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' ► Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Bay Lane, Centerville, MA ',
Property Address
Coyle, Cormac 55 Bay Lane _L
Owner Owner's Name
information is
required for every Centerville MA 02632 9/12/2018 .'�
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 51-# l 3 M"
on the computer,
use only the tab Joseph M Martins
key to move your Name of Inspector
cursor-do not Accu Specheck
use the return Company Name
key.
d Drive
Company Address
ess
South Dennis MA 02660
City/Town State Zip Code
»� 508-385-5891 SI 147
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. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10/5/2018
Ins 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 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 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 time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owners Name
information is required for every Centerville MA 02632 9/12/2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
PER ATTACHED PLUMBER'S BILL GARBAGE GRINDER HAS BEEN REMOVED. PUMPING OF
SEPTIC TANK IS STRONGLY RECOMMENDED.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional P ss"section need to be
replaced or repaired. The system, upon completion of the repla ent or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND r the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or a septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfilt on or tank failure is imminent. System will pass
inspection if the existing tank is replaced wit complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspe on if it is-structurally sound, not leaking and if a Certificate of
Compliance indicating that the to is less than 20 years old is available.
❑ Y ❑ N ND(Explain below):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Bo .of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static wa r level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ N ❑ ND (Explain below):
❑ obstruction is removed Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replac ❑ Y ❑ N ❑ ND xplain below):
AA Z
Z I
❑ The system required pu ing more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspe on if(with approval of the Board of Health):
❑ broken pipe are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstructi is removed ❑ Y ❑ N ❑ ND(Explain below):
IV
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the rd of Health in order to determine if
the system is failing to protect public health, safety or a environment.
a. System will pass unless Board of Health d rmines in accordance with 310 CMR
15.303(1)(b)that the system is not function' g in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Cityrrown 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 etland or a salt marsh
b. System will fail unless the Board of Health (and Public ter Supplier, if any)
determines that the system is functioning in a manner th protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption sy em (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surf ce water supply.
❑ The system has a septic tank and SAS and the S is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and t e SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS a 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 a lysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and t e presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that n other failure critWia are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is Centerville MA 02632 9/12/2018
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
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/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the ab9A failure
criteria exist as described in 310 CM 15.303, therefore the tem fails. The
system owner should contact the Board of Health to deter Ine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the syste ust 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 c of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 et of a s rface drinking water supply
❑ ❑ the system is within 00 feet of a tributary to a surface drinking water supply
❑ ❑ the system is to ted in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) r a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
r
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Cityrrown 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 following for all inspections:
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 b ak out?
® ❑ Were all system components � u Ing 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)]
t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
1500 GALLON SEPTIC TANK, DISTRIBUTION BOX, AND FOUR FLOW DIFFUSERS IN A
46X13X1' STONE VOLUME.
Number of current residents: 0
Does residence have a garbage grinder? (C4___'Ce S /p.'»oV-pa J ® Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 814
9 ( Y 9 (gp ))�
Detail:
2016: 367,000 G ; 2017: 228,000 G HAS IRRIGATION SYSTEM AND POOL
Sump pump? ❑ Yes ® No
Last date of occupancy: AUGUST 2018
Date
t5insp.doc•rev.7/26r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Cityfrown State Zip Code Date of Inspecti n
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): gallon perday(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Titl system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NO HISTORY OF PUMPING PER HEALTH
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
23 YEARS. INSTALLED 1995 PER BARNSTABLE HEALTH DEPT.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: -3
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: >10feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
NO LEAKS OBSERVED.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 3
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: APP 10 X6X5 1500 G
Sludge depth: 14 INCHES
Distance from top of sludge to bottom of outlet tee or baffle 15 INCHES
Scum thickness 3.5 INCHES
Distance from top of scum to top of outlet tee or baffle 6 INCHES
Distance from bottom of scum to bottom of outlet tee or baffle 17 INCHES
How were dimensions determined? CORETAKER
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
NO INLET TEE- INLET PIPE INVERT JUST AT OR ABOVE LIQUID LEVEL W NO OBSTRUCTION.
HAS PVC OUTLET TEE. NO EVIDENCE OF LEAKAGE. LIQUID LEVEL IS 48.5".
it
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberg ss ❑ ethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to/evidence
baffle
Distance from bottom of scutlet tee or baffle
Date of last pumping: Date
Comments (on pumping recolet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outle of leakage, etc.):
�7X
8. Tight or Holding Tank(tank must be pumped at time of ins ction) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑f erglass ❑ polyethylene ❑ other(explain):
V Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
C� Commonwealth of Massachusetts
p ,-Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/ 18
page. Cityrrown State Zip Code Da of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: es ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float itches, 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):
Depth of liquid level above outlet invert AT INVERTS
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.):
DBOX IS IN FAIR CONDITION. FLOW DISTRIBUTION IS EVEN.
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: Zpumps
s ❑ No"
Alarms in working order: s ❑ No"
Comments (note condition of pump chambeances, etc.):
* If pumps or alarms are of in working order, system is a conditional pass.
11. Soil Absorption S tem (SAS) (locate on site plan, excavation not required):
If SAS not loca d, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4 FLOW
DIFFUSERS
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Cityrrown State Zip Code Date of Inspection
D. 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.):
SAS IS DRY. MODERATE STAIN LINE AT 6"ABOVE SAS BOTTOM. SIDES ABOVE STAIN LINE
ARE CLEAN AND STONE IS CLEAN. SOIL ABOVE SAS IS CLEAN. NO SIGN OF HYDRAULIC
FAILURE.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on 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 groundwat inflow ❑ Yes ❑ No
Comments(note co ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26r20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac. 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/20
page. City[Town State Zip Code Date of spection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of ydrau i failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is Centerville MA 02632 9/12/2018
required for every
page. Citylrown 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
44 ��
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;t
w
l 3 o i
l
t5insp.doc•rev.7R6MIS Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 18
1 .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
11. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.� 55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is Centerville MA 02632 9/12/2018
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12.1
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:
FRIMPTER
You must describe how you established the high ground water elevation:
HAND BORING THROUGH SAS . NO GROUNDWATER AT 14.0'. GRADE TO SAS BOTTOM IS
6.75'. MIW 29A ADJUSTMENT FOR 8/2018 IS 1.9'. SEPARATION MATH: 14-(6.75+1.9)=5.35'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.� 55 Bay Lane, Centerville, MA
Property Address
Coyle, Cormac 55 Bay Lane
Owner Owner's Name
information is required for every Centerville MA 02632 9/12/2018
page. Cityfrown 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 4 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
INVOICE
bDATE ORDERED ORDER TAKEN BY
PHONE CUSTOMER ORDER NO,
508-95 7-2483
JOB NO.
774-836-0784
Fax 508-957-2496 °��`� e ' ��
JOB LOCATION
11 Camp Street sy 6d- I&A-' ez^ '�U I t Ise
West Yarmouth JOBPHONE STARTINGDATE
MA 02673
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TOTAL LABOR
WORK ORDERED BY
TOTAL MATERIALS Z
DATE ORDERED
TOTAL MISC.
DATE COMPLETED
SUBTOTAL
CUSTOMER SIGNATURE
FORAPPROVAL TAX
GRANDTOTAL ��
contract uate� �2
ATTACHMENT sales Represent five Slgnatur -
Customer Phone M l- — 't'2 Ste— `1 Q�.S� ^^ �
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NOTES:
•Each box equals one toot unless otherwise noted:This sketch is a good faith
H V6 �tF representation of the work to be done,it is understood:that all dimensions
derived from this sketch are approximate,and that all locations of outlets,light
fixtures,plugs,jacks and/or switches are subject to changed necessary.
F
6�(,, atoll . 00a
.-LOT 'NO. ADDRE S S:_ .''� ('Q �✓ ,`��
`OWNERS NAME: zwt yje ;
SEWAGE PERMIT NO. : — __ _ NEW: ✓ REPAIR:
DATE ISSUED:_ i` S' DATE INSTALLED:
INSTALLERS NAME; � � ��'►''�
INSTALLATIONI OF:
nd wad )� � ` k G/�S
WATER TABLE: FINAL INSPECTION BY:
DRAWING OF INSTALLATION ON REVERSE SIDE:
',
�7 �'' d :J
Y'e �
L^ �• ��$
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l�`:M 1 I ��-.e
P V.
v��
���F,t��
�_t-r -�'l r TOMO BARNSTABLE
��r'�� � , � .��1 t C. SEWAGE #
LOCATION'-6\-°.' ' / 4)v-e-
VILLAGE�>�cy Iri II �P ASSESSOR'S MAP& LOT eg6�6�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY t S D D l
LEACHING FACILITY: (type) C�r- 14 f 6 I..61^ (size) 14,
NO.OF BEDROOMS t'
Ta6
BUILDER OR OWNER
PERMITDATE: Y"l �' COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
Nd ��
r
3z
tia
7 �
o '
No.....C�_Y'_.�e) FEB
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Dhripoml Warkg Tvwitrurtion Prrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
...._.-__c. n Address No.
r Address
Installer Address '77
d Type of Building Size Lot.... 3: ^....L...Sq. feet
Dwelling— No. of Bedroom�s�l/..._..3. _._.Expansion Attic ( ) Garbage Grinder ( )
p`4 Type gK/ No. of persons-_------------------------ Showers ( ) — Cafeteria ( )Other—T e of Buildiu _____ _____
A4 Other fixtures ------------------------------- - -
Design Flow--------------------- -- �
W g ���_____________gallons per pgrsen per day. Total daily flow.._._.. .._��...__....__gallons.
WSeptic Tank—Liquid capacity__W_gallons Length................ Width---------------- Diameter................ Depth___-.___-__-....
x Disposal Trench—No. .................... Width-------------------- Total Length----_-_---...____--_ Total leaching area....................sq. ft.
Seepage Pit No..-__---_-_-----.-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing taMI.
)_
'~ Percolation Test Results Performed by. ..f .................... Date..--- -� ......---�--.....----
,.-I Test Pit No. I----2_�----minutes per inch Depth of Test Pit----_-------------- Depth to ground water---Vd!v....--.-.
GT, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
--------••-----------------•-•-----------------..................................................................................
Descriptionof Soil - 2----------------•------------------------------------------.--_-----------------------------------------------------------------.
x
w
VNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia as ue n b d b th e board of health.
---------
Signed ---1=- --- - ----------- -- -------
Dare dd
Application.Approved By ----------- .... .....
' Dare
Application Disapproved for the following reasons- ------- ----------------------------------------------------------- ................. ......................
....... . ............... ...... ............... ........... ... . ............ ....................... ----------------------------------------
Permit No. - ���? . � - .... Issued ......................................................
Dare
Ode
No----- u 7 FEE........1.r?..G.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirtt#ion for Di-nVinial Wor1w Tomitrnr#ion Prrmit
Application is hereby made for a Permit to Construct •( or Repair ( ) an Individual Sewage Disposal
System at:
t
...................................T................. . --......... ......
--------------------------------- ---------..........-----...--------------------------
Location-':•\ddress <' or?Lot No.
,I�✓l.l-�[/f!4�11[./CY. /1''l�c.n�uJ /�!'If_./-------•----•-•--- ,./( -/(iC1C�1".
W ( Address
�C�-•/-------•----•-----------•-------------------- -•----••-•--------------•-••--.-•---........ -----••----._..............................
Installer Address
Q Type of Building Size Lot____�3..0-6-. ...Sq. feet
Dwelling—
No. of Bedroon _._.___.___.__.____-_.__Expansion Attic ( ) Garbage Grinder ( )
p`k., Other—Type of Building ------------------�iDAa-No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------ ------- - =n
d ------- ---------------- ••--- -•'U
W Design Flow............................................gallons per person per day. Total daily flow-.---_ .._ _ ........._gallons.
WSeptic Tank—Liquid capacity./60-gallons Length---------------- Width---------------- Diameter_------------- Depth................
x Disposal Trench—No- -------------------- Width.................... Total Length---___-.-______---__ Total leaching area....................sq. ft.
Seepage Pit No--------_----------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank( ) _
Percolation Test Results Performed by-.----..-- ..y-�---- .................... Date------ ...........
... --_*----�---•---.._..
W
Test Pit No. I---.W. __.minutes per inch Depth of Test Pit-------------------- Depth to ground water.._if'E .....
(i Test Pit No. 2................minutes per inch Depth of Test Pit---................. Depth to ground water........................
D Description of Soil---- /2P�
--
V -••••-......•••-••••----••------•--•--------•••-•-•--•----•--••--•----•--•--•-••-•-••••-•---------•••••--••-•-----------••-••------•-------•....••••----•--------••••---••-••-••--••----•-••------••-•--
W
---------------------------•------•---------------------------------------------------------------------------------------------------------------------------------------...........................
V Nature of Repairs or Alterations—Answer when applicable-------------------------------------------.-.--.---_-_--_--.--_----_--------_-__------------__.
Agreement: 11
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed .... ........ ---------------
Date
Application.Approved By ...._..... -------------- ---- ---- ----------------------------------------------------------------- .......:-.---
f Date
Application Disapproved for the following reasons: ..... ...................... . .............. .............................
---- ---------------------------------------------- ----------------------------------------------------------------- --------------------------------- ----------------------------------------
Date
Permit No. ?r ,5--- --------------------- Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BAR�TNSTABLE
�Qrtifirate of IImplianre
THIS IS Q CERTIFY, That tb_e,l.nd•ividual-Sewage Disposal System constructed or Repaired ( )
by ...' '�� ....f Gi:._.-/%may-- '�a---------- ---------------- ----------.-.-..------------------......-----------------------.................... .....
/ M t_ L_
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..-....5?`------';K_57D....... dated .--. :_,.9_ _-._....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
,,/'
DATE........ - - Inspectsrr'. -----.-flrtl r
_ ——� --_--__----_ ——_ ———_-— ___
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No...�.r..•.`..�Fa}� FEE---../0 d
3�i��ro��t1 urk� C�on�#r�tr#ion �rrmi#
Permission is,hereby granted--- ��J l /liil...................................................-..............................................
to Construct ( or Repair ( ) an Individual, Sewage Disposal System
s r ' /'d'u.1 /tin 2A C %uL k_W
Street
as shown on the application for Disposal Works Construction—Permit No..6.`..____%.E- Plated....__.�."_. .......
Board of Health
DATE........ --------------------------------- --
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
Ii P
g� TOWN Of BARNSTABLE a�
2m9 SEP 2 U Ali S: 58 a
r x Y
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