPHER ®` a COSTA c ' NO.31306 � 1. pp commonwealth of Massachusetts Registered Land Surveyor Commonvoeahh of Massachusetts Registered Professional Engineer Commonwealth of Massachusetts GEP Certified Waste Water Technicians .+ - • ... ... .Commom6eahh of Massachusetts DEP SO Evaluators; - TOWN OF BARNSTABLE LOCATION 1 �° �. ,�✓ l�i`���2 t� SEWAGE#ats64 VILLAGE 3,oie ASSESSOR'S MAP&PARCEL3�S INSTALLERS NAME&PHONE NO.A lZG •�S> S® F 7 i �� SEPTIC TANK CAPACITY / S D O LEACHING FACILITY:(type)y SaC! e'op S e e2J(size) ele X /e x NO. OF BEDROOMS OWNER /3/ / Al A U x GZ _ PERMIT DATE: COMPLIANCE DATE: �O 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 70to z �� G No. o©clo FEE c/ -� COMMONWEALTH Of MASSACHUSETTS y Board of Health, ,4 RA. APPLICATION ® DISP S ]C SYSTEMCONSTRUCTION PEMIT Application for a Permit to Construct( Repair( Upgrade( Abandon( - ❑Complete System ❑Individual Components Location 18 Owner's Name Map/Parcel# Address Lot# -3All — Telephone# Installer's Name .9- Designer's Nam PHE\J.DOI I E ANT) Address `� Address EAST FALMOUTH;MASS Telephone# >7 Telephone# Type of Building Lot Size '1'Z4 sq.ft. Ce:ll,iliiType of Bedrooms g4 Garbage grinder ( ) of Building No.of persons Showers ( ),Cafeteria( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow d _ Design flow provided gpd Plan: Date A—A ✓ O Z Number of sheets Revision ate Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator S tM Date of Evaluation SL DESCRIPTION OF REPAIRS ORALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree not to Wace the�mm tion tii a Q_ej&j4jQe of Compliai a has been issued by the Board of Health. Signe Date `� l 9 Inspections a No. ,;.. FEE t a . = OMMONW LALTH OF M SS CHUSETTS } �J Board of Health, -•'[ J4+�-L�1 y'3t�,�MA. ' APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair( Upgrade( Abandon( - ❑Complete System ❑Individual Components Location ,g Owner's Name Map/Parcel# Address Lot# -3%,Qt — Telephone# E J.DOYLE.AND ASSOCLATES Installer's Name Designer's Name Address W; �6� Address EAST FALMOUTH;MASSACHUSETTS o253 Telephone# Telephone# ... 7af1 73e o y s^,yr Type of Building Lot Size VZ 5 "3 sq.ft. Dwelling- of Bedrooms 1�.. Garbage grinder ( ) t er-Type of Building No.of persons Showers Cafeteria Other Fixtures 1 Design Flow(min.required) 4*D gpd Calculated design flow. d*p Design flow provided 4 -AA gpd Plan: Date D to Number of sheets t Revision ate 9 Title �, Description of Soil(s) 5.r r-j-g Snit►_. Soil Evaluator Form No. Name of Soil Evaluator_S , '� Date of Evaluation i� DESCRIPTION OF REPAIRS OR ALTERATIONS 9 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agreesltb not to Place the system in opepation until a Certi irate of C mpli ce has been issued by the Board of Health. Signed, Dates v L/ Inspections �)60-No. (� �j D v COMMONW LT 4 OF MASSACHUSETTS FEE _ / Board of Health, �J fit- c-r1`� `fJ 1 , MA. CERTIFICATE OF COMPLIANCE ,R Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereb certify that the Sewage Disposal System; Constructed ( ),Repaired (NA,Upgraded ( ),Abandoned ( ) at has been installed in accordance with the provision of 310 CMR 15.00 (Title 5) an a proved design plans/as-built plans relatingkto application No..`_��rl F' -�t� 5, dated �.� I I Approved Design Flow (gpd) Installer Designer: F 1 Inspector: Dater The issuance of this permit shaIllot be construed as a guarantee that the system will function as designed. No. —I LI S FEE COMMONWEALTH OF MASSACIIUSETTS Board of Health,&C -e MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to;:Construct( ) Repair(V/ -Upgrade( ) Abandon( ) an individual sewage disposal system at � 1•-i is l ��,1 as described in the application for Disposal System Construction Permit No. C,�C-/t'15, dated ')4 4 Provided: Construction shall be completed within ree years oft a date o 'this p'ermjt. All local conditions must be met. Form 1255 Rev.5l96 A.M.Sulkin Co.Boston,MA Date `7 'b Board of Health ��� FF AL 48.E S 4 VV-,a leS�Vs t �e T2-2 -1 �e Vi le Vv- -M T. ,S, P"inish Grade El 43't F&Lvh Grade A7 425t 1/8" to 1/2" )lashed stone O 3" "dalrAZ BVMV AS gAR1y5sA6i� HARa� �.' n�rrrrr _s» rr /l1 Il ! ll Iil 1lil !l Illl ll pp��,y�UBM 6» Illlllllllll r Arra. 1hnish Grade Z 4a" A&Z RUM Grade A2 420't 42.T 24 Die. 24 Die. I 6" / � ® t . 8.5' R o�F EL 39.00, o y` 11'Below F7os Zane 14"Beloir Flom Zane lGa 6�- d. . ' Z t' INV EL Grp V EL INV EL °• a m _ ___ _ - EI 36.17 51" 1xv Ez Bw Az 3B.1 38.17 s 4" - 1 1 Wished stone o ¢ 41.23' 38.82 ;B:stone. :; / /2' 4149 Liquia �� 40" 3 � 3' Ro � DISTRIBUTION BOX 40' 177" PROPOSED LEACH TRENCH o v PROPOSED 1500 GALLON PLASTIC SEPTIC TANK PRECAST REINFORCED CONCRETE DISTRIBUTION BOX LOCUS R0U(E 6A SEPTEC ST-1500 Install on a level base Bottom of Dee Observation Hole EL 25.8' Minimum wall thickness = 2" P .L,C4 C:' T T.IE3' M.".1' Minimum inside dimension = 12" Tank minimum wall thickness is 114" Outlet inverts shall be equal to each other and at Adj. High Ground Water (Fetland) <E'1. 15' The inlet pipe elevation shall be no less than 2" nor more than 3" 2" minimum below inlet invert. above the invert elevation of the outlet pipe. The distribution lines from the distribution box shall all have Septic tank shall .have a minimum cover of 12': equal inverts as determined by flooding the distribution box to P the height of the distribution line invert after all lines have �-=- 10' -►� Two 24" manholes with readily removable impermeable covers been sealed in place. of durable material shall be provided with access ports Invert adjustments shall be made by filling with durable and 34" •'d� _ m 24" The outlet tee shall be equipped with gas baffle. nondeformable material permanently fastened to the line or 25' 25' reconstructing the lines until all inverts are of equal elevation. --01 58" [-•--- Number of p enches - 1 Note.• Number of Chambers - 4 All unsuitable material 5' around SAS shall be PROPOSED LEACH TRENCH -- END VIEW N.T.S. removed down to the T layer and replace with clean GENERAL CONSTRUCTION NOTES granular sand per 310 CMR 15.255 (3), (4), (5). witt h Ih .11 Four 500 Gallon Units 1. All the workmanship and materials shall conform to R E.P Title 5 and (6). 2 6' Feet of Stone at Sides and the Town of Barnstable rules and regulations for the subsurface A.M. 318 and 3.O' of stone at Ends disposal of sewage. PAR. 38 2. At least one access port over tank tees shall be accessible Zoning District: RF within 6" of finish grade, with any remaining access ports brought "W 107.00 Overlay.- AP to within 6" of finish grade. SE8'14 20 _ 44 44.00' 3. All components of the sanitary system shall be capable of FENCE FENCE -� I FjM Data: zone "c" withstanding H-10 loading unless they are under or within 10 ft 4 REPLACE ExISTtNG TANK of drives or parking. H-20 loading shall be used under or within SEE GEN. f VTR 1500 GAL. 21.5 PINE Paneffm Rev. 25f/Oe, 992 Il P g g NOTE �s + PLASTIC SEPTIC 44.3' t Panel Rev. July 2, 1992 10 ft of drives or parking unless noted. Plastic equals may be a 0 TANK (n 44 x o Reference Deed.- 4504-80 used in lieu of all recast units (A _ ;FENCE OT 31 A ' ► � Reference Plan: 134-55 w 4 44.30 4. The exca va tor�ontractor shall call dig safe and verify the location 38 0 7.4.77 - A.M. 318 0 ' z 3 O .����. , ������ 1 Assessors Ma 318 Parcel 39 of all site utilitiesall matters relating to electricrior to yeasements ' and shall be responsible for BLHD �/ AREAA 2,33f S.F. r*i Ic Locus Street Address- 5. Sewer pipes shall be 4" Schedule 40 PVC laid at a min. 0.02 slope. SILLJE: , 185 Indian lull Road, cummaquid 6. An masonry units used to bring covers to grade shall be EL=46.7 z (- Y Y g ° 15 ;; (G.I.S. ±) J }44.�o' r- mortared in place. ° 7. Finish grade shall have a minimum slope of 0.02 ft per foot. 1 `.,41� 8. Pump and abandon old septic system. 27.5 0 ,, o � � GRAPHIC SCALE 4" PVC9. The excavator/contractor shall be responsible to check all grades CLEAN UT I D 20 0 10 20 40 and elevations and to contact Doyle Associates of any discepancies, A.M. 318 HOUSE PAR. 41 + „ #185 , w w '" prior to construction. , DECK 45.2 , 10. Contact Do le Associates 24 hours prior to system inspection. I - f - x _ ' 44.90 IN FEET Cob 3.8:/ ­,i -OH W - 1 inch 20 ft 39 Soil Lags P# 11202 38 1 7, CEDAR . .. .......:ASPHALT.*.'.' -.•:. .•.. ..� DRIVE : :: .► Test Date: January 19, 2006 i ;; ,,,;; :::_:::::':., SEPTIC REPAIR AND UPGRADE' PLA / 40 , 1, ..... ..... _�__ 4S PREPARED FOR Siol Evaluator.• Stephen Doyle ° 21 ;� -j �_y -- I 2p N 45.1 185 INDIAN HILL ROAD Health Dept. - Barnstable w Design Data: ' x 28.8 In Pere Rate. <2 Min/Inch Number of Bedrooms Four No Garbage Disposal Allowed Barnstable, Massa eh use t is ' 42 3' 0" Use. Chamber Trench 401 x 10'W x 2' Eff/Depth 4 4 46 �S�D' Scale. 1" = 20' Date.- April 4, 2006 "A» SL IOyr 312 4„ [40' + 40' + 10' + 107 x 2.0 = 200 sf 1 � "B" LS IOyr 514 40' x 10' = 400 sf 40 oo .Prepared By. " 600 x 0. 74 = 444 GPD Total Design Flow Stephen J Doyle And Associates LS WITH 38 86.35210"W 59.00 M. 42 Canterbury Lane, E. Falmouth, A1A 02536 VERIG LS IOyr 516 42 EDGE OF WOODS Telephone.• 5081540-2534 o�' �s o r� o c 1 LAYER5 Glep 5-58 46 � Z31 F GLEY 132 pert 132" y " ' P�•(H OFM,�, A1ED. 2.5Y 614 SAND OT CONSTRUCTED �� Cq FES��Q y0 2 ROAD N :. ND :UR <n CFIRISTINE � FAIRN» El. 25.8' l96 v� �o , -.55 926�a H No Ground Water Encountered CI'T 06-02-06 MOVE SAS, ADD PROPOSED 1500 GAL. TANK, ONE DEEP TEST HOLE WAS PERFORMED ADD PVC CLEANOUT DUE TO LOT CONSTRAINTS. L--10-06 DATE DESCRIPTION