HomeMy WebLinkAbout0007 BEECHWOOD ROAD - Health 7 Beechwood Road
Centerville P j
A = 252 001 J
1
No. 42101/3 ORA
ESSELT E
10%
O 0 0 0
� 6
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is
required for Centerville Ma. 02632 8/5/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer, use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
t� P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
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 ElFails .o o
❑ Needs Further Evaluation by the Local Approving Authority X- z
o
►-, -n
8/5/2010 .r,
Inspectors Signature Date
--i
The system inspector shall submit a copy of this inspection report to the Approving �At:�fiMY oard
of Health or DEP)within 30 days of completing this inspection. If the system is a share4)sysji5m or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall kftmime
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal ys am•Page 1 If 10
Y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every 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:
® 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:
The septic system is in proper working order at the present time.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts .
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every page. CityTrown State Zip Code Date of Inspection
B. Certification (cont.)
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
l5ins•09/08 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
7 Beechwood Rd.
M
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every page. Cityfrown 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 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
El ® 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 'h day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is Centerville Ma: 02632 8/5/2010
required for j
every 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.
t5ins•09/08 Title 5 Official Inspection Form: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
7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® 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: i
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 8/5/2010
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-09/08 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
7 Beechwood Rd.
M
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every 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: Capewide Enterprises,LLC.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Measured
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•01/08 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
7 Beechwood Rd.
M
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
18"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10'+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
1'
Depth below grade: 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 gallon
Sludge depth:
5"
t5ins•09/08 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 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every 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 27
Scum thickness
1"
7"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every 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 No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
a
t5ins•09/08 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
7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ 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.):
Sandy dry soil.no signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line
observed 44" below invert.
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-09/08 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 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every page. CitylTown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
:Map Page 1 of 2
Town of Barnstable Geographic Information System
Parcel View Custom Map11 Abutters Map Size ® Zoom Out ®In
er
AK R
P R KA
L
F31
A� q?
t.
Xa
y�
.3 J
µ
s.
i g
p
rd..'
arv�.
Set Scale 1" 20 t I Aerial Photos x° I MAP DISCLAIMER
f n—trinh4 )Ann-_) in T—Ain of Rarnefohle KAA All rinhfc recant,
liffn-HAA 101 45 72(./arrimc/ar�r�rTanar�n/man aenjr�r�rnnPrtvTll=757(1(11.P�rrmannarhar.lr= R/7/7(11 0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
C4M 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every 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: Bottom of LP 12'
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:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 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 7 Beechwood Rd.
Property Address
Irene Knapp
Owner Owner's Name
information is required for Centerville Ma. 02632 8/5/2010
every page. Cityfrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
1 1
COMMONW ALTH OF M ASSACHUSETTS
EXECUTIVE OFFICE OF ENV N IROMENTAL AFFAIRS
DEPAhTMENT-OF ENVIRONMENTAL PROTECTION
.o
MAP IS Zt
PARCEL,
LOT
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
/J A
ti �'l� s Name:
Owner's Address:
, Co? RECEIVEp
Date of Inspection: V
Name of Inspecto : lease rin )-�g .y `�—C� FEB 13 2004
Company Name: TOWN OF BARNSTAg
Mailing Address: A �� HEALTH D LE
�`� o C DEPT.
Telephone Number: /.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information r-eported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based can my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
- approved system inspector pursuantypasses
ection 15.340 of Title 5(310 CMR I5.000). The system:
Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
,,Inspector's Signature: 7_1- _ Date: �� a
�.-
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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
t
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner•
Date of Inspe ion-- 0 ('
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S stem Passes:
I have not found an information w r r y hick indicates-that any o�the failu.e criteria described in 310 CMR - --
15:303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
& 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,�Vill pass.
Answer yes, no or not determined(Y,N,ND)in the for the following statements. If`'not determined"please
explain.
The septic tank is metal and 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
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(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of l'l
OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
J
Owner: J� f. >
Date of Inspe ion:.�,;�� ,Qj—�Z e
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
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
systern 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 coliform
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.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Insp tion:_ p.
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes Nq/
_ 1/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the around or surface waters due to an overloaded or
J clogged SAS or cesspool
Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS or
l cesspool
>/ Liquid depth in cesspool is less than 6"below inverfor available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
JAny portion of the SAS,cesspool or privy is below high around 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 coliform 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.]
(Yes/No)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•
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
i 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 f o a public water supply Iv 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.
4
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_.. . PART B
CHECKLIST
Property Address:
Owner: C q7
e;;
Date of Inspeakn4Z
Check if the following have been done.You must indicate."yes" or"no"as to each of the followine:
Yes No
Pumping.information.was provided by the owner, occupant, or Board of Health
VWere.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?
V Were as built plans of the system obtained and examined? (If they were not available note as N/A)
V _ 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
ofI the baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge and depth of scum?
V _ 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:
Yes o
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(3)(b)]
5
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Y j
Owner:
Date of Insp tion:d &gjA .
/ VfLOW CONDITIONS
RESIDENTIAL ✓
Number of bedrooms(design): .3. Number of bedrooms(actual): .
DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x 9 of bedrooms):
Number of current residents:
Does residence.have.a garbage grinder(yes or no)`Z2�
Is laundry on a separate sewage system es or nod-[if yes separate inspection required]
Laundry system inspected(yes or no)• ,
Seasonal use: (yes or no);_�
Water meter readings, if available (last 2 years usage (gpd)):07—
Sump pump(yes or no)•
Last date of occupane�.
COMMERCIAL/INDUST � .RIA`L�,
Type of establishment:
Design'flow(based on 310 CMR 15.203): gpd
Basis of design flow('seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):—
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records f `
Source of information:
Was system pumped as part of'A he (yes or no
If_yes, volume pumped: - gallons- How was qu' tity,pumped determined?
Reason'for pumping:
TYP,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 copyof the DEP,approval
Other-(describe):
proximate age o all co . �?nts,date installed(if kn n)and source o information:
Were sewage odors detected when arrivingatte site(yes or no
6
Page - ofll
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL; SYSTEM INSPECTION FORINI
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 elA �r
Owner:
Date of Inspe tion:
BUILDING SEWER(locate on site plan
Depth below grade:
Materials of construction: cast iron 40 PVC_other(explain):
Distance fiom private water supply well or suction line:
Comments (on condition of joints. venting, evidence of leakage, etc.):
SEPTIC TANK:_ Kocate on site plan)
ld
Depth below grade:
Material of construction:�oncrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by,a Certificate.of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: °
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:.
Scum thickness: it
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom f outlet teQ or baffle:
How were dimensions determined: r
Comments (on pumping recommen ations nlet and outlet tee or baffle condition, structural integrity, liquid levels
related to outlet invert,evid nce of leakage, etc.): _ ,
Pf
GREASE TRA ��(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polvethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or bailer
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage. etc.):.
Paae 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
.SYSTEM INFORMATION(continued)
Property Address: ! ao'32e/
1 j9
Owner: 17
Date of Insp tion: —' j
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: y
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:--Z(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:2&1z �- ,j .
Comments(note if box is level and distribution to outlets Vqual, any evidence of solids carryover, any evidence of
4e4age into or out f box, etc. :
fe
PUMP CHAMBER. (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):^_
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
8
Pane 9 of 1 1
OFFICIAL INSPECTION FORM —.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'PART C .
SYSTEM INFORMATION(continued)
Property Address: 2 y
AL 4
Owner: -
Date of I sp ction: 'YY�fCt
SOIL AIBSORPTION SYSTEM (SAS): r—�(lo`c'ate on site plan, excavation not required)
If SAS not located explain whv:
Type leaching pits;number:
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 hvdraulic failure, level of ponding, damp soil; condition of vegetation.
e c.):
CESSPOOLS: &(cesspool must be pumped as part of inspect ion)(]ocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids laver:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hvdraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY1`(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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM Ili'FORMATION(continued)
�?
Property Address:
Owner: / t ,
Date of I sp tion: _—T � �` C)w C�
V
SKETCH OF SEWAGE DISPOSAL.SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
CL-j _
q"
,976
0
qi,6
10
Pace I 1 of 11
OIFFICIAL INSPECTION FORUM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: � �
Owner:
Date of In p tion: a(
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells t
Estimated depth to around water ,} feet
Please indicate (check)all methods used to determine the high around water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
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 � � �
n, f _ J' D/ 0 CD
11
Permit Number: �aDate:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: / Aelfb�G Ozw)lj.
Lot.No.
Owner:_ Address:
Address:
.Contractor: �J� � Address: ��/' �/`'�y
Notes:
STEP 1 Measure depth to water table ` >
to,nearest 1/10 'ft. ........................ .............................. .Date-
month/day/year
STEP 2 Using Water-Level Range Zone �
and Index Well Map Locate
site and determine:
OA Appropriate index well................ ..................
CWater-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to C/
water level for index well ........................... Zy3
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
'to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ................................. .
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) .......................... f Z Z
Figure '13.--Reproducible computation form:
15
4
J
• ,1 t
{ y
f
5
its
4
ji
• f
p
a j
4S ,
i
TOWN OF BARNSTABLE
gyp{INN t0�
OFFICE OF
{ ,A",,,AML BOARD OF HEALTH
VAB& 367 MAIN STREET
1639. ` HYANNIS, MASS. 02601
& e&A
ry
August, 1988 7i6 Z
Dear Underground Tank Owner:
You are now required by the "Health Regulation Regarding
Fuel and Chemical Storage Systems" published in the December
17 , 1987 issue of the Barnstable Patriot, to register your
underground tank with the Board of Health.
Please complete the enclosed Registration card. Include
any evidence of the date of purchase and installation, a copy
of the permit from the Fire Chief, and a sketch map showing
the location of such tanks on the property.
Upon entire -completion of the Registration card, you
will be issued a brass valve tag by the Board of Health.
This valve tag shall be picked up by you or your
representative at the Health Department located in the
Barnstable Town Hall . The tag shall then be attached to the
filler pipe of the underground tank.
Please return completed Registration card to: Town of
Barnstable Health Department, P.O. Box 534 , Hyannis , MA
02601 , as soon as possible. You were required to comply with
this regulation by May 31 , 1988. After this date, if you do
not have an attached valve tag, your oil supplier is required
to report to the Health Department any untagged underground
fuel tanks .
If you plan to hand deliver the Registration Card or if
you have any questions, please see or telephone ( 775-1120
extension 182) Donna Miorandi or myself during office hours .
Office hours are Monday through Friday at 8 : 30-9 : 30 a.m. and
12: 45-2: 00 p.m. . .
Ve-4t►-W-4 u r s ,
Thomas A. McKean
Director of Public Health
a C/
L A ON
SEWAGE PERMIT N0.
VIL ,
L •
A & B CESSPOOL SERVICE
1 BISHOPS TERRACE,HYANNIS, MA 02601
BUILDER OR OWNER
DATE PERMIT ISSUED. �3
DATE COMPLIANCE ISSUED
i
.,t LZ
Tiro`......$ .-
Fxs. ...�...10.00...
THE COMMONWEALTH OF MASSACHUSETTS
.. BOAR® OF HEALTH
. +�,%Town OF............Barnstable
------ ---------------------------------------------------
Appliraa#ilin for Uhipaa al Works C omtrur#ion umi#
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
7 Beachwood_ Rd:...-Cexl. xy].11.�a --..02b,32....... ......................•---•------.........--------...-------•------------------------.............
Location-Address or Lot No.
Charle.-• -----------s Feinson. ... ..61...Shermcm..IU ,...C]�stnvt..Hi1d,,..24&----0216-.7
--•-•-..... ....
Owner Address
A.A..I...CesaPaQL.Se=.ice....----•---•----------------------------•-•--... ----- esxace.,•--l�yar�xii sT M.....0260.1
Installer Address
U
Type of Building Size Lot............................Sq. feet
,., Dwelling—N3. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.............................. Showers ( ) — Cafeteria ( )
Q' Other fixtures -----------------------------•- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter---------------- Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft'
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................................................... Date----------------.....---------------....
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•----------••--•-•-••••-•••---•----••---••--••-••-••------------------------•--•----•---••---•..............----------•----•-•------••----------------.--.•.
0 Description of Soil------ Sand--------------------------------------•------------------------------------------------------------------------------------------------------....-•--•-
U --•--•----•--••----•---•-•••-•--••----------------------------------------------•---------------••------------------••------•-----•-••-••----------•••--------••---------------------------••-•-----•--
W
Z. ••------•••--•--••---•-••----------•------•-•-••-••-•---•-----------•-------•------•-•-----•-•-•-•-------•-••------------------------------•-•----••--•---•-...........................................
U Nature of Repairs or Alterations—Answer when applicable...:-installati on cf a 1,000__ga 11on septic tank
distribution box and a 1,000 gal. stone packed leach pit (overflow .
..-•---•----•----------------•••••--------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System i accordance with
the provisions of iITI.i� 5 of the State Sanitary Code—The undersigned furtl: grees not t pl e the system in
operation until a Certificate of Compliance s e ue by the h
Si -- .........--•------•--•--- ---- -- , .....i0f 27/83.------.
y . Application Approved B --•-.......... •----•• -------------44`_-=.----------
Date
Application Disapproved f th ollowing reasons:---•----------------------------------------------------------------------------•--------------------------•--•-
..............•--•-----......•••----•-------.----
Date
Permit No.--------83.......................................... Issued•.......10/27/83.............................
Date
J f.
83J.. Fims...... ...10.+!.OQ..
- r
THE COMMONWEIA LTH OF MASSACHUSETTS
BOARD OF HEALTH c
--•...................Town.........OF............Barnstable �'
r -----------------••---......_.......
Appliration for Diopuoal Workri Tonstrurtiun Erred#
Application is hereby made-,for'a<Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at: '
7 Beachwood Rd. , Centerville! MA 02632
................__--------.................-----......... -••......._....•--•-----••------------•....----------•-------------•--.......--
Ch�rle$ FeinSon Location-Address or Lot No.
. -• ............................................. ..........61 hermaxl•... ...a.Cl _striLt�..Tiyl�.g C Owner Address
.a; Cesspool Service 2$_. �.3}as .T rrac�,.-H3ranni s,---1��......0260_1
C Installer Address
VType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
04 Other fixtures -----------------------------------------•----
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............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......................................................................... Date-----------------------------------------
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----------.............
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a
ODescription of Soil--------------------•....---•-------•-•---------------------......--------••----------------- ---------------------------------------------------------------------•-••-
x
w
x r to at' n —An er hen a li bl .. installati on 4f a 1,000 gallon septic tank
U ditPi� OxQ a ',t�00 gad. s` one pp c e each 9 t overflow .
Pa P }
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in-.accordance with
the provisions of TITL% 5 of the State Sanitary Code— The undersigned further-agrees not to/place the system in
operation until a Certificate of Compliance.ha's`�e-n 's eed by the oarh<Yof health!
n .. �--- 10�?'7� ..........._
r
Application Approved BY r-•--•--•--•--•---•----- -----------1�� 3--•-•.••--••
Date
Application-Disapproved ,or t following reasons--------------------------------------------------------------------------------------------------------------•-
n ate�
- 10� /g3
PermitNo.......................................... ------ Issued.......................................................
r Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barns table
..........................................OF.....................................................................................
�. (9rdifiratr of Toutplianrr
H S„L� T CER T FY.That ��II •vidual Sew. e Disposal System constructed ( ) or Repaired (x )
�es�pooler�tice, t� shops Terrace_, l:yar_nis, r{t� 02601
by..... ..--•--•-•••-••._...•--.......---•-••-•---•--••---•-• •-•-•-•--••-•-••-•-•--......--••---------•------•---._...._
7 Beachwood Rd. , Centerville, MA 026JValler Charles Feins on
at................................................................------------------------......---------•--••---•---•-••-•-•-•--•-•--•-•-•---•••--•--••----•----••-•----••--------------------------
has been installed in accordance with the provisions of '"�' C�_ofZXhe'State Sanitar Me as described in the
application for Disposal Works Construction Permit No __ ................ dated.....7�$3_._______--_____._............
THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONED AS A GUARANTEE THAT THE
SYSTERA WIL F A CTION SATISFACTORY.
DATE.....fr..��..P- ----------------------------------------------------
Inspector.. `
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Pares table
.......................OF............:..... .......... $ 10.00
No. FEE `......---••••..-•---
i3iopouul Workp %Tonsirttrtion rrutit
Permission is hereby granted vice
------------•--•- --•.............A & P Cesspool Service ......................................
to Con t or air�y l an I dd vidu-1 Se�� Disposal System
� a(eh oal t�., 'CerTtery I'le, tRA t �32 P Charles .�einson
atNo.. - ------------------•-------• ------.............. �-
Street
as shown on the adlica on for Disposal Works Constructio rmit!No.. ..... ......... Dated.......... 0I27183.............
,apt
DATE...... . .. ._ ............. ...............---••--•------------------------ Board of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
�- 9c/7,
Z Q 6A-bON SEWAGE PERMIT NO.
waoto R®.
VIL 1.
`f
Z
A & B CESSPOOL SERVICE
128 BISHOPS TERRACE, HYANNIS, MA 02601
BUILDER OR OWNER
CH 9gLazlr %FISc�V
DATE PERMIT ISSUED / l�
DATE COMPLIANCE ISSUED
,
fl
, tl
a� e
0
I
i
Oflic,q W o,,,o n�
36'-3 7/8"
16-6 1/8"
2'-0"x 4'-6" 5'-0" 5'-0" 5'-0"
'4
-v
x
c DlnningrOOm 2'-0"x 4'-6" 2'-0"x 4'-6" 2'-0"x 4'-6"
CV
Bedroom �
Knapp Residence, 7 Beechwood, Centerville
Y
-v
x
o �
fV N
O7
fD
N
Q-
Livingroom N
Ioo
Bathroom ~'�d
v5'-0" 5'-0"
x
9 24'-0"
iv c
fV
2'-0"x 4'-F 0"x 4'-6" 2'-0"x 4'-ir-0"x 4'-6"
12'-3"
16'-7"
�x
7'_ "
DECK
14'-(o"xB'-0"
1x MAHOGANY DEC ING
B
PAN RY
0 0 �
� o
i
O'-4'► DW 1 `-i ►t�
_J
KITCHEN o
LIVING RM. r
REF OVEN j
i
- �O
-------
O
D i PULL DNi ►
_ O i STAIRS
10 LIN O
i CAB ' o
i
- i i1 (D
i
CL 1 '-3" BATH
BEDROOM 00
CL. n ti
® 4B"x3
II 12 ►-all . (o"
4 17g R FIBER GL.
CL wI/OER
LASS NCLO URIC
1
r
CENTER ON ,_ "
6'_ ►� GABLE
30'- ►►
t-
C)�5 ICON D FLOOR PLAN
S AI-F-:1/4" 1'-0"
C�
NDOW
SCHEDULE
T. MANUFACTURER'S UNIT ROUGH OPENING REMARKS
ANDERSEN TW18310 1 '-10 1 /8"x4'-1 1 /4"
�t
ANDERSEN TW24310 2'-6 1 /8"x4'- 1 1 / "4
ANDERSEN TW2842-2 5-7 5/16"x4'-5 1 /4"
ANDERSEN CR235 2'-10 1 /4"x3'-5 3/81)