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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G-1
M ' 254 Ames Way `A
Property Address n.
Paul Gregory a
Owner Owner's Name
information is
required for every Centerville MA 02632 7-15-15
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes. ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7-15-15
In ector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
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t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
y
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'p 254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
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:
® 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:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no-or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
w Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments
GSM 254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑, ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the'system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® _❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid,depth of sludge and depth of scum?
Was the facilityoccupantsprovided with
if different from owner)® El Was owner(and information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
4
Sump pump? ❑ Yes ® No
Last date of occupancy: 7-2015
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design.flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (f known) and source of information:
1980's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
16" !
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
16"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. Cityr'rown State Zip Code Date of Inspection
D. System Information (cont.) •
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
RNE
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from pit.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts .
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type.
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:.
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
Leach pit in good condition and empty at inspection with stain line at 24"off bottom of pit.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference 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
lj
. � C
r � 1
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' M 254 Ames Way
Property Address
p y
Paul Gregory
9 fY
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 0' 254 Ames Way
Property Address
Paul Gregory
Owner Owner's Name
information is required for every Centerville MA 02632 7-15-15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
1 I
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form a3l
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000.Inspection forms may not be altered in any way.
A. Certification
When
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City/town
ZIP CodeDate of Inspection: S� / O
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Certification Statement: o R. N ED r-
I certify that I have personally inspected the sewage disposal "MMMMRdd n that the
information reported below is true,accurate and complete as of ction.The inspection
was performed based on my training and experience in the pro mtenance of on site
sewage disposal systems.I am a DEP approved system inspect o Section 15—W of
Title 5(310 CMR 15.000).The system:
[ Passes ❑ Conditionally Passes ❑ Fails
❑ NeesLr E u do the Local Approving Authority
Inspector's Signature Date
The system inspector shall submit.a copy of this Inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DER 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 Ume.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5insp.doc-11t M We 5 OBidal
Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cons)
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ftssI L) rl(C 11-1f-�rr d 2 (0 3)
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Owners Name Date of Nupection
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
ave 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.
C4ffpqnts:
k cU-1 �� Ar—Ic'. -,T peeoz tact
B) System Conditionally Passes:
i
❑ One or more tem components as described in the"Conditional Pass'section need to be
replaced or repa .The system,upon comple' of the replacement or repair,as approved by
the Board of Heal will pass.
Answer yes, no or not de rmined(Y,N,ND)In e❑for the following statements.If"not
determined;please expi
❑ The septic tank is metal an over 20 y ars old"or the septic tank(whether metal or not)is
strWuraily unsound,exhi ' ubs tial infiltration or exfiltration or tank failure is lmminent.
System will pass inspection if 'sting tank Is re aced with a complying septic tank as
approved by the Board of Heal
*A metal septic tank will pa inspect! If it is structurally sound,not leaking and if a Certificate
of Compliance indicating t the tank is than 20 years old is available.
ND Explain:
t5ffmp.&c•1 MOM Title 5 OfB W Inspecbm Form:SWMwface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cons)
25
71'a�t,r,, L) en 62.)
�Mwl B/Ll 7 e .0 A 1 , e gIZA,
Owners Name Date of trMpectlDn
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with a al of Board of Health):
❑ broken pipe(s)are re ced
❑ obstruction is removed ' �+
❑ distribution box is leveled or repla
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(7approval' ard of Health):
❑ broken pipes)are rep❑ obstruction is remove
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evai tion by the Board of Health in order to determine if
the system is failing to protect public health, or the environment.
1. System will pass unless Board of Health termines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning a manner w h will protect public health,
safety and the environment: J✓/,�
❑ Cesspool or privy is within 50 feet of a surface wa
❑ Cesspool or privy is within 50 feet of a bordering vege wetland or a salt marsh
t5msp.doc•11/2004 Title 5 OMcW inspection Form: Sewage Dispose!system
Page 3 of 16
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification cont.)
vJrl(e_ I-q-3s1 6.263a
cityq9W6 state ZIP Code
/zv / 1311y Te--JAS, I vrit I S C)F
owner's Name Da of Inspecifon -
C) Further Evaluation Is Required the Board of Health(cont.):
2. 5ys m will fail unless the Board of Health(and Public Water Supplier,if any)
determin that the system Is functioning In a manner that protects the public health,
safety and vlronment:
❑ The s has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet o surface water supply or tributary to a surface water supply.
❑ The system has a s 'c tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank an SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and 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
conform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5
ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached
to this form.
�t0
A
3. Other.
ttiinsp.doc•1112004 Vile 5 Oftkaal inspection Form:subsurface sewage Disposal system
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
AwleS �•
ress
cuyrf /i J( LJ ��'v S s a U ae e ! �� apco
Ownees Name Daft of inspection
D)System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ 1� Backup of sewage into facility or system component due to overloaded or
dogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or cogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or dogged SAS or cesspool
❑ Llquid depth In cesspool is less than 6°below invert or available volume Is less
than%day flow
Required pumping more than 4 tunes in the last year NOT due to dogged or
El obstructed pipe(s).Number of times pumped:
❑ `� Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ `' Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
0 i 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 collform bacteria and volatile organic compounds
Indicates that the well Is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than S plan,provided that no other failure criteria are triggered.A copy of
the analysis must be attached to this form..]
Yes lNo
❑ kh The system fails.I have determined that one or more of the above failure
�L 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.
t5imp.doc•1 MOM Title 5 Mid!Inspection Form:Subsurface Sewage Disposal system
Page 5 of 16
' Commonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System.Form
A. Certification (cunt.)
S XI s� es
�
Code
Owniees�►Name Date of Inspection I
E) Large tams: To be considered a large system the system must serve a facility with a
design flaw o 0,000 gpd to 15,000 gpd.
For large system ou must indicate either'yes"or"no"to each of the following,in addition to the
questions in Sectio
YES NO /B
❑ ❑ the sys is within 400 feet of a surface drinking water supply
❑ ❑ the system is 200 feet of a tributary to a surface drinking water suppry
❑ ❑ the system is loca in a nitrogen sensitive area(Interim Wellhead Protection
Area—tWPA)or a Zone it of a public water supply well
If you have answered'yes'to any question in n E the system is considered a significant threat,
or answered"yes"in Section D above the large s has failed.The owner or operator of any large
system considered a significant threat under Section failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system er should contact the appropriate
regional office of the Department.
t5insp.doc-11/2004 T09 5 Official Inspection Form:Subsurface Sewage Disposal Systern
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
s
e S CJ.o
�,I (Q M -9 (-f a d- 63.),
� ')l Q/i 4 /�j �` „ Q� I f o if code
T�
Owners Name Date of Inspection
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 anyy 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 WA)
❑ 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(3xb))
fttsp.doc•11=04 Title 5 Oflictai Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
' Commonwealth of Massachusetts
MUMEW Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
wte
Owners Name Date of hupecU n
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms):
1
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system?[d yes separate inspection required] ❑ Yes No
Laundry system inspected? [ Yes ❑ No
Seasonal use? ❑ Yes H No
Water meter readings,if available(last 2 years usage(gpd)): e S
Sump pump? ❑ Yes & No
Last date of occupancy: D /
CommercialAndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gakm per day Wd)
Basis of design flow(seats/persons/sq.fL.etc.);
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? JAU) ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,If available:
Last date of occupancy/use: Data
Other(describe):
t51nv.doc-1 IMM We 5 OMdal Inspection Fomr.3ubsu t m Sewage DbpwW System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form.
C. System Information (cont)
cityM -i TP--'J ej S , t /0 P�
owners Nam Date of inspedlon
General Information
Pumping Records:
/UC)-kj
Source of information:
Q
Was system pumped as part of the inspection? ❑ Yes No
If yes,volume pumped: gas
How was quantity pumped detenTdned?
Reason for pumping:
Type of System:
Septic tank,distribution box,soil absorption system
((❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes,attach previous inspection records,if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximaje age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
t5lnspAm•I W004 Tits 5 Olfidal inspection Form:Subsurface Sewage Disposal System
Pape 9 of 16
Commonwealth of Massachusetts
Title 5 Official. inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt.)
Ad&egs 70"Y-" a,� o rr a .)- 6-?�
c;ty own sm code
nJ N�� �l�/� u1Qc 19j o
s lame Date of kupecWn
Building Sewer(locate on site plan):
Depth below de: feet
�. 7
Material of constru '
❑cast iron ❑ VC ❑other(explain):
Distance from private water sup 11 or suction line: feet
Comments(on condition of joints,venting, nce of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
YZ-7
crete ❑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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle `
Scum thickness
Distance from top of scum to top of outlet tee or baffle `
Distance from bottom of scum to bottom of outlet tee or baftie
How were dimensions determined?
t5k%sp.doc•11/2004 Title 5 O fdal inspec Um Form:Subsurface Sewage Disposal Systern
Page 10 of 16
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System information (cont)
o? ' c
ccatyy _ s z�code
owiers Name Date of Inspection
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet in rt.evide ce of leakage,etc.
Grease Trap(locate on site plan):
Depth below grade: A/A feetMaterial of construction:
❑concrete Elmetal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recom dations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet in0vt evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped a of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑po thylene ❑other(explain):
t5iospAw-1112004 We 5 oflidal Inspection Form:$Wmwface Sewage D System-
Page 11 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System information (cons)
state— zo code
Ow fiWs Nam Date of hupecoon
Tight or Holding Tank(cont)
Dimensions:
Capacity. g
Design Flow: ga&=per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes❑ No
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
Distribution Box(d present must be opened)(locate on sit plan):
�. r �
Depth of liquid level above outlet invert Lo
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.):
Pump Chamber(locate on site plan):
Pumps in working order. ,#IVA ❑ Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
Mgnsp.dm•11M" We 5 Otffdal Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
A"I eS tea.
P Andd�_
ro .1 t e— f S 62�
CityTrevn /e�sgs. s .j 00i� /�/c�bs Zip cone
Owners Name Date of Inspection
Comments(n condition of pump chamber,condition of pumps and appurtenances,etc.):
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located ex lai(hy:
Y 6 CJ dt- S /0,4 e,
Type:
leaching pits number.
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovabve/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydrau'c failure,level of ponding,damp soil ndition of
vegetation,etc.): r
w.r S
t5insp.doc•1 MOM Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt
?�v 4'-n e-S
P Add '
Zip Code
0!j,!Q e A) 4
Owners Name Ufa of Inspection
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and con uration
Depth—top of liqui o inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes [] No
Comments(note condition of soil,signs of hydraulic failure,lev of ponding,condition of vegetation,
etc.):
"t-�zPrivy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure,reve nding,condition of vegetation,
etc.):
t5insp doc•I U2004 Titie 5 Official inspection Forth:Subsurface Sewage Disposal System
Page 14 of 16
f
Commonwealth of Massachusetts
Title 5 Official Insp
ection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.) r�
4w e-v A lo
9 state Zip
Code
owners Name Date of Inspection
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 1 tO feet.
Locate where public water supply enters the building.
A &,vt e-S LJ a��
a�
onv+� O woos I
(� A
AA
� A �
O 4
0
IL3 e
15msp. •11I20Q4 TWO 5 official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
P rty AdAmss
City wn j
State Zip Code
�v 6 to 7FL)�4e- 1 o
Owner's Name Da of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: (�
Please indicate all methods used to determine the high ground water elevation:
Y— Obtained from system design plans on record
7
If checked,date of design plan reviewed: Date
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health- ain:
Checked with local excavators,installers-(attach documentation)
Accessed US database-e in:
You pst describe how you established th high rroun water eleva�t*
7 L/ lvy, A d 0 f
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
JUN/18/2008/WED 09: 07 AM C-0-MM WATER DEPT. FAX No, P, 002
r= � C-O-NM WATER DEPT
CUSTOMER STATEMENT
ACCT NO 6,451 6/18/2008
BRATENAS,PAUL
LOCATION_:
254 AMES WY
CEN
LOT: L223
MAP&PARCEL: 170123
Consumption History
DATE REAR CONS
12/31/07 437 18
06/30/07 419 6
12/31/06 413 11
06/30/06 402 5
12/31/05 397 15
06/30/05 382 7
12/31/04 375 13
06/30/04 362 10
TRANSACTION HISTORY
.DATE DESCRIPTION 0 to 30 31 to 60 61 to 90 ...Over 90-
10/02/2000 A4;[NIMUM BILL 0.00 0.00 0.00 15.00
10/23/2000 PAYiv N 0.00 0.00 0.00 -15.00
01/01/2001 N11N 0.00 0.00 0.00 15.00
01/17/2001 PAYMMNT 0.00 0.00 0.00 -15.00
04/02/2001 MIN 0.00 0.00 0.00 15.00
04/12/2001 PAYMENT 0.00 0.00 0.00 -15.00
07/02/2001 MIN 0.00 0.00 0.00 15.00
07/16/2001 PAYMENT 0.00 0.00 0.00 -15.00
10/01/2001 MIN 0.00 0.00 0.00 15.00
10/16/2001 PAYMENT 0.00 0.00 0.00 -15.00
01/01/2002 MIN EX 0.00 0.00 0.00 26.60
01/22/2002 PAYMENT 0.00 0.00 0.00 -26.60
04/01/2002 MIN 0.00 0.00 0.00 15.00
04/16/2002 PAYMENT 0.00 0.00 0.00 -15.00
07/01/2002 M1 N 0.00 0.00 0.00 35.00
07/22/2002 PAYMENT 0.00 0.00 0.00 -35.00
01/01/2003 MIN 0.00 0.00 0.00 35.00
.Balance Due: .0.00
JUN/18/.2008/WED 09: 07 AM 0-0-MM WATER DEPT. FAX No. P. 003
-- - C=O-NAM WATER DEPT
CUSTONMR'ST.A.'TEWNT
01/22/2003 PAYMH 0.00 0.00. 0.00 -35.00
07/01/2003 MIN 0.00 0.00 0.00 35.00
07/22/2003 PAYMENT' 0.00 0.00 0.00 -35.00
01/01/2004 MIN EX 0.00 0.00 0.00 52.40
01/22/2004 PAYMENT 0.00 0.00 0.00 -52.40
07/01/2004 NUN 0.00 0.00 0.00 35.00
07/20/2004 PAYMENT 0.00 0.00 0.00 -35.00
01/01/2005 MIN 0.00 0.00 0.00 35.00
01/19/2005 PAYMENT 0.00 0.00 0.00 -35.00
07/01/2005 MIN 0.00 0.00 0.00 35.00
07/15/2005 PAYMENT 0.'00 0.00 0.00 -35.00
01/01/2006 MITT 0.00 0.00 0.00 35.00
01/17/2006 PAYMENT 0.00 0.00 0.00 -35.00
07/01/2006 MIN 0.00 0.00 0.00 35.00
07/21/2006 PAYMENT 0.00 0.00 0.00 -35.00
01/01/2007 MIN 0.00 0.00 0.00 35.00
01/12/2007 PAYMENT 0.00 0.00 0.00 -35.00
07/01/2001 iAP4 0.00 6.00 0.06" 55.00
07/16/2007 PAYMENT 0.00 0.00 0.00 -35.00
01/01/2008 MIld 0.00 0.00 0.00 35.00
01/18/2008 P,AYNMN'T 0.00 0.00 0.00 -35.00
Balance Due: -0100
I
Town of Barnstable
CF THE Tp�
P� o� Regulatory Services
BARNSfABLE, : Thomas F. Geiler,Director
16 a`0� Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIODisclaimer Private Septic Inspections.DOC
�. .s%/
No.............S?X...e Fps..............................
THE COMMONWEALTH.OF MASSACHUSETTS
J J I BOARD OF HEALTH
......-Town ....................OF.......... arnst_able...............................................
�r Appliration for Bhipoga1 Vorko Tonitrnrtion ramit
Apflication is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: '
Ames Way-. _Centerville .Lot 22� � �5 �0'
-•- - ------------------------ -- -- ------•-------- --- --
��� n Lo- ion A dress or Lot No.
.... ...... ..................... ................... _.................................•.......
Address
. V'~�...................... •............................._ .... ..............•..
Installer Address 15 4 2 5 ,
d Type of Building Size Lot.... �._.e_:-._:—/.Sq. feet
Dwelling.v No. of Bedrooms.•.......:...........2....................... Attic (E� Garbage Grinder
aOther—Type of Building ............................ No. of persons-_----_------.----.-----. Showers ( ) — Cafeteria ( )
aOther fixtures -------------------------------- ------. ...------------------------........------•--•-----•--••-----------------:....---........-----•--
Design Flow............:...... 5-_._----____----_--gallons per person per day. Total daily flow---220U.5--3_3Q.--.--_-.gallons.
W `
W Septic Tank—Liquid capacit 50Q gallons Length a 0-1.6.7 Width._ 5 t 1°. Diameter................ Depth-
Septic t V
x Disposal Trench—No. .----_--_-..----•- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...._..._.I........ Diameter------- ,Q!...... Depth below inlet...........6 ._.. Total leaching area.,16L7.......sq. ft.
Z Other Distribution box (X) Dosing tank ( )
~' Percolation Test Results Performed b3Cape__..Ced...S r'3;rey...Consuj tar tSDate................9/28/7-9-....
aaa Test Pit No. 1...2..........minutes per inch Depth of Test Pit------J.2....... Depth to ground water..-..no
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.. �Akk-(0)F- ss
----•------•-----------------•----••----------•------•--------------------------•---......--•---..........------................ z�.. ............ 9c
O Description of Soil...Q..0_nD..5...wood,_lasm,-..�0,5 2.D•••subs0-il.,._-.2...Q-.7.. _..me-d. mJrc.
x . BMAN
v s.and.,•---7.•0 12-.Q--.med.•--Whit.e...sari cr-..--CHAP
W - --------------------------------------------------- -------••-•-•---•-----------•--•-------------------------- --
t / 7 o p 1Vo. 7J1i54 p Q
U Nature of Repairs or Alterations—Answer when applicable.-------------------------- -----------1....................... .�o �....... .
F� STE
Agreement: `�S10NAt
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T�.;,:. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een issu d by the o •d of he lth
Si d- V Aj �
Date
Application Approved By...... fs`' ...... ... 4 G '`
Date
Application Disapproved for the following reasons:......................... ..............
•...................•-•--------------------------------------•--••---•---...----......------•----------------------------•-----------------------------------------------------------------------------
Date
°Permit No--------------- . __ -issued_.=------
=
- - - ----• - —- --- .,. � � � ! Date
c..
THE COMMONWEALTH OF MASSACHUSETTS l
4Go'
BOARDZ HEALTH
...........OF*....... ..... ....... ........................
Oprr#ifiratr of Ton thane
THI I ER Y, at the Individual Sewage Disposal System constructed (�r Repaired )
staller
at---
has �- = ,
been installed in accordance with the provisions of T + 5 o The Sanitary yod�e as described in the
application for Disposal Works Construction Permit No.-- ...-._if�=f--._.. ---. -•- da.ted-------{-�..�—..�'�.................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM Vj4LL FUNCTION SATISFACTORY.
DATE......-•--......?.:` -----------•--------•..................••....... Inspector
THE COMMONWEALTH!OF MASSACHUSETTS
BOARD OF HEALTH
Town OF Barn;�t4bie
............. ...................................................
Appitration for UhipwiallUorks Totulrurfian "punfit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Ames J...flenterville'
-................................................... .................................. ....A------------------
L cati Address or Lot No.
Zt................ ----------—-----------------------------------------I...........................................
wner Address
----------------------------- .............................................................Installer ...... ............................
...teh#....Z-4-4--u—P.
Address /1:5 A 2
Type of Building Size Lot-___ ....Sq.jeet
U oms........D....2........................Expansion Attic)DwellingV-No. of Bedrooms..._ ...... 5inde,
rm , �-
Cafeteria Other—Type of Building ..!......................... No. of persons............................ Showers
Other fixtures...............................................................
..........................................................................................
", X ..� 11 . I., , '11., "
Pq -,V16w------------- 0..........gallons.
. ......5-.5....................gallons per person per day. Total daily ---2-2011-5-33
Design 3
__gallons Length-�J-.'10 idthA5',jr 1,,�Diameter---------------- 9!!-..
1:4 Si2�tic..TTILnk�l Lipid.capacit gal _611 W Depth'39
1500-
I - -Disposal T�6ich�L`-No. ..........Y500 Width_..._...__......___. Total Length..:.____ Total leaching area____ ....sq. f t.
ispo ........... ....
Seepage Pit No........�*.j........ Diameter......10�...... Depth below inlet......_ 617.. Total leaching area.'467......sq. ft.
Z Other Distribution box (,X —Dosing tank 4,
r.
Percolation-hest Results Performed bf-ape...Cod--$urvey----aonou—Itant-s Date.................9/W79--
Tq�t Pit No. 1...2--------minutes per inch . Depth of Test Pit ....12 ...... Depth to ground water..__ ....
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground orate
............................................................................................................................... . .. ............. .
. 0
Description of Soil... 'VID.Od...10AM7---0 5rek-2,0...subaoll.,
0 0...M
Z B.
............................ nd--�7................ .... ....
--
CHAPMAN CIO
---- -----N07127654-----
------------ - ----------- 1P .
---------------- ----------------------------------------------------------------------------------------------- -------�-
Answer when
U Nature of%Repairs or Alterations ,en applicable----------------------------- .. ... .. .......I........
0 C/.......
. .................. ............................................ ....................................................................................................... - WC
Agreement:",
The undersigned agrees to install, the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has d by the board of health
by thee
? sf.11,4---- Lr................. ...Y17/%.��
-,/-7-��-4U
Sig
Date r
......... .. . . . ... ..........I.................. .........V-
Application Approved By.......1
Date
Application Disapproved for the following reasons,.......... ..... .......................
- -------------------------------------------- -----------------------------
........................................................................................... -----------------------
-----------------------------------------------------------------------------ii�
Pate,
PermitNo..................................................... ......... ....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALT
..................
..7.0 ..OF.......... . . . . .... .. ..
Quatifirav of Tompliaurr
"y
THISR Y, T t the Individual Sewage Disposal System constructed <r Repaired
............ .... ..... ...........by .... ..... . . ...... ..................................................................
I taller r
4P
at......Aw. ........ N. ... .. ..... ................... ...............
r provisions o T 0•
The State Sanitary. o�Tas described in the
application for Disposal WorlS§ Construction Permit No... ......../%Y-f.............. dated---
has been installed in accordance with the the
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE.THAT THE
WILL .FUNCTION SATISFACTORY.SYSTEM
DATE................................................................................ inspector:................................................................................I...
Rep
aired �1
Y I
Of
Sanitary
f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF/)HEA*LTH
0
...... ... .. ........OF..................V.,jj:� ....................................
No. .... ..... FEE.,,_ . ............
�a gal tr ftion ranfit
s4 v' I'
Permission is hereby granted..,,�----- ............................ ----------- --------
air- "an Indivii Se Di� sal ystem
C
S .... ........... f. ..... L*
to Construe 40'or"k'epai
�% V..............
4 1 . W,
Street
as shown on the application for Disposal 'Wor s Construction Per i No------ ...../bated......... ......7..,rz�
......................
................... ...... ...... --------I............Board of Health
DATE...........-.......",
............................................ ..............
FORM 1255,_HOBBS & WARREN, INC.. PUBLISHERS
't't?TIJ T,oV.IBARNSTA�BLE
Sr-
IWAGE
X OCA►InON
VILL,AI.Crl : " �r A SSFSSOR'S.MA i'd't LOx —
INSTF���LEIt'S bTAt4ltlw Sc �tONE N077-777-77
S��'1"1C 7CA1�tI�L'f�FF�Cl'CY 1) /t 6 j)
L C&iITTG PAC -TPY ef
Nd.OF [) OOP1lS
ei ,Da 77
.--
P RMB'I'bXIM' ..-. .;: Cf�f�JtaL S+�t7� 1�A► 'i .._.. _--- --�...w- ;
Supxntta�t tmct4 Bctvreeta cue:;'
:Maximum d}us Grputacfwatec"t'nbtetailic}�aitona Leuc:hingBidlity .»�..�.,
1�lrintc W t�► Sup ly Vla l aatd Lcvhite .�?�csltty PfC ax►y::�vel9s axtst aa,
a�a elt�s oc wltltatOp feet of ls�ictugt faciYity)
wetlands exist
F�cluc�cy�'V`Vet.4aad and L�eacl�tn�t��ctlity(o uny.
Y'
tvitllix�.3t10 fcct cite
#ltan8 War)
l
- I bac I
L jo
�r
6 -F- 314
y,.
J
I
.J
SOIL LOG
X�d,SI�✓,,.0 y;L LX—ld.",,._..Y�il, v,.r,.J.,.tr i1= -
r :•F8ASTONE •LOAM 'S FILL••' IT MAX
` 'too a-~° : •.�-....—ham Tj.�•r�.� ,- �� �� • i
DIST.
IS 00 BOX �;.o•�0 1000 GAL. , e a • I MAC ,
#
!o MIN. GAL. e: PRECAST OR n 24 �.
TAN IC i %.• BLOCK o : MIN
6� I, SEEPAGE
II PIT o r 714
r` 20' MIN. �... '
•-FOUNDATION
WASHED STONE""
ELEVATION KETC PERC RA E
SKETCH T
o
r--- I
SCALE 1 = 4' TEST BY : G;F; WR
E TOWN INSPECTOR _- /93t/. �:Ki ✓
BACKHOE OPERATOR:
B
TEST MADE ON :
Q
3 49 "�47- ,
- tI
. m 1
N �
aaaa�a� mI
/500 AI, t
~ sE t
_ en
94
1 I I#
Q# .
l / �
_ .
/ rdt.Tic•,'. 1«�4 F+ lt. +'. tcx r% :«:, %'t1r� �.�; I AM M *'��
1 #1.� fi+lfir.5 i .r" a ✓ i`t.rife.�'s ax. t,.',t ?,•t'p,/�.1�,1 '^ `mow•p<tj'R
75
CHAPMAN
pt
rl� K
ELEVATION SCHEDULE i47
PROPOSED S I'i'E PLAN
I: INV. ,AT FOUNDATION _ Z.
- SEWAGE SYSTEM DESIGN
2. I N V. INTO SEPTIC TANK
s ell
IN
3. ' I N.V. OUT OF SEPTIC TANK _ .t J`�r~.V.�7A Q4.4S� .A/r' .Q i�''! E. t /h'f .5 o ,'I
4. INV. INTO DISTRIBUTION BOX = r
SCALE.; I°= � 19 7
5. INV. OUT OF DISTRIBUTION BOX = S C - � -
6. INV. INTO -SEEPAGE PIT = 94, CAPE COD SURVEY CONSULTANTS.
ROUTE 132
71 BOTTOM OF PIT = HYANNIS,MASS.
III
w m