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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ti
710 Bay Lane
Property Address new
Karen Gadbois
Owner Owner's Name
information is required for every Centerville ✓ MA 02632 9/08/2017
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. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return Name of Inspector
key.
Ford Septic Services, LLC
„b Company Name
P.O. Box 49
Company Address
erg Osterville MA 02655
City/Town State Zip Code
508-862-9400 S 12482
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 valuation by the Local Approving Authority
9/1317
Inspecto Signatur Date
The s m inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Healt 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal pystem•Page 1/off117
4
Commonwealth of Massachusetts
y v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
710 Bay Lane
M A SV ey`
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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•3/13 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
710 Bay Lane
M
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. CitylTown 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 '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. City/Town 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.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
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 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
tins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M a 710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: unknown
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:
unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: currently
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
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
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: unavailable
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
maintenance
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 710 Bay Lane
M
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
system installed -date unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
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.):
Septic Tank (locate on site plan):
Depth below grade: 22
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: 1500 gal.
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
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 29
Scum thickness 4
Distance from top of scum to top of outlet tee or baffle 5
Distance from bottom of scum to bottom of outlet tee or baffle 10
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present. No sign of leakage. The tank is under the raised patio and only the outlet
cover is barely accessable.
Grease Trap (locate on site plan):
Depth below grade: n/a
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. City/Town 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):
N/a
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. CityfTown 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 even
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.):
The D-box was normal. No solids were present
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® teaching pits number:
1- 1000 gal.
❑ leaching chambers number:
® leaching galleries number: 3-500 gal.chambers
❑ 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.):
The chambers and the leach pit were dry. There was no sign of failure. A camera was used for the
inspection.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
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.):
N/a
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
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
13Ack
A _ -�
wst d
PAI10 +
STONE W411
O
oL O
3
y
B
a a-7b ys`
3 3a`
y —19 a?
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
710 Bay Lane
M
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
30' +/-
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 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:
Topo and water contours maps
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M e 710 Bay Lane
Property Address
Karen Gadbois
Owner Owner's Name
information is required for every Centerville MA 02632 9/08/2017
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
s r
No. VJ(IJ � Fee$ rJ O •0�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: A'
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppfication for Xkgooal *pgtem Comarurtton Vermtt
Application for a Permit to Construct( )RepaipNX)§Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
710 Bay Lane Centerville, Mass. Patricia Danser
Assessor's Map/Parcel / 4?6F /.0—J-1—
Installer's Name,Address,,and Tel.No.5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No.5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc,
Box 66 Centerville,Mass.02632 Box 66 Centerville,Mass. 02632
Type of Building:
DwellingXXX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(NO)
Other Type of Building RES No. of Persons 3 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 4 4 0 gallons per day. Calculated daily flow 3 x 110=3 3 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 000 existing Type of S.A.S. 1 —6 'x8 ' pit existing
Description of Soil Loamy sand to medium fine sand
Nature of Repairs or Alterations(Answer when applicable) Adding three 500 gallon
chambers packed in 4 ' of stone.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed by this Bo d Health.
Signed Date 91211
8
Application Approved by Date
Application Disapproved for the Yollov' g reasons
Permit No. Date Issued
No._/ (� �f-7) ' Fee$ 50.00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Zigoal *pgtem Construction Permit
Application for a Permit to Construct( )Repaii;NX�Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
710 Bay Lane Centerville, Mass. Patricia Danser
Assessor's Map/Parcel / F /
Installer's Name,Address,and Tel.No.5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No.5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc,
Box 66 Centerville,Mass.02632 Box 66 Centerville,Mass. 02632
T pe of Building:
DwellingXXX No.of Bedrooms 33 Lot Size sq.ft. Garbage Grinder(Ng
Other' Type of Building RES No.¢of Persons 3 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 4 4 0 gallons per day. Calculated daily flow F3 x 1 1 0=3 3 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 000 exiksti.ng Type of S.A.S. 1—6 'x8 ' pit existing
Description of Soil Loamy sand to medium firawe,.$4nd
Nature of Repairs.or Alterations(Answer when applicable) Adding three 500 gallon
chambers packed in 4 ' of stone.`
Date last inspected:
1,
Agreement: ..\
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal'system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed by this oald of,Health.
Signed Date 9 21 98
Application Approved by Date
�4 Application Disapproved for the Mlow14 reasons
Permit No. — �o Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
A Certificate of Compliance t
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repairedll;XX) Upgraded( )
Abandoned( )by J.P.Macomber & Son Inc.
at 710 Bay Lane Centerville Mass. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ~/0 3 dated
Installer J.P.Macomber & Son Inc. Designer J.P.Macom er & Son Inc.
The issuance of this permit shall not be construed as a guarantee that the syste ill function as designed.
Date '(� ~ �i ~-� Inspector—
————---———————— -
No. Fee $ 50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mizpooar *pgtem Construction Permit
Permission is hereby granted to Construct( )Repair�X*Upgrade( )Abandon( )
System located at 710 Bay Lane Centerville,Mass.
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: 1 D —�--� Approved by
t
• I0/9N7
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
1,Joseph P MacomhPr .Tr , hereby certify that the application for disposal works
construction permit signed by me dated 9/21 /98 , concerning the
property located at 710 Bay Lane Centerville Mass_ meets all of the
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed G'.
• There are no variances requested or needed.
• If(lie proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the
proposed leaching facility will 114i be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) f I _
B)Observed Groundwater Table Elevation(according to Health Division well map) /,s',l _
SIGNED DATE: 9/21 /98
LIC D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER Z�
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submit(ed).
q:hcalth folder:ccrt
.dr .
Existing 1000 pit.
New; 3-500 gallon Distribution
chambers packed in Box
4 ' of stone.
Existing 1000
gallon k
O
tan
Fro*JV
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
L
22 gg / ��- — - __ '`- Permit# �� -2
Map CJU Parcel- _-Y /
Health Division I �`� 3 23 03 i I`}�2 '}a� r0o t Date Issued / -,,;2 U
e
_� _ -=� S i( BDRM ON L ``
Conservation Division � � $ .(� ., - � 1� Application
r
Tax Collector l�' O _`" �- Permit Fee 2
Treasurer s y��'�O SEPTIC SYSTEM ??,US o
Planning Dept. W-STD' LED IN C08'�i?L1 IN-
VWTK TITLE 5
Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND
Historic-OKH Preservation/Hyannis TOWN REGULt,TIoNS
Project Street Address Ito
Village 0rJ'LWt&
Owner V444, Address P d L
Telephone 96- -70
Permit Request �+^
—
AM AJ � Adf&z aJ Al
Square feet: 1st floor: existingproposed
2nd floor: existing proposed r020 Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
fi
Lot Size X. 537 ' Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family l Two Family ❑ Multi-Family(#units) "
Age of Existing Structure Z7 Historic House: ❑Yes No On Old King's Highway: ❑Yes ¢ZNo
Basement Type: $LFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing 2 new l Half:existing O new y
Number of Bedrooms: existing 2 new
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: Gas ❑Oil O Electric ❑Other
cn
Central Air: ❑Yes Q➢No Fireplaces: Existing New Existing wood/coal stove: ❑Ye§ No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new" size,-.
Attached garage:Cl existing ❑new size Shed:❑existing ❑new size Other:
{
Zoning Board of Appeals Authorization ❑ Appeal# Recorded
Commercial ❑Yes (*No If yes, site plan review# \
I
II
1
E:EJ I
4Y,
1
TOWN OF BARNSTABLE
/f i
LOCATION /7 0 9 A y /�I�� SEWAGE# E— W/ 3
VILLAGE C eN''f 9 V/LL e ASSESSOR'S MAP & LOT ! s
INSTALLER'S NAME&PHONE NO. I /V M A C D eP t S oAl
SEPTIC TANK CAPACITY
LEACHING FACII.TTY: (type) .3",rLOWC#,4M P)ePs(size) bO 'GAL
NO. OF BEDROOMS
BUILDER OR OWNER_TG �=- •_-r
PERMTTDATE: 0- . q COMPLIANCE DATE: �6 _S 21R
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
TOWN OF BARNSTABLE !— G
L�.C:ATiON 71D ,6A Y G/4�e SEWAGE# O —t/o
VILLAGE C eNl'eg V/1L'e ASSESSOR'S MAP & LOT —
INSTALLER'S NAME&PHONE NO. J /�' A4 A c D m 13 elf t 5 ON
SEPTIC TANK CAPACITY
LEACHING FACU rrY:.(type) 3 AZo yCh1Am 1°°r�e'Pf 0(size) 6 "GAL
NO.OF BEDROOMS a✓�4St\g� � �1
BUILDER OR OWNERri:tsci .r /
PERMI TDATE: JD-T. a COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
I
E:lo -
r
No..7f..��5 � F s........ ....................
THE COMMONWEALTH OF MASSACHUSETTS
/ BOAR® F H A H
� 0
----- ............. ...........- ...--.........
Apphratiun
for DiupuiiFal Workii Tatuitrurtiun Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: � /t---..._......... ... ... .....
.--••-Locatio dre�sa,�� �--.••--•-.or Lot No.
- ... — �--------------•....rc l =. . - .........
Owner ,•--Add re -
a -------------- ,�:.... ....-
Installer Address
Type Building Size Lot__ _ ___Sq. feet
Dwelling—No. of Bedrooms......_:2..........................Expansion Attic ( Garbage Grinder'4 Other—Type of Building .._. ..
a yp g S _____________ No. of persons-------- ___ Showers ( /) — Cafeteria (�-.
Other fixtures
W Design Flow.......... ......................gallons per person per day. Total daily flow....... ....................gallons.
.9 Septic Tank—Liquid capacity/R gallons Length._._....�. Width....4-------- Diameter________________ De h .._..._..._...
Disposal Trench—No_____________________ Width_Zal-------------- Total Length....______.___ Total leaching area.............. ...sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet........... Totalleaghmg afea..................sq. ft.
Z Other Distribution box ( ) Dos n ank/( � Q� OK
Percolation Test Results Performed b . . :__�..... ./ '! �are---_---__-_--•. .�7
Test Pit No. 1....=� -_._minutes per inch Depth of Test Pit---..../�._... Depth to ground water________________________
(T, Test Pit No. 2....t7 ...minutes per inch Depth of Test Pit.....1.7...... Depth to ground water........................
9 ....................A.................................._.......�
Description of Soil -�> a_ -: . L'� 1"
W ........................................ --Q___ -------------- .............................. ............
UNature 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 iITLE 5 of the State Sanitary Cod The undersigned further agr no o place the system in
operation until a Certificate of Compliance hass' It
by the board of 1
Signed, .... //G
_..�--------------------•---••-•----
/� Date
Application Approved By....L: - f- C E Y �d �'.
..Date
Application Disapproved for the following reasons:...................... ............. ._..._..__.._
-------•--•---------•------...-•--•---------•---•---•------------------------------------------------------------------------------------•-----•-•--------------------•--•-----------------••----------
` Date
Permit No......................................................... Issued..-.,e 7� rlz`
Date
t
Noo :�.
THE COMMONWEALTH OF MASSACHUSETTS
f BOARD ZF
H ALJH
OF.... ...............
.... .....-----L_ � . . . . ----------------------------------
Application is hereby made for a Permit to Constructt,( : or Rep . ( } an Individual Sewage Disposal
System at: �'�,.
......... ........................ .� ... ........... -----------------------
L cats dre s or Lot No...-
....
Own erL iI Dp/"7 ...................
`d A■ddGej
W Installer , Y-V' Iswr5 1
------------------- ---•••-Address-- -' ----_ -.-.......-..----
Type Building Size Lot__ ...Sq. feet
Dwelling—No. of Bedrooms---•- ............................_Expansion Attic Garbage Grinder
Other—Type of Building _ _____________ No. of persons....._t _............... Showers ( /) — Cafeteria
a' Other fixtures
- --------- ----------------- -•----•----•--•------------------ ----•-----------------
W Design Flow_.:...... ......................gallons per person per day. Total daily flow--------*21- .......................gallons.
WSeptic Tank—Liquid capacityf` gallons Length......___ _____ Width.... +► Diameter___ Ike 1 •...
x Disposal Trench—No..................... Width- _-.---_------ Total Length..... Total'leach mg area_• .__ ____ sq. ft.
Seepage Pit No------------------- Diameter.................... Depth below;inlet=.....�, Totalll hingaf�'ea.._ ........sq. ft.
z Other Distribution box ( ) Dosin nk`" Percolation Test Results . Performed by_. _._ . , ate... ....�-
Test _.
1 Pit No L:."" .�..-...mmutes per inch Depth of Test`.Pit •_� :,._..... Depth to ground water .................
rx, Test Pit No. 2---rX.-...minutes per inch Depth of Test Pit----- " ...... Depth to ground water .....................
a' *: --
Description of Soil "'- ....,. ' .. =5 ' �
x
U Nature 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 TITS:. 5 of the State Sanitary Cod The undersigned furth agr no!o place the system in
operation until a Certificate of Compliance has ued by the bo rd of l al
Signed ". .._ ... .... .:.. f
j ,��. Date
Application Approved By.... /jj+/ .---- .... - = `r Date
-•
Application Disapproved for the following reasons--------------........--------- ---- --=------ -----..........................................................--
.......................................-----•---------------•---•----•--•------.........------........---••-•••---•-•-•-••••••--•-•------•-------•--•--••-----•-----•---•-•---•.......................
Date
PermitNo.........................-............................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
<• "'" BOAR OF HE, L
le . .........OF. e...........::.: ... .................................................
(In#ifirtt#r of Tl mptianre y.
THIS IS TO CERTI , , the In idual ew-tg Disposal System constructed or Repaired ( )
by �� 1� ✓ '
-•-•-
jInstat- --•.. ..._ .. --- -------- - �!.. -------------••-•---•-•--•••--------•---- •••...
hasbeen installed in accordance with the provisions o5 of The State Sanitary Code as describe in the
application for Disposal Works Construction Permit ..... "1'�,. ................ da.ted__ �.'--_------' ' -----:IA-�T
.___......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE T THE
SYSTEM WILL FANCTION SATISFACTORY.
DATE..........................�C.'...... Irispecto V ,'.-%%' .........•......................•...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEAL
Y --- ------- ----.. ...........................
IL
No FEE ......
14f1p asa kn n1 Win ami#
PerlAb
is h by granted...... --- --- ..............................................
to Construct ( R air ( } a Individu Sewage Dis S a"
at No........
__ _ :
Street
as shown on the application for Dispos Works Construction P No. _____ _.__ D ........ "
Board of Heal h
DATE.FORM'f�`,1255 HOBBS & WARREN, INC.. PUBLISHERS
•III
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`' r' " '} LEGEND 1
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Icy , ;`'E�'15TING�'-SPOT EL VA71o`Nt' '0 '0 '` , e' CERTIFIED BLOT 'x PLA,N•
4� pP` �1
x�l ��i�/1 T .7 T i .. 1( { 1 J'.I .. rx
NGJ'h CONTOUR — — 0 — 8 �; .��4 E
,, a FIN -.SHFD 'x SPOT
ELEVATION � L v: ry 3 , E ! "
?EI 'I l�FIN'.SHED`': C,ONTOU,R � -- _,'0 ------ -- -��71/v" E ,�.ts' ��.G.-� )�,,g ' t.
^ this r E 1 , _
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> , t +
{L F1 [ 3
'�"(j tt I I, A-T E `�'I g: A GENT f V r, is 1 t
.PyJ _ ' SCALE /. — �7o ,OATE /,o ; f
J! � L`Zo;R.r E ENGIA/ TRII�IG CO ING�I I
' CLIENT Dt c.�w':�/" I CERTIFY THAT THE PROP® EO
" E +' t ^, 31STE RE ;'REGISTERED
"I JOB N0:._ _ _.. BUILDING SHOWN ON THIS PLAIN
:' '` %I'Vlh : LANDQNFORINS TO THE ZONINa,;,LAWS
I�f ,',A ,I r�ENGANEERS. -,SURVEYOR DR- BY :A . � _ --...
— OF BARNS 8 E ,. MASS
r1A ; lr j ;,M1 rv ' v+A •e' yT 7t2 MAIN ST '' P, /3 .
CH.. BY: o, x4;
`, SCI" t1Mli@,'?"ti, MASS. HYANNIS, MASS. — �G/�y/�q
a , , SHEET OF .`=— DAB E RE
l,I„ G LANO SURYEIYOR
YI Z�'t't'{l P,.�A�S 1 'H 4 (a_'!� — _- - r — ..— ___ _ — `,.
O?E /TNER .TNE S�PT/G,.7"A/V/<
20 .FT MrN ` /Y / .:
�Ef+C.rH//vG _f�/T-:4RE MORE _TN.9,V 12 �ELOyt/
/N T.
1� C CO
1- — = SWA L &AF �BQOUCaNT TO 6/�AOE.�.-i/✓ EX7$h'/9.�
CONCRETE h'ERvy'C/iST /?O/Y COl/�I? S/�,QLL,l3E USE.[
M/iN: A&CH l
co //v DR/VELv.4y,
- e 9 FAQ•F _
O T
a 2 3Q
CLEAN -5�A/0
i
�O AOLs CU VE.4
o r . _ &ACAF/L y
- �--•-� L/QU/O LEVEL - - - - 11
4" C45T �b 2"LAYER
IRON P/PE OF /'9: dl M/N. P/TCN : _� YG.'4L. ° a e • o�• • • • • • o m��
%4"PErt vT. A9/VK
- D/ST,
SEPTIC T o o h • • • • . • • • • • o WASHFO STt�NE
MX B O .r O • • r ""I c
B
gb • •EFFECT/VE •.,` . o b 314
r • e • • •' •
l�t/.9S/JED-STONE
o.. e ::• Yl.v ti .t b /
- _ oc o _
d o a t r • • o e e • • • • v o b P Pi?ECAS T,$EEPAG E
rI • a. o P/7OR EQU/V.
• r • • • . .• •
/NV/eK—r ELEVATIONS
INVERT AT BUILDING 9 7.0 FT _ 6 FT D/AM.
INLET SEPTIC TANK 9 G. 5 FT i_ I U FT. U/AI+7. „ C(SEE TfIBlJLATlOAV)
Ou7-LE7- SEPTIC_ TANK 9 6, 3FT. r-• --
INLET 4)/57R/t3U7-/ON BOX 9 6. 0 FT. GROUND WATET TABLE
OCITLETD/STR/BUT/UN BOX_9 •& FT
SECT/ON OF
/rVL6r 4.EAcH/NG PIT 9 S, S FT SEN/AGE O/SPOSA L ,.SYS7E/>'1
TABULfiT
LEAC�9//VG P/T lON
DES/6N CR17TER/R - SCALE �4 . _ /•_ Q.• D/HENS oN $ 16 FT.
;-.NUMBER OF BEDROOMS _ --
0AR6AGE D/SPO.SA4 UNIT_ a SD/L LOG - SOIL TEST
TOTAL. EST/MEO FLUH/r Z 2' G.4L DAY._. SOIL TESTA/ SOIL 7A5S72`
(UMBER OF :=EACN/NG PITS_ !^FGEK �7•n -EL�1!_ 96:0 PATE OF SOIL TEST �/ �'7 /I y
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