HomeMy WebLinkAbout0055 ALLAN ROAD - Health 55 ALLAN ROAD
CENTERVILLE
A= 194 -001 -004
5 M EAD®
KEEPING YOU ORGANIZED
No. 12534
2-15MR
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Commonwealth of Massachusetts copy
�MINITitle dal I e t'o Foy
F_al iJ
' f1
=:;: P.. J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r-0
^
55 Allan Road
Property Address h.b
Jean CamerlengoOwner
Owner's Name =
information is T'ti
�°' 4le CQiYI -�/I((� _ MA 02668 September5, 2018 _
required for every _ _
page. City/Town-__ -_— --- — _ State Zip Code _—Date of Inspection_ -
Inspection results must be submitted on this form. inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
important:When A. Inspector Information - --------- �� �ag y-- ------- ---
filling out forms
on the computer:
use only the tab Patrick T. Sullivan
key to move your Name of Inspector
cursor-do not Ready Rooter Excvating
use the return --------------------
Company Name
key.
PO Box 89
Company Address
Forestdale MA 02.644
City/Town State Zip Code
�k 508-509-0802 S112843
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above, the information reported below is true, accurate and complete as of the time of my
inspection, and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
'that the system:
1. N Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
September 6 2018
Inspectors Signature Date
The system inspector shall submit a copy of this inspection report.to the Approving Authority (Board
of Health or DEP) vvithin 30 days of completing this inspection. If the systern has a design flow of
10,000 gpd or greater, the in.spec':or and the system owner snail subi-nit the report to the appropriate
regional office of the DEP The original form should be sent to the system owner and copies sent to
the buyer: if applicable and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that titre. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
_;,,.ci�c•r=v.r!?iiL018 "ri6e S Jffin*d InsPat,lon Ferm:S Ubsur:"ac-Sewage Disposal Sys:em.Page 1 0`as
DJQQ''"" __IL.?�(_
cl
Commonwealth of Massachusetts
Title 5 OfficialInspection For
ff,.:I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlenao
Owner Owner's Name --- —
information is West Barnstable MA 02668 Se tember 5, 2018
required for every -- — p —.--- -----
page. Cityl—lown State Zip Code Date of Inspection
C. Inspection Suni airy --- - —
Inspection Summary: Complete 1; 2, 3, or 5 and all of 4 and G.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated 'below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box. for"yes", "no" o-"not determined" (Y, N;AND) for the following statements. If not
determined," please explain.
The septic tank is metal and over 20 years old*err 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 witl�a complying septic tank. as approved by the Board of
Health. fJ
' A metal septic tank will pass inspection if it is structurally sound. not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑. N ❑�JID (Explain below):
i
i"
t5inso.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 OffidalInspect'on Form
-� >
-i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlengo _
Owner Owner's Name
information is West Barnstable MA _ 02568 September 5, 2018
required for every _-- ---- ---------_._-..--------____--
page. City/Town State Zip Code Date of Inspection
C. inspection Summary (cont.') -- —
2) System Conditionally Passes (coat-):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or beak 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 Boardof Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
obstruction is remq#ed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box/is/leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
r
❑ 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):
I
❑ broken pipe(s) are replaced j Y ❑ N ❑ ND (Explain below):
I.
❑ obstruction is removed %r. ❑ Y ❑ N ❑ ND (Explain below).
i
3) Further Evaluation is Requii"ed by the Board of Health:
I
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing toJprotect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(r)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
i5insp.doc e•v.712612019 ?i;l=S Official ln�e=dor:Form.Subsur:'ac:e Savage Dispo=_a!Sys!e;n•Page 3 of IS
Commonwealth of Massachusetts
Tide 5 Official Inspection Form
T ,.JI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlengo_
Owner Owner's Name
information is b m West Barnstable MA 02668 September 5, 2018
requiredfor every -------------..-------------...----_- ------- -------------- --.� _._ __....------------------
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) -- ------
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. 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 Sur ace water supply.
❑ The system has a septic flank and SAS and the%SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well`*. `
Method used to determine distance:
`* This system passes if the well water analysis, performed at a D�-P certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form. /
c. Other:
/ I
——----------- -------- ------------------- ---------------- -- - ... - ----- ---- - --
i
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No"to each of the following for all inspections:
Yes No
E] E-1 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev. 126/2018 Title 5 Official InsF;ection Porn:Subsurface Sewage Disposal System•Page 4 of 1.8
A Commonwealth of Massachusetts
`i4 Ai
r_d=xis'\
Title Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Allan Road
Property Address - ---------------------------
Jean Camerlengo
---------------- -----
Owner - -- -----------_- _...---------- -----------------------
Owner's Name
information is required for every West Barnstable MA 02668 Sep tember 5=2018
=--------- — - --- ---- -- ------------------- - --------- ----------
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
-------- --- --
4) System Failure Criteria Applicable to All Systems: (cost.)
Yes No
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
❑ z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times purnped:
❑ 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.
El Z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Z 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 coiiform 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 2000 gpd-
10,000 gpd.
❑ ® The system fair. 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.
5) 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"yet>or°no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is with) 400 feet of a surface drinking water supply
is ithin 2 0 feet of a tributary to a surface drinking water supply
❑ ❑ the system0 y g pp y
the system i`. located in a nitrogen sensitive area (Interim Wellhead Protection
❑ ❑ Area — IVU�A) or a mapped Zone II of a public water supply well
t5insp.dec•rev.7126,12018 / Nle 5 O'i dal Inspection'rorm:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title ci Inspection Foy
c.6j i.<< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v'y __ !a,
55 Allan Road
Property Address
Jean Camerlengo
Owner ------- ---------------- -
Owner's Name
information is West Barnstable MA 02668 Se tember 5, 2018
required for every ----- -- - -- -- ------ --- -- --- ----- - ---P-- -------- -----
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) ------ --- --- -
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate `'yes" or "no" for each of the follouving for all inspections:
Yes No
M ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ❑ Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) (310 CMR 15.302(5))
I5insp.doc-rev.7/26120 1 8 Tile 5 O ficuai inspedien Form Subsurfaces Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Tide 5 0'ffficial Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L 55 Allan Road
Property Address
Jean Camerler:go
Owner Owner s Name
information is West Barnstable MA 02668 September tember 2018
requiredfor every --------- -------------- ____-------------- -------- _-_-- --------- ---p-------`'------------- ---
page City/Town _ State Zip Code - _Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3------- Number of bedrooms (actual): 3---------
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 394 GPD
Description:
533 sq ft = 394 GPD w/ .74
1
Number of current residents:
Does residence have a garbage grinder? ❑ Yes E1 No
Does residence have a water treatment unit? ❑ Yes Pj No
If yes, discharges to; ---- ---- - --- - ------------- -----
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Z No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
2016= 109 GPD
Water meter readings, if available (last 2 years usage (gpd)): 2017= 41 GPD
Detail:
Sump pump?------------- — Z Yes ❑ No
Current
Last _
Last date of occupancy: Date
Sin o.doc-re,,.7/:26/2018 Title Of cia!Lispecth,,n.Form:S:bsuriace Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,n Title 5 Official Inspection Foy
f � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlengo
- ------- --------------------------------- -----------------------
Owner Owner's Name
information is West Barnstable MA 02668 Se tember 5, 2018
required for every --- -- -------------- ---- ---- -- -- -----._.. �- - — ------------ -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industriai Flow Conditions:
Type of Establishment: ---- --------- ------ -------
Design flow (based on 310 C M R 15.203). - -- ------------ ------- -- ----------------
/ Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft.,/tc.): ------- ------ ---- -- --- ----
i
Grease trap present? f ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:/ -- ----- ------ _ ---- -----— -- —
Industrial waste holding tank pyesent? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if availab!e: -------- ---------------- -
Last date of occupancy/use: Date
Other (describe below):
3. Pumping Records:
Source of information: Owners records: Pumped 2+- years ago_
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: _._- ---- -- ---- ----------- -----..._ -
gallons
How was quantity pumped determined? ----- — -- ------- - -- -
Reason for pumping: ---- --- -- — ---- —
e5osp.doc•rev.71:16/2018 -;!!e 5 official inspecron Fora:sucsu aace sewag Disposal system•Pace 8 of 16
Commonwealth of Massachusetts
Title gp—
Subsurface i Sewage Disposal System Form - Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlenqo
OwnerOwner's Name .-- ----- -----------...---------- ------- ---------------------------------------------
information is
required for every West Barnstable MA 02668 September 5, 2018
---- ----._. - ------- -------- -- --- - - ------ --- -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) — -- —
4. Type of System:
F� Septic tank, distribution box; soil absorption? system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by systen) operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
Approximate age of all components, date installed (if known) and source of information:
System installed G7/29/1994_ Certificate of Compliance on file at Health Dept
Were sewage odors detected when arriving at the site? ❑ Yes No
5. Building Sewer (locate on site plan):
Depth below grade: .8
feet
Material of construction:
❑ cast iron FA 40 PVC ❑ other(explain): - -- --- -- ------------- -
Distance from private water supply well or suction line: fit--- -------------- -----
Comments (on condition of joints, venting, evidence of leakage, etc.):
-------- -- - --.. -- ---- -- -- - -- -------------— - -------- -- —..- ---- -
t5tnsp.doc•rev.7i26/2018 rille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 or 18
Commonwealth of Massachusetts
TRIe 5 OfficialInspection Foy
a ,
-t Subsurface Sewage Disposal Systems Form Not for Voluntary Assessments
_ is
55 Allan Road _
Property Address
Jean Camerlenga _
Owner Owner's Name -------- ----------------...----._.....__------ -----
information is ~Nest Barnstable MA 02668 September 5, 2018
required for every ---- ------ -------------------- ----- ------ - ----_p--- -------------------...----
page. Cityi-rown State .Zip Code Date of Inspection
D. System Information (cont.) —
6. Septic Tank (locate on site plan):
Depth below grade: . ----------- ------
feet
Material of construction:
0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: - -- ---------_-----------__ .---
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.5' x 4.5' x 5' 1000 gallons
5"
Sludge depth: ------------ — -- -- ---
Distance from top of sludge to bottom of outlet tee or baffle 29 ----- ---------
Scum thickness 7" at inlet, 4" at outlet
Distance from top of scum to top of outlet tee or baffle -------
Distance from bottom of scum to bottom of outlet tee or baffle -- --
How were dimensions determined? Dip tube and tape measure
Comments (on pumping rec ornmendations, inlet and Outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet PVC tee and outlet concrete baffle in place. Inlet has slight back-pitch. Flow should be checked
during maintenance pumping. Liquid level at outlet invert. Recommend maintenance pumping within
3 months. Electrical line for post light runs over Outlet cover. Outlet cover in partly under brick
walkway.
t5insp.doc-rev.7/262018 TWe 5 Official Inspection i--orm:SubSU face Sewage uispcsai System•?age 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fore
, n 'i Subsurface Sewage Disposal! System Form - Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlengo
Owner Owner's Name
information is West Barnstable MA 02668 September 5, 2018
required for every ------------_.._____..__._..-----.._..----- ------- ----------------
page. City/Town State Zip Code Date of Inspection
D. System Information (cons.) - — -
7. Grease Trap (locate on site plan):
Depth below grade: --fee--- .__.._.--------------------- --
i
t
Material of construction: /
concrete ❑ metal 0/fiberglass ❑ polyethylene ❑ other (explain):
i
�I
Dimensions: ---- ------ --------------
Scum thickness %
--------- - --- - ----- ----
Distance from top of scum to top of outlet tee or baffle -- ------------------
Distance from bottom of scurin to bottom of outlet tee or baffle - -------- ----- ------
Date of last pumping:
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.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: -------...---- ------------- -
Material of construction:
i
concrete ❑ metal �� ❑ fiberglass ❑ polyethylene ❑ other(explain):
i
Dimensions:
i�
Capacity: / galions -
Design Flow. --------
gallons per day
i5insp.doc•rev.71:2612018 Title 5 Officiai Inspertion Fenn,Subsurface Sewage Disposal Sysstein-Page 11 of 18
Commonwealth of Massachusetts
_ Title 5 OfficialInspection Fore
,- iIi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Allan Road
Property Address
JeanOwner Camerlengo
---- --------------------
Owner's Name ----------.-__.
information is
required for every West Barnstable— _-- MA _02668 September 5, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
8. Tight or Holding Tank (coat.)
Alarm present: ❑ Yes ❑ No
i
Alarm level: ----------- �-- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: / ----------- ---- -- - -
Date
Comments (condition of alarm and flc}at switches, etc.):
*;Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
011 Depth of liquid level above outlet invert -- - - ----- --
Comments (note if box is level and distribution, to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
One inlet, four outlets. Level. No speed levelers. No high water staining over outlet inverts. Light
solids carryover. Riser brings cover within 6" of grade
i5insp.doc•ray 712W015 Title 5 Offidal Inspection Form.Suosunace Sewage Disposal System•Page 12 of 18 .
i
Commonwealth of Massachusetts
Title 5 Official Inspection Fore
>.
„J Subsurface Sewage disposal SystemForm - Not for Voluntary Assessments
-�t::'
55 Allan Road
Property Address
Jean Cameriengo
Owner — - --------- ------- ---------------
Owner's Name
information is West Barnstable MA 02668 Se teber 5 2018
required for every --=---------------..----_____------------ --------- -....-------- -— m
p---- -'--------------
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt) ---
10, Pump Chamber (locate on site plan):
Pumps in working order: �! ❑ Yes ❑ No*
Alarms in working order: /` ❑ Yes ❑ No"
Comments (note condition of pump cha Aber, condition of pumps and appurtenances, etc.):
1
* If pumps or alarms are not in working order, system is a conditional pass.
11. $oi€ Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
----------------
Type.
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 4 flow diffusors
w/4' stone
❑ leaching trenches number, length: - --------------
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/narne of technology: ------__—_--
t5insp.doc•rev 712E:12018 Title 5 Official Inspection Form.Subsura Sewage Disposal System•Page 13 of 18
X Commonwealth of Massachues
Title 5 OfficialInspection Form
t_,
��i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlengo__�
— --- -------------------------------
Owner Owner's Name ----------------------------- - -
information is
required for every West Barnstable MA 02668 September 5, 2018 _
page. City/Town State Zip Code Date of Inspection
Do System Information (cont.) —
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Diffusors located and inspected with camera. No standing liquid in unit at time of inspection. No sign
of past hydraulic failure. Diffusors are partly under driveway Rated_H-20. No vent found.
—
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
i
Number and configuration j' ----- -- - ----
Depth -top of liquid to inlet invert --
Depth of solids layer --- -------
i
Depth of scum layer ; ------------ ------------
Dimensions of cesspool f
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of/ oil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
f5insp.doc-rev 7/26/2018 Tifle 5 Official inspection Form:Subsurface Sewage Disposal System•Pape IA of 1&
Commonwealth of Massachusetts
Title 5 Official Inspection Form
! I'.4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
(` 55 Allan Road
-.� - ------------ ------ - ------ -- --_ ------------------ ---------- ---------------
Property Address
Jean Camerlengo
Owner Owner's Name -- -----__-- --------_---..------ ----------- - -------- ---..
inform
equine fo is West Barnstable _ _ MA_ 02668_ September 5, 20.1_8_
required for e��e,y —__ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) --------------- ---
13. Privy (locate on site plan):
Materials of construction: - - --- --� ------ -------— - ----- --__.__--
i'
Dimensions -----------
Depth of solids -; - --- -------- --------- ----------
Comments (note condition of soil, signs of hey raulic failure; level of ponding, condition of vegetation:
etc.) i
i
i
t5insp doc rev.7i26l2018 Title 5 Offirial Insp2cilon i7orm.S:bsurfisce Sewage Disposal System•Page 15 of 18
f
.�, Commonwealth of Massachusetts
1 - p Title 5 Official Inspection Form
'1 t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlengo
Owner Owner's Name
information is West Barnstable MA 02668 September 5 2018
required for every _ P !
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
_ A
� I 1
-t
10 _
' t
! � 1
fJ
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
-� Title licl l Inspection For
1
.�� r) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlengo _ ____
— - ---- -- --------- — --------- -------------------
Owner Owner's Name
information is West Barnstable MA 02668 Se tember 5, 2018 _
required for every --- ------- ----- ----- ---- -- ----- ---p ---
page. City/Town —__ State _ Zip Code-- Date of Inspection
D. System Information (cont.)
15. Site Exam:
M Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
>5
Estimated depth to high ground water: 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. 08/1 r/1984
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:
maps.massgis state.ma.us/oiiver_php------- ----- --- ---------------_--------
You must describe how you established the high ground water elevation:
Test hole in 1984 to 132" (elv= 57) found adj. ground water at elv= 59.4. Base of SAS at elv= 66.
Accessed local ground water contours and topo mapping. Slope at rear of property drops below base
of SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc•rev.7/26/2018 Ti!1�5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
1 - -r Title 5 Official Inspection Fors
F is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Allan Road
Property Address
Jean Camerlengo
Owner Owners Name
information is West Barnstable -MA—.-------- 02668 September 5, 2018--------------- --- ----------------
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist --- —
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
.5insp.doc•rev.7/2G2018 Tile 5 Oflklal if Subsurface Sewage Disposaj Sysk;m•Page 18 of 18
h
tel.(508)362-4541
939 main street rt 6a fax(508)362-9880
yarmouth port
mass 02675 down cope eftgiaee.in f
civil engineers& land surveyors
structural design
Arne H.Ojala P.E.,P.L.S.
Timothy H.Covell,P.L.S.
land court
surveys
site planning September 29, 1994
sewage system
designs
Mr. Jerry Dunning
Barnstable Board of Health
inspections P. O. BOX 534
Hyannis, MA 02601
permits Re: Lot 4, Allan Road, West Barnstable
Dear Mr. Dunning:
This is to certify that the sewage disposal system located at Lot 4,
Allan Road was installed in accordance with the plans which were
previously approved and submitted to the Town of Barnstable Board of
Health. The system'conforms to the Town of Barnstable Board of
Health Regulations and to the Title V State Sanitary code.
If I may be of any further assistance, please contact me at your
earliest possible convenience.
Very truly yours,
Arne H. Ojala, P.E.,P.L.S.
.. _ i-r-i J �. A -n5 .OTd Y xt 'k } r3rit..,,(XyT+y„k✓,,�f`f''3�` ' '.s, F.K �- .i r
,;y���"ae
09/28/1994 ..11:08 `'�� ' 5087713113 �_ F g�� PRESTIGE PROPERT S ?PAGE 01 '
Ng
,,. EP-2Et�,44 WED 08 57 DOWN CAPE ENG I NEER I NG � fS08 '3fiS�2 µ9960 s"��' P 01
Y. .-r., ' , .�Y: t �'�r
v`` F i Ij t Mf S -h 7
�` `` ' �' � . lei.(1549)36x•4�t
939 main street rt tea
yarmouth port ;
mass o2s�5 down oft �n �ait
eer�n
civil engineers& land surVOY041
MM H,01414 Rgg PX,8.
ftrueturrl dNi�►
Timothy H.Cow9.PL4
Isnd Court
SUNIVt
Site plu►nlnq
$swap SYMA 2M.of September 1994
detiORt .
To:Jerry Duwr ng,Damsteble&+aid of Health
inlP4ction� Rom, Arne 0jalk PE.
Re-Lot 4 Alan Road,in West Bamstable
perrtl�ti
Dear Mr.Dw kg,,
This is to cecti.><y that the sewage disposal system located at lot 4.Alan road was
installed in accordance with the plans which wire previously approved and attbzttitted to the
Town of Barnstable Board of Health.The system conforms to the Town of Bamstable Board of
Health Regul bow and to Title V the State Sanitary code.
If I may be of any fallber assistance please contact me st your earliest possible
convordenee.
Sincerely Yours,
Av ex
a ttqjalai PY.
G� Q of ) 07 /�V 6 M
._ -... ._l. FRs ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
XpVftralion for Uhi-Voottl WorkB Tomitrur#inn Urrmit
Application is hereby made for a Permit to Construct Y_J or Repair ( ) an Individual Sewage Disposal
System at
----------_1� . 1sTs - _.
• ........................ ............
Location-Address or Lot No.
. /L..P _----- - Gam''----1-----TAd
.................................................
W C� S(Y377�•���((�� Y 'Installer s
Uof Building rl ot_--_---_ _2-_�_� ..Sq. feet
Dwelling—No. of Bedrooms.._..._____7___________________________--Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------. Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- - -
Design Flow............... _ ____ __________gallons per person per day. Total daily flow....................._._..............__..__gallons.
WSeptic Tank—Liquid pacit_V,1 b.,.gallons Length__- _ --- Width.__`�__ ._ Diameter._.-..____--_- Depth S
x Disposal Trench—No. ..... :....! tlVidth..._� --._._______ Total Length_.__`f�......... Total leaching area... 3 .....sq. ft.
Seepage Pit No.-.-.- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( ) r-
aPercolation Test Results Performed by..... :D4` ._..�2 _� ___.... Date........ ...�__-.�.._.__ ...
,.1 Test Pit No. 1__`(e....minutes per inch Depth of Test Pit.-.---� _Z... Depth to ground water_---_-..�.ZP_".�j�S�
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
�+ ••-•-•-•--•-----••------•-----._-_--•--------------•--------•--------•--•-•-•-•--------•-----•--------------------------------------------
0 Description of Soil------------ ............ ................... .0 �'1? 5`)3m- 3 Z— = ` {�'
..................................... — --. -------- -----------------------------------------------------------....----------------------.......------------------.
W -•-•--••------------------ -------------------------------------------------------------------------------------------------- -------- {{
U Nature f Repair or Alterations—Answer wh; ....
a, pl' le._ ? eatckl._.. �.� ._.. ..... x`'�c
7`
,���.l�L �ePQf � � �--•- r�h= n- ,ate. ....�. . /
Agrec�miY¢lt'ala
The undersigned agrees to install the aforedescribed Indio' al Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environm tal Code he u ersigned further a rees t lace th
'
system in operation until a Certificate of Comp n has bee iss4edj the bo r o ealth.
Signe --------------- ..........................
Dace
r ................
.Application Approved By .. ........ ..�... . ... ... ----------- --------------- . ......... .....
.C------------f anq..: .. Cnm OG6. ......5 kAAPPlication
. e—---- --------P ------ ------
Issued
— Dace
Permit No. - -........._... ...................... Issued .1/7 `1. ..............
Dace
`1��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiuit for Diupuuttl Wurku Tunutrurtiun �Vrrniit
Application is hereby made for a Permit to Construct (,k) or Repair ( ) an Individual Sewage Disposal
System at: I _� , r'': r.
....................................� ......�.....�v._.�.� vll (���P_ (S`f tt c� .
...........................•-• -- ... .........................................
Location-Address or Lot No.
-•--............_•..... .... O,r -� ........................ Cam......c
a
� � Address-• --•......................•---••---....
............................ ................................ ._.. ____ - /
Installer f Address
oa / I L�G 2 �f� Type'of Building � Size Lot_____________________�..Sq. feet
Dwelling—No. of Bedrooms............................__--___---_--._Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures -----------------le°-------------------------------- -----------
W Design Flow.............................,..gallons per person per day. Total daily flow....................................__._....gallons.
R, Septic Tank—Liquid capacity. Pj&_gallonse�Length---3?�•.�... Width..-` ___ . . Diameter--.............. Depth..S:B...
Disposal Trench—No.'__ ar._..�1 'Width___.t ----------- Total Length----_ • '--------- Total leaching area.... 3 .....sq. ft.
Seepage Pit No............----------Diameter_--._--_.-.:--.:_. Depth below inlet.-:.------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) - Dosing tank ( )
aPercolation Test Results Performed by.... -?��r2 _�� 1'._._ .'��__�''.��......_ Date__ ._._C�............................
a Test Pit No. 1..`�J----minutes per inch Depth of Test Pit------ Depth to grourid water........
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 --------------------------------------------------------------------------------•----------------••-•-••---------------------------•---------------•----.._. .r
D Description of Soil....................................................'n..� S-' t
-----------------------------------------------------------------------------------------------------------------------------------------=-
U Nature of Repairs or Alterations—Answer when appl'-able._. �nt_----ieetc
- SC��c�t_ fl.( �1 - ��c- 1, C�• /
......
- o lard �i��
Agreement:
The undersigned agrees to install the aforedescribed Indiv,.idual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code L The undersigned further agrees of o�place th
system in operation until a Certificate of Complia ce has been issued•by the board/of health. ,✓ ��t!
Si ne ...� - f - - -
g tf
Dare
Application Approved By^ / ---------------- / 77`f
�C �c ,�t. oDate SApplication C� LJ .>- lnw.o......-- - h�1E
Permit No. ..--�'L- . ------------------------------ Issued ---------------------- `..7.%1.` ......
Dare
-------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE •.
&r#ifi a e of C outplianre
_THIS IS TO CERTIFY, That the Indiv�i'cdt,! lzSew g Disposal 42tdh°co.nstructed ( ) or Repaired ( )
bz_ M_ k�
r` �t -....... f -...... - - ...
Y ...... -------------- ------------- --._..---- ......,....-....
ler
at .. f' ~, ._a �4'-a `` - !�' �l�I . • -------------------------_--------------------------------------------._--------------------
has been installed in accordance with the provisions of TITI. of The tare Environmental Code as described in
the application for Disposal Works Construction Permit No. E� _ ------ .._-. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
-�-y
DATE----------/.... ----�---�..... .... ------------ ------ Inspe tort'- ----------------- -------.---------------- ----....----------------
------------------------------------ --------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
nn TOWN OF BARNSTABLE
No.... _. _ FEE 1 ---.....--
1is11uuttl luorkii (Tunutrii wr r "it
Permission is hereby granted...........J � P�_ -{� _ .. ......
to Construct („ ) or Repair ( ) an Individu 1 Se.wa Disposal System -�
atNo..........'� �.�� _' .' i �'� '� ` r. --- -=-'- ..... -----------------
Street
as shown on the application for Disposal Works Construction Permit No� Dated-__j_1 .7Z_;7_'`5."5''
DATE-- ------ -----•-� -
�J Board of Health v
FORM 36508 HOBBS Q WARREN,INC.,PUBLISHERS /
1 N p` � TOWN OF BARNSTABLE
LOCATION Lof#5� #4(tg--, 4 SEWAGE # 9�-99
VILLAGE CgtA�(vit !�9'_06/ /
ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY 1, LUy y11
LEACHING FACILITY:(type) (,e.nc.tl'%lAl, 01 Z-f/\ (size) y Am JSC
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER Q�t��°�d Qc°fie(41,
DATE PERMIT ISSUED: 4 26/ q q
DATE COMPLIANCE ISSUED: "
VARIANCE GRANTED: Yes No
S-5
is -
3l0
� J
(pO �
s
1
1
__.________ •_t 1 y_3 ��.�� �E ..IG���:,r�C. lvt•.�L. 4rav^ �x, `--r-y
TEST TOLE LOGS -
\ LOCATION MAP (NOT TO SCALE)
R5 9� I ENGIA'EER:
o. WITNFSS: 1' o�r o BUILDING ZONE: �2•r
DATE: °%- -°>4 SETBACKS:
PERC. ItAT'E: L
� FRONT = �a
' s► ''r SIDE = s
REAR
1 v,ATe ovT rlr 1t` ; ASSESSORS MAP PARCEL :-
k 1 FLOOD ZONE
r O
-
fof �
0 T
1. DATUM NCVD TAKEN FROM
2. MUNICIPAL HATER IS --
1 3. PIPE PITCH TO BE 1\4"/fit UNLESS OTHERWISE NOTED.
4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO-H
5. PIPE JOINTS TO BE MADE WATERTIGHT.
J lo_ fir, ' r 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE MASS.
j y j r ENVIRONMENTAL CODE TITLE V.
7. THIS PLAN FOR PROPOSED WORK ONLY AND NOT TO BE USED
1
r.7
- ' A SEPTIC PROFILE FOR LOT LINE STAKING.
8. SCH 40-4" PVC TO BE USED THROUGHOUT SEPTIC SYSTEM.
—
No
,/ M
Pr � ���� -- �t
p
._ ars ,� �+� e
1 e•
i
� _- � J �.tom, ffrrdd � �•. � -
`
Y \)---..-�-' �- ' '•�:; p+..� �., 1 c� � � I o ° YINIYrlY 1' Ol COIjR OIaR PRlG4ST �
7:1
.� _
`T 000 It__
Opp Op��^SS
TEE DEPTH OF FLOW=
i5E y,,t r r1 c.i I - ZMIN6" CRUSHEDINLET DEPTH = 1OUTLET DEPTH = E' UNDER
S D' BOX E
so S ✓ 1
`j 4,
1 ( FOUNDATION — i SEPTIC TANK D' BOX LEACHING
FACILITY
SEPTIC DESIGN
DESIGN FLOW: .3 .gDP..YS A 110 GPD/BR = _3 GPD SITE AND SEWAGE PLAN
SEPTIC TANK.- GPD X (t.5) _ _`}`�S GALLONS IN THE TOWN OF:
d wn cape engineering, mc. ;aye r USE A i E12�~CALLON TANK
r,.l j►. LEACHING: ta�r �1G.+ -� r-. •.. /v, ' - 'v G
CIVIL ENGINEERS �'�`►� ''
LAND SURVEYORS r . BOTMN. 4= , , Lram---- _ _ 533 _ (> �) _ - _�P --�
� � � .�.+ PRdPARED FOR:
TOTAL:
YARMOUTH, MA Uss: � �+.� �fry .:R�,���. �-��i �� � � �,��� �;�►�r.=-- �vM��
r{ = AT: 4
`.z ,Alt SCALD. DATE
v 3 q,�. <
_.-
_ � RO DATE
T L I
ALA, Pyg., 1�,L.S DATE '�-. APP VB'D �
N .. � �r.'�'� p r,1 Q�2w.+ey •.rt�r4 t..��..i..t._ (�tO r.l G%i G tires J114w• W��. '"°i�'431+.i 1s )
DESIGNING ENGINEER MUST SUPERViI .
INSTALLATION AND CERTIFY IN WRITt'
THE SYSTEM WAS INSTALLED IN STi4
ACCORDANCE TO PLAN.