HomeMy WebLinkAbout0018 BROKEN DIKE WAY - Health 18 Broken Dike WaY
Centerville P
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UPC 12543
No.53LOR FPp�-CONSJ�D
HASTINGS, MN
No. Fee J®y
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIppYicatiou for �Bigogal �§pgtem Cougtructiou Perron
Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) ❑ Complete System ❑Individual Components
i 44
Location Address or Lot No. C /t/T 6A Owner's Name,Address,and Tel.No.
l d o�� v�yh,. S
Assessor's Map/Parcel
Installer's NaLne, ddress,and Tel ��pe�c� Nis Designer's Name,Address and Tel.No.
w > /�D• f3®xz t,
Type of Building: _
Dwelling No.of Bedrooms S Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 5 d gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank t X 1 s, Type of S.A.S. S' 3 0.S"d
Description of Soil
Nature of Repairs or Alterations(Answer when applic b
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site se age ilisgo '�ystem in
accordance with the provisions of Title 5 of the Environmental Code and not to place the s tem in o er i i a erti cate of
Compliance has been issued bY this-Board-ef Dealt
S'g Date o ?�
Application Approved b Date
Application.Disapproved by: Date
for the following reasons
Permit No. �LW G '' 7 s Date Issued 3
a., �"" l .', s�� •�, w� \ vim,,.,.�•i � 7
No. (LL�b{ ti Fee
THE `COMMONWEALTH OF MASSACHUSETTS ^ Entered in computer:
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes „
"~ Zlp�tication for ai.5po5al *Vgtem CoTlgtructiou__Permit ,
Application for a Permit to Construct( Repair( �) Upgrade('`Abandon O ❑ Complete System [:]Individual Components
Location Address or Lot No. c v T F2 Owner's Name,Address,and Tel.No.
/8- a4..4,6 / WAY `Q -
Assessor's Map/Parcel —2 7 a /
Installer' N e, ddress,and Tel a {�'t''' ` T" ' Designer's Name,Address and Tel.No.
�16f Y3
Type of Building:
Dwelling No.of Bedrooms S Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 5� gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank' f' X s i x /J-p y Type of S.A.S. S' 3 a S'y L i�i•P A T 2,-
Description of Soil 1
r
Nature of Repairs or Alterations(Answer when applicable•
log
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site s1wage dimosai�ystem in
accordance with the provisions of Title 5 of the Environmental Code and not to place the s stem m o erat�o��u�ti9-a Certificate of
Compliance has been issued b this Board-of Heal-t:h,
>gn Date
Application Approved b Date 'a 3
Application Disapproved by: Date
for the following reasons
Permit No. 3 5 Date Issued `a 3 >
-----z=---.—
, It THE COMMONWEALTH OF MASSACHUSETTS
*` BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( )
Abandoned( )by
at / 5;� .4 o`r E f/X Gl 4 y �+� r r has been c�tructed in accordance )
with the provisions of Title 5 and the for Disposal System Construction Permit No. '-3 7S dated <R�
Installer 2 G '� Designer y E 1"7 0!0 <-ej
#bedrooms Approved design flow d, / gpd
>i \ P G
n f his •errmt shall-not/be construed as a guarantee that the system will function as desi ned.The issuance o t , �
Date J) / //d 7 f / Inspector
rot tom, �+
—__-------2—^�—=—=— ------------- --- t=------
No. -Dw (.0 J / Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
1=i5po5al �&pgtem Construction Permit
Permission is hereby granted to Construct ( ) Repair ( 4-T Upgrade ( ) Abandon ( )
System located at S v �✓ yy �-/'r= �—r/f� s�
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to co
d
mply with Title 5 and the following local provisions or special conditions.
Provided: Construction ust be)ompleted within three years of the dat• of this p
Date 3 Approve
i
Rug 29 07 09: 4?-p " 508-833-2177 p, 1
Town of Barnstable
o
Regdatary Services
i Thomas F.Geiter,Director
'AS` Public Health Division
Thomas McKean Director
200 Main Street,Hyannis,MA 02601
o-
Office:.508-862-4644 Fax 508-790-6344
Installer&Designer Certification Form
Date.- 27 7oo`7
Designer: ..Dw 1 F j. W110 iV" e
—r—_ Installer: �a� �, (�i
Address• , Address:
°off ,r;'. 4' ,` `,jam; was Yssued a permit to install a
(date) installex)
septic system P1K �on adesz drawn b
(address) II Y
11I �• NOME da#ed � �I Zoo (�
ce tify that-the septic.system referenced above was installed substantially according to the deaign which may inchcde minor approved changes such as lateral relocation of the
distribution box and/or septiic tank.'
I certify&at the septiic system refimaced above was installed with n4or cbanges (i e.
greater tbxa 10'lateral reloc atiou of tbie SAS or any ve3cca2 relow ion of�.component
of Ih.e septic system)but in accordance with State&Local Regulations. Plan revision or
certified as-bnitlt by designer to follow
he's
�V.h
(Affix DIN
es '$; - Here}
QF Co T r....A. �UB�IC HF,A,LZ'$DIVISION C�tT CAT :CEI,I, NOT BB ISSUED D$M AND AS-
BUII,T BARD ARE, Mu 8Y THE BARNS�ABLE FUBLIC REACTS DIVISI(?N
TBANK__MOM
Q:He9W&-PhcJDesiPwCertificetionForm
i
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION-EXEMPTION FORM
d hereby certify that the engineered plan signed by me
I, ���/l � y
dated $5 4 v L ,concerning the property, located at
Cf4 \ [`'�_Zlrneets all of the
following criteria:
• Two soil evaluations excavated for detailed examination(no hand augering)and two
percolation tests shall be conducted.
• This failed system is connected.to'a residential dwelling only. There are no commercial or
business uses associated witfi the dwelling.
• The soil is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes
per inch.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
1
• The bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) z6. D
+adjustment for hi
B) G.W.Elevation J �G.W.
DIFFERENCE BETWEEN A and B
SIGNED DATE: '^1 �
NOTICE
Laseponllhe above information;a repair peimit will.be issued for bedrooms
o additional bedrooms are authorized in the future,without,engineered septic system
zap : G LADS.
q:VSeptiapermemp.doc
TOWN OF BARNSTABLE (7 ko—3`7 S�
LOCATION SEWAGE# ZW 4,
VILLAGE SESSOR'S MAP&PARCEL Z1-7
INSTALLERS NAME&PHONE NO. CqO
SEPTIC TANK CAPACITY 1 S Can kd y o {
LEACHING FACILITY.(type) Cs- 3y sp H-1U (size) 7c, u�/
NO.OF BEDROOMS
OWNER �:� u�
PERMIT DATE: "2 k" 01 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 facilitty)� Feet
FURNISHED BY
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S3 ��`•�'
3� �.v
COMMONWEALTH OF MASSACHUSETTS
UV EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
4
i
Ai,k 1 7 2004
ToVv,, LiARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
r��� 2°�7
Property Address: 18 Broken Dyke Way 114AP PARCEL
Centerville, MA 02632
Owner's Name: Tim Scales L01
Owner's Address: -�
Date of Inspection: April 9, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
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
Needs F her Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: April 14, 2004
The system inspector shall submi 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 \6/15/2000page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Broken Dyke Way
Centerville, MA
Owner: Tim Scales
Date of Inspection: April 9, 2004
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.
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:
i
2
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Broken Dyke Way
Centerville, MA
Owner: Tim Scales
Date of Inspection: April 9, 2004
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
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 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 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Broken Dyke Way
Centerville, MA
Owner: Tim Scales
Date of Inspection: April 9, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either`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 'h day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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.]
No (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 System:
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
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.
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Page 5 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 18 Broken Dyke Way
Centerville, MA
Owner: Tim Scales
Date of Inspection: April 9, 2004
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:
Yes No
✓ 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)J.
i
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Page 6 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 18 Broken Dyke Way
Centerville, MA
Owner: Tim Scales
Date of Inspection: April 9, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 7 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Number of current residents: 4
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system (yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
C O MME RC IAL/INDU S TRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): pd
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
Source of information: Pumped 2 years ago-per owner
Was system pumped as part of the inspection (yes or no): No
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Installed 2127189-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Broken Dyke Way
Centerville, MA
Owner: Tim Scales
Date of Inspection: April 9, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 2'
Material of construction: ✓ concrete _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: 1250 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 5"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
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Page 8 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Broken Dyke Way
Centerville, MA
Owner: Tim Scales
Date of Inspection: April 9, 2004
TIGHT or HOLDING TANK: None (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: izallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
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 level. No solids were present.
PUMP CHAMBER: None (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
• Page 9 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Broken Dyke Way
Centerville, MA
Owner: Tim Scales
Date of Inspection: April 9, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-4'x 6'w/]'stone (per design plans)
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.):
One leach pit 04)had 4'of water on the bottom. Liquid was up to the pipe. The bottom to grade was 8'. The cover was 42"
below grade. The other leach pit(#S)had]'of water on the bottom. The bottom to grade was approx. 8.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Broken Dyke Way
Centerville, AM
Owner: Tim Scales
Date of Inspection: April 9, 2004
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.
' 8
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Page 1 1 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Broken Dyke Way
Centerville, MA
Owner: Tim Scales
Date of Inspection: April 9, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 21' +/- feet
Please indicate (check) all methods used to determine the high ground 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: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the pit to grade was approximately 8'per design plans. Water was observed at 21'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
I1
Q TOWN OF If STABLE �.
LOCATION SEWAGE #
V`&LAGE CQT/fT'!-f%/A LL ASSESSOR'S MAP & LOTaa'/ 04l/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY UvD nn LL
LEACHING FACILITY: (type) a' el tD I'�TJ (size) 6^ I
NO. OF BEDROOMS
BUILDER OR OWNER �^'� S7c
PERMITDATE: 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 cility) ^� ) Feet
Furnished by on J r0/G
p �rOnT e
3 ,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 18 Broken Dike Way EREIVED
Centerville, MA 02632
Owner's Name: Catherine Haves
Owner's Address: Same 2001Date of Inspection: June 8, 2001 NSTABLEDEPT.
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map: 227.
Osterville,MA 02655-0049 Parcel. 081
Telephone Number:._ (508) 862-9400
CERTIFICATION STATEMENT
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
Con ti ally Passes
N s F rther Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: June 13, 2001
The system inspector shall sub 't copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completin 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 I
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Broken Dike Way
Centerville, MA
Owner: Catherine Hayes
Date of Inspection: June 8, 2001
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: r
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.
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
f
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Broken Dike Way ..
Centerville, MA
Owner: Catherine Haves
Date of Inspection: June 8, 2001
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
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 ce*tihed 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: 18 Broken Dike Way
Centerville, MA
Owner: Catherine Haves
Date of Inspection: June 8, 2001
D. System Failure Criteria applicable to all systems:
You must indicate either"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
a r
clogged SAS or cesspocl,
✓ 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
✓ 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 1.00 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.]
No (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 System:
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
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
` CHECKLIST
Property Address: 18 Broken Dike Way
Centerville, MA
Owner: Catherine Haves
Date of Inspection: June 8, 2001
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 ins ected for signs of break out .
P gn _ .
✓ Were all system components,excluding the S'AS,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:
Yes No
✓ 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
..�:. �J wFF M�• a�y� 4 M1gc,l if< d''y3�
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 18 Broken Dike Way
Centerville, MA
Owner: Catherine Haves
Date of Inspection: June 8, 2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 7 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): go
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2000-211,000 gals.; 1999-112,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persoris/sqf,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
Source of information:Pumped on Nov. 26194-per treatment plant
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
.Other(describe)::. ,
Approximate age of all components,date installed(if known)and source of information:
Feb. 27, 1989-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM`INFORMATION (continued)
Property Address: 18 Broken Dike Way
Centerville, MA -
Owner: Catherine Hayes
Date of Inspection: June 8, 2001
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _40 PVC _other(explain):
Distance from private water supply well or suction_ line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 24"
Material of construction: ✓ concrete _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: 1250 gal.
Sludge depth: . 2"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness: 12"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: 4"
How were dimensions determined: Measuring stick
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. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping
and installing risers to bring covers within 6"ofgrade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping.recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
R
� ; t r
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Broken Dike Way
Centerville, AM
Owner: Catherine Haves
Date of Inspection: June 8, 2001
TIGHT or HOLDING TANK: None (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: Qallons
Design Flow: Qallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
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 level. There weree solids in the D-box. There were no signs of leakage. The flow was equal. The cover was 3'
below grade Recommend installing risers to bring cover within 6"ofgrade.
PUMP CHAMBER: None (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
.Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property Address: 18 Broken Dike Way... -
Centerville, MA . .
Owner: Catherine Haves
Date of Inspection: June 8, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits;number: 2-4'x 6'with]'stone(per design plans)
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.):
One pit 04)had 2'6"ofwater on the bottom. The scum line was 3'up from the bottom. There were no siens'offailure. The
bottom to grade was approximately 8'. The cover was 42"below grade. The other pit 05)was located, but not dug up.
Recommend installing risers to bring covers within 6"ofgrade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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. .
'IJ
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Broken Dike Way
Centerville, MA
Owner: Catherine Haves
Date of Inspection: June 8, 2001
Map: 227
Parcel: 081
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.
AJI
i
07
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3
A;t a I
Al-
A S- 3 5
as. 38�
10
i
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property Address: 18 Broken Dike Way
Centerville, MA -
Owner: Catherine Hayes
Date of Inspection: June 8, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground 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:
_ r
You must describe how you established the high ground-water,elevafion:
The bottom of the pit to grade was approximately 8. Per design plans, water was observed at 21'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
f'� F
TOWN.OF BARNSTABLE
LOCATION �1- SEWAGE #
VILLAGE IXn_ �VV!IL ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I0L SD
LEACHING FACILITY.: (type) 0'1 ' _ P►TS (size) yX�e� 1 SrOnl
V NO. OF BEDROOMS__
BU LDER OR OWNER_CA 144 —_—�-
A� -PERIvIITDATE: 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)I Feet
Furnished by
Aa- a
d O A3- 8
Ay- yy y
3 4N• a-7
Af• 3Sr, J
" �s• 38,
THE COMMONWEALTH OF MASSACHUSETT�SQ,Fe�. B�. C�tidJ.�.������•v:�
BOAR® OF HEALTI-I ®rnr�vsf���
----0 co_J ......... OF -----------------------
Appliration for Bi"vii al Works Tonstrurtiaan Prratit
Application is hereby made for a Permit to Construct (jQ or Repair ( ) an Individual Sewage Disposal
System at:
i
LLocatio. •.Address or Lt No.
-••--... - •-.--•-- -.-- ......._...__......... ..........?.... :............................
Owner ----•---------------------------------------Address
�_._. .&.
Installer Address
Type of Building Size Lot..33.j. a....Sq. feet
Dwelling�No. of Bedrooms______________________________________Expansion Attic ((�®) Garbage Grinder 'k a)
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p' Other fixtures ............................... ..
--- ---------
d -�
W Design Flow............ . .....................gallons per person per day. Total daily flow_........_.�'�.................._.gallons.
WSeptic Tank—Liquid capacttyl .gallons Length................ Width................ Diameter................ Depth...--:..e......
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------?......... Diameter----4�..-_...... Depth below inlet........ ......... Total leaching area..��? �� ft.
Z Other Distribution box (�) Dosing tank ( _ A -
Percolation Test Results Performed by.......................................................................... Date �....
Test Pit No. 1....�.....minutes per inch Depth of Test Pit___O Z ➢•-_-__-- Depth to ground waterA0
(i Test Pit No. 2...�------minutes per inch Depth of Test Pit......at_i__.._... Depth to ground water____a__............
x .�.........................................•---------------------•------......-----
----- ---------------
--------------....................
o Description of Soil------ ---------------------------------
x / r i
U ---------------------------•---------..•-------•.. -- D -„���
W -------------------------- ...........................................................................................................................................--------------------------------
UNature of Repairs or Alterations—Answer when applicable._..............................................................................................
---------------------------------------------------------------------------------------------••--•----•------••--•---------------------•---•----------•-------•-•--------------••--•---------•...------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
'1 T/•1'^
the provisions of f21 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board f health.
-� bb
4folow
ned- ........ t ------- -- - /--••-•--G �-"---------------- -- - --
� / �Date
Application Approved By........ -------- --- _. ----•-•----------------------- ...... .r .�.1A-/$-7
Date
Application Disapproved for th reasons:................................................=--.............................................................
-•------------------------------•--•...............................--•-------•-------•-•--•------------....------------•----•--•---....------------......------------------......--- -•------------
Date
PermitNo......................................................... Issued_.......................................................
Date
i
"WILLIAM LIEBERMAN
REGISTERED PROFESSIONAL ENGINEER
LICENSED REAL ESTATE BROKER
235 TIMBER LANE(MARSTONS MILLS)
W. BARNSTABLE. MA 02668
t617)425.2592
February 27, 1989
Town of Barnstable
Board of Health
Hyannis, Ma. 02601
Re• Lot 10
18 Broken Dike Lane
Gentlemen:
I have inspected subject septic system prior
to installation and after installation of the system.
I found the system to be in accordance with the
approved drawings and suitable for the intended purpose.
Very truly y s,
(/U l L/Z r/g9
WL/el William Lieberman R.P.M.
�Pm �N OF P44ssq
WILLI?M
v; LIEBEMOAN
FSS;O r•:A��
e
No......... '•--�S`� Fms.............................
t THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4...v�_�.................OF.` .Z�S....................................................( ��
Apptiration for DhipwiFai Works Tomitrurtion thrutit
Application is hereby made for a Permit to Construct (YQ or Repair ( ) an Individual Sewage Disposal
System at•
q T I o 13: .Q�� _ < Q A �EL C./v% 1t v.4- ---•----......-•--•---•.... ..........
.. _ . .- - .....
Location-Address or Lot No.
Y-----•-------•..................•---------- --........----------.....--------•-------- - ---------•-----•--•--.....-----•.............._
Owner Address
a ---•---- -�-�- � -��-41:s------------------------------------------- ------------------------- ---------------------------•--------_____-_ x�
Installer Address
Q Type of Building Size Lot___ feet
Dwelling--X-No. of Bedrooms______________________________________Expansion Attic (/(/) Garbage Grinder (A/c)
`4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Ga Other fixtures =- ---------------------•--- - .
d _ - - -
W Design Flow____._.___._-`_ ____________________gallons per person per day. Total daily flow_..__.._.._..`_��..____._______.______._gallons.
WSeptic Tank—Liquid capacity.iz��gallons Length........ Width................ Diameter................ Depth.... __`__.__-
x Disposal Trench—No_____________________ Width____.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------fir-------- Diameter......(, ...__..__ Depth below inlet.......4.....__. Total leaching area___4U.(_.sq. ft.
z Other Distribution box (A Dosing ta4 ( ) B A)� Tc f- ��AYE � 7,94- 67
'-' Percolation Test Results Performed b ............... Date....
Test Pit No. I-----_g_--.....minutes per inch Depth of Test Pit.....C2.......... Depth to ground water__Nn4j t__..EAJ6
Test Pit No. 2___!1......minutes per inch Depth of Test Pit______ _ _______ Depth to ground water-----t5.............
RI' r
ODescription of Soil Q - C=------L..C2.6_M__.�±.•y. {' ---- -------------------------------------------------------------------
W ---•---•------------------------•••-•--•-----•-------•-••--------------•------••••••--------••--------•-------------------------------•--•--•-------•-••-----------•••-•••••-•-•------•-----------_---
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'2TTLE, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board health.
AO
jigned ric _ _-- /-•-- Date
Application Approved BY---------- }- - - - ----_-----------••------ ------ Date
Application Disapproved for theg reasons:------••---------------•---------------•------------------------------------••---•----••-----------------------
rr
----------------•-----------------------•••---•---------•--------------------•----------------------------••--------------------•-•----------------•---------=-----•----•--••-•------••--•----...._..._
Date
PermitNo......................................................... Issued_.......................................................
Date
t THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..v .! ...............OF. ..A... .tJ. T/ s...s�...................
Tlertifiratr of Bout 1t�tnrp
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (' )
Installer '
at.............................................................................................._...___..---------------------._._.-•---•----------....................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
• application for Disposal Works Construction Permit No------
.......................}__________ dated................................................
`THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTE&I�-WILL FUNCTION SATISFACTORY.
DATI:--•-----•----=---------------�=-.=-7- .��-----•-- Inspector.. =
�IVV�IV ►u� ST THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................................OF.....................................................................................
f+�
FEE....c".� !........
AsPermission is he granted_..:; ______________ �. �__
,
to Construct ( or Repair ( ) an IndividualSewage Disposal System
10'at No........... ........1 ---1 ........
-i n��tIV.....W�q �f =
Street +�
as shown on the application for Disposal Works Construction Permit No.__�+__l�_ Dated.............................................
•••----------- = { ---•-•--
f l^ Board of"Health
DATE. 1 " . L
FORM 1?55 HOB S & WARREN, IN:., PUBLISHERS
%,ASSESSOR'S / � PARCEL
LOCATION SEWAGE PERMIT NO.
VILLAGE
I N S T A LLER'S NAME i ADDRESS
Z
• UILDE R OR OWNER
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'
DATE PERMIT ISSUED
DATE -COMPLIANCE ISSUED
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S 0 1 L LOG
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N0. 1 � N0 . 2SITE PLAN
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— TOP OF FOUNDATION EL . S �
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IN.EI ;,� IN.E _ 1 _ -
_
IN EL L ' lN.E�. 61165
_ — - _ `1'� u � •. ✓ — 2 COVER 1 8 3 8 WASHED STONE 1 12
O/B W/ 6 SUMP Nf b o 3!4 1 1i2 WASHED STONE r--- -- . 13
• 4 LIQUID LEVEL • - �. c . 14
o � .
1 "EFF. DEPTH! r 15 --
`}; f PERC T ES T RESULTS
! PRECAST SEPTIC TANK WITH �� ° � � i - - PERC RATE :
! ,a =� PRECAST LEAC4NG PITS
CAST IN PLACE FILET AND _ � ° ' •° wr- WHITNESSED BY '�' �r�rr
' ( OUTLET T " EL. _ � �ri _ SIZE : - 4 _ �_ _ _._ T_
U S PER TITLE y NO
f , _ �_ _ . - BOARD OF HEALTH
SIZE : � c, >_�� � DIA - � ' DATE : w �:., 19 34 _ _
?5�4- 7CST t3 'f 3�x7te.
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PROFILE CIF ' PROPOSEDSEWAGE � .�S SYSTEM � ` F' ��, ��- }.
SYSTEM DESIGNED BY THE TOWN OF _ T1 . ��'__ REGULATIONS AND
STATE TITLE V FOR SUBSURFACE DISPOSAL OF SEWAGE , SCALE : 1/4"- 1 ' 0 "
N . B . �' �� � -�� � :_
1. ALL PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE 4 ` :
2. ALL PIPES SHALL BE SLOPED 1/4 PER FOOT EXCEPT FOR },
THE FIRST 2 FEET OUT OF THE 0 / 8 WHICHlLEVEL % ' -t' `•. - '`SHALL A L B E
/ 1
3. DESIGN FLOW __ ,BEDROOMS AT 110 GALDAY PER BR . ¢��_ GAL /DAY ,�, �.�y
SEPTIC TANK SIZE 4� X GA � '�• - � � ' � J , +-y ;
� USE -. � ;.F ` ,� �/ � 1 � .� ,, � t � `� � ��
IZ �? _ GAL. W/ r- GARBAGE DISPOSAL ' ��
LEACHING SYSTEM. USE - �' ;,,��.. 'f �� --- ��� ,, f . ` fr ►. ''
EFFECTIVE : SIDE
AREA •
BOTTOM
a1
TOTAL ;
TOTAL REQ D FLOW X W/ -- GARBAGE DISPOSAL
_y
RESERVE _ -F ,Y � - :�
LOW . �� _ GAL/ DAY > ��
REFERENCE PAN �.f� -i �n z � 1 � f ✓r _� � .� !'� - - 1� ter ;
C PLANS . -Jr � .�
1 '
--- '
f L 4 '1-
APPROVED BY 4
- - BOARD OF HEALTH
DATE : _ _____
PROPERTY OWNER : - � o - - -_ _ - ___ ---- -. ,j; �� �� �✓HG� P- J/ / N
.�»___ _..______ _—...—_._.____ _._ —___ _,..... ...__ i.''•1�{,0_ +..r'jC,r :,;'�- _ ...., 4-- k�'L-o�C70iilt ..71 t'V C'7E..L.
1
DA Tc 8
�'�� {.' �,,� � �_� ~,�-��•,�, L��_�t���E »tip
>f ' L 2.3 5 1 mrJrc�L N,-PN V
ASSESSORS MAP : TEST HOLE Lt_;)GS NOTES:
PARCEL: -� �j1 + r
FLOOD ZONE: t�p� ��-�.,�C.�t'�L--� _ --_ SOIL EVALUATOR:�AV1�^,"
►
WITNESS : 0f t' 1) The installation shall comply with Title V and Town of Barnstable Board of
REFERENCE: '`A9 ?�IuTr rY L�T RA�4DATE : l 1-- \ 1 Health Regulations.
',Q PERCOLATION
2) The installer shall verify the location of utilities, sewer inverts and septic
components prior tc installation and setting base elevations.
q " ' Z ` 3 All gravity septic piping to be 4 inch Sch 40 PVC at 1/8 per foot. The first
TH- I \ TH-2 ) � Y P P P g
two feet out of the dbox to the leaching.
')W fey l W 4) This plan is not to be utilized for property line determination nor any other
t" DKE INA P t' 1 .'� sj �` l 3 tij purpose other than the proposed system installation.
>-0 5) All septic components must meet Title V specifications.
tp
10 { 6) Parking shall not be constructed over H10 septic components. Proposed units
Y1L'(o ��� 1 _ are H2O.
7 Za 7) The property is bounded by property corners and property lines.
OCAT I ON MAP t , ppy
8) The property ovmer shall review design considerations to approve of total
design flow and number of bedrooms to be considered for design. Receipt of
2 l l payment for the plan and installation based on the plan shall be deemed
ll ' approval of the design flow by the owner.
9) The existing leach pits shall be pumped and filled with material per Title V
3
abandonment procedures. Those within the proposed SAS shall be removed
\ q10 � � �a 1 �f (� {� along with contaminated soil and replaced with clean washed sand per Title V
specs.
dl fP� 10)System components to be 10 feet from water line. Sewer lines crossing the
` water line shall be sleeved with 6 inch SCH 40 PVC with ends
SEPTIC SYSTEM T E DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility
C M of the
owner to ensure such.
FLOW L6jT 11«ATE 12 Existing tank to be verified as 1500 gallon tank. If tank is less than 1500 it is
) g
f� \ to be replaced with a 1500 gallon tank minimum per Title V.
U �\ BEDRO: ,S AT ��O GAL/DAY/BEDROOM - GAL/DAY
Requested Variances;�
\ \ _TANK- - -— —
n \ Title V; Section15.211
(� , SAS to Foundation. 20 feet required, 18 feet proposed, 2 foot variance
L0 GAL:r!AY x 2 DAYS - ` V GAL with 40 mil poly liner.
USE. GALLON SEPTIC TANK
IZ /
\ \ f _ �- �/ �UWXAL �O1 k��AD) Section 15.221 7S011� 0iPTIONYSTEM - O Requires that the top of the SAS be within 36 inches of
\ \ \ \\ I Grade. Top of proposed SAS is 3.5 feet below grade
Which is 6 inches deeper than allowed due to depth
Of existing septic tank.
S I D : AREA: 7iX ��l��o -f 1��L�j X�� O A =
B07 ,Z"! AREA-
-SEPT ���',� � � `� ' " '' ✓ t � -
\ I C SYSTEM SECT I ON
l
1, \ A fif.l
z�
4, �� / D to I� 3 -_ 2 � -��' _ �i�►A(,
14
LL
�--- ,_ GAL
\ SEPTIC T 46
M
1
n : may- - ��No.X ID
os� o �� SITE AND SEWAGE PLAN
L{�CAT ION : I
PREPARED FOR : . 4oKc �149 5gM6
Ila
° \ SCALE: I
0 O
_ D;4V I D B . MASON DATE:
DBC ENV I RONMEN�6t L DES I GNS
W Q�Ell�-� EAST SANDWICH . MA
Z �
22 DATE HEALTH AGENT ( 508 ) 833- 2177