HomeMy WebLinkAbout0286 BUCKSKIN PATH - Health f 286 Buckskin Path
Centerville
A = 191 — 123
5 M E A D
No. H163OR
UPC 10259
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No. / .--- Fee Vs '
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYitation for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System PeIndividual Components
Location Address or Lot No. "a$�0 130C4eSKLA1 P47N Owner's Name,Address, d Tel.No.
Assessor's Map/Parcel t al t (01� �t�?�Cl�4JltLL ��F �A.�W
Installer's Name,Address,and Tel.No. 50 8—417—$g{71 Designer's Name,Address,and Tel.No.
`'53 C- eE
Type of Building:
Dwelling No.of Bedrooms Lot Size 0 sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature"of Repairs or Alterations(Answer when applicable)
8tQrPtAc,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ea .
Sig Date
Application Approved by Date L�
Application Disapproved by Date
for the following reasons
Permit No. �� % Date Issued
C vlgt
l ' �o<-g,— es ®�
,boA d'�"
No. 4/ � `! / 1!( Fee D
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
PUBLIC HEALTH DIVISION -TOWN;'OF BARNSTABLE, MASSACHUSETTS Yes
application for Nsposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair()Q Upgrade( ") Abandon( ) []Complete System (Individual Components
`Location Address or Lot No. ;Z$� jv iC1�/ p�y�'rt-H Owner's Name,Address,and Tel.No.
Assessor's Ma /ParcelIX-:;
�trlJCr�GC�./� h'lA'R�< C��Hrcl1�l�I
p O R i F a'l C6tA?Xl E2D CoAv4srfC.
Installer's Name,Address,and el.No.,5 p is-4 7 g,$7 7 Designer's Name,Address,and Tel.No.
ra�'v-�xa� �lea�s+� uc, ��A
rs
! Type of Building: _
Dwelling No.of Bedrooms Lot SizejD sq.ft. Garbage Grinder( )
Other Type of Building ��7,'(/�(! No.of Persons Showers( ) Cafeteria( )
`O-ther Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
1 '
Size"of Septic Tank Type of S.A.S.
Description of Soil
x
t =
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
Thei undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
1
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
A Compliance has been issued by this Board of Health- ,
Sig Date �'��� O F
Application Approved by Date ��L
Application Disapproved by Date
for the following reasons
Permit No. �G f-� �L`� Date Issued L�
-------------- - - ,- - -. ---------------- -----— ------ ------------ -------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance'
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( " ) Repaired( x) Upgraded( )
Abandoned( )by CAL945&jCaj5 EL2?t9Qljl�l�
k ,
at has been constructed in accordance with the provisions"ofTitle 5 and the for Disposal System Construction Permit No._!20 le If Q 144-Idated "�/ >�� (
Installer 0-0 —Ib;E:� &—IRZAMS65 UIC Designer N/A
i
#bedrooms Approved design flow gpd
The issuance of this permit shall not bf construed as a guarantee that the syste will f inctio de ig ed.
Date /� / Inspector '
-----------------------=----------------------- --- -----------------------------------------------------------------------------------
L �" -
No. r� � � �`�� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS 4
Misposaf 6pstem (Construction Permit
Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( )
System located at R cx G K w
Y
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be/c�o-mpleted within three years of the date of this,pie It. \
Date / ,1 � Approved bey
i
i
TOWN OF BARNSTABLE
LOCATION &CY SkeL%Nk ATR SEWAGE#
VILLAGE Ce-4t w oke ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. �v�t ENCEQPRses "1-4 c
SEPTIC TANK CAPACITY I Sup Cg Aftr4
LEACHING FACILITY-(type) (size)
NO.OF BEDROOMS
�"„ �
OWNER w 4*12H
PERMIT DATE: -Z t- 14 COMPLIANCE DATE: 7-2
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHEDBY
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Postal
T. RtCEIPT
ITlProvided)
r3 For delivery
I informatin visit our website at � ,
me
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C13 Postage $ \�,5 A4 Q
Certified Fee `�Q\ ��
C3 A Postmark p
O Return Receipt Fee Here
p (Endorsement Required) re
O Restdcted Delivery Fee
(Endorsement Required)
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O Total Postage&Fees $ i/S P S
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o Mark Whelan
27 Chapman Road
Wakefield, MA 01880
Certified Mail Provides:
■ A mailing receipt
■ A unique identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
o Certified Mail may ONLY be combined with First-Class Mails or Priority Mails.
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■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt maybe requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail•
receipt is not needed,detach and affix label with postage and mail.'
IMPORTANT:Save this receipt and present it when making an inquiry.
} PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
,i ,
Y
ti Town of Barnstable Barn
Regulatory Services Department AlAmeftaCft
BABNSrABM
116¢ A, Public Health Division
" 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 1010 0000 2851 4143
July 25, 2014
Mark Whelan
27 Chapman Road
Wakefield, MA 01880
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 286 Buckskin Path, Centerville, MA was last
• inspected on 6/27/2014 by Paul Martin, a certified septic inspector for the State
of Massachusetts.
The inspection of your septic-system showed that the system "Conditionally
Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the
following:
• Distribution box is rotted and walls are gone, box needs to be
replaced.
You are ordered to repair or replace the septic system within sixty (60) days
from the date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement action.
&PERORDER OF T E BOARD OF HEALTH
i
Thomas McKean, R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\Conditionally Passes Ltr\286 Buckskin Path Cent Jul 2114.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path
Property Address
Mark Whelan__ --- --
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for 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:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector: UU
key to move your
cursor-do not Paul Martin
use the return Name of Inspector
key.
Neighborhood Waste Water
Q Company Name
350 Main St ---
Company Address
gym W.Yarmouth _ MA 02673
City/Town State Zip Code
_508-775-2820 S15016
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 16.340 of
Title 5(310 CMR 15.000). The system:
❑ Passes [ Conditionally Passes ❑ Fails
❑T Needs Further Evaluation by the Local Approving Authority
7/8/2014
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the 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•3113 Title 5 Official Inspection or ubsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F'
286 Buckskin Path
Property Address
Mark Whelan ----
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every — — ---
page. City/Town State Zip Code Date of Inspection
B. Certification (coot.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path
Property Address
Mark Whelan_
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every _ ----- -- —_----
page. City/Town State Zip Code Date of Inspection
B. Certification (coat.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
® Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Box is rotted and walls are gone. Box needs to be_repllaced.
❑ 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:
El Cesspool is within 50 feet of a surface water
pool or privy Y
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
az ,ys Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well'".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
'`�, Commonwealth of Massachusetts
a) ..,r` Title 5 Official Inspection Form
t,
l=� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
\ 9_ ; 286 Buckskin Path
Property Address
Mark Whelan _
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every - — ---
State Zip Code Date of Inspection
page. CityFrown
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path _ --- -- -
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every - — --
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® El 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 Informat
ion
Residential Flow Conditions:
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): 110x3=
330gpd
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.I .:...... '.....--.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every — -
State Zip Code Date of Inspection
page. City/Town
D. System Information
Description:
1
Number of current residents: "--
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 2012=88gpd
g ( Y 9 (gP )) 2013=27gpd_
Detail:
Sump pump? ❑ Yes ® No
Unknown
Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(god)
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: --- --
t.5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
i
w Commonwealth of Massachusetts
eo Title 5 Official Inspection Form
(=� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
286 Buckskin Path
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for 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:
OH
Source of information: B -
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? —
Reason for pumping: --- -- ---
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path -
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every -
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Unknown on tank. Leaching is 8 ears per plan on file.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2' _
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Line inspected with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank (locate on site plan):
1'5"
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: 1000Gal H-10
5"
Sludge depth: - — -- ---
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
..�f - ,.s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path _ —_—
Property Address
Mark Whelan
Owner Owner's Name
information is MA 02636 6/27/2014
required for every Centerville
page. CityFrown 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 -- -----
0.1
Scum thickness _
11
Distance from top of scum to top of outlet tee or baffle 0 - —
Distance from bottom of scum to bottom of outlet tee or baffle
0"
How were dimensions determined? Sludge Judge/Tape _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 Gal H-10 tank in good condition. PVC tee in place on inlet with concrete baffle on outlet.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
.. Commonwealth of Massachusetts
:axl �W�S
Title 5 Official Inspection Form
\l"NIN 1,1111 1".i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: -----
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: —
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: —— Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
51 -rz�� Title 5 Official InspectionForm
�c` Subsurface Sewage Disposal System Form Not for Voluntary Assessments
9;c 286 Buckskin Path
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every — —
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is in bad condition and needs to be replaced.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
required):
Soil Absorption System (SAS) (locate on site plan, excavation not
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
�} Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
286 Buckskin Path
Property Address
Mark Whelan _
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every -- —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
5-High capacity H-20 Infiltrators intrench formation with 3' of stone around. 10x37.25' Leaching area.
Leaching was found dry at time of inspection with no sign of overloading or hydraulic failure.
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
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
6,, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I- ; i 286 Buckskin Path
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: -
Dimensions - —
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-.
(Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
} Commonwealth of Massachusetts
Title 5 Official Inspection Form
,,II'rr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every — - - -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
I
.� Commonwealth of Massachusetts
! Title 5 O9 p Y Voluntary Official Disposal stem Form Not for Volunta icial Inspection Form
Subsurface Sewage Dis S - Assessments
_-_ }
286 Buckskin Path _
Property Address
Mark Whelan
Owner Owner's Name
information is Centerville _MA 02636 6/27/2014
required for 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: +10'
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: 10/26/2006
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test hole data per plan on file at BOH dated 10/26/2006. Test hole to 10' with no water encountered.
Bottom of leaching is at 4'. Minimum of 6' groundwater separation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
Commonwealth of Massachusetts
azl Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
286 Buckskin Path
l
Property Address
_Mark Whelan _
Owner Owner's Name
information is Centerville MA 02636 6/27/2014
required for every — -- -
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 17 of 17
Assessing As-Built Cards Page'! of 2
` I TOWN—OFBARNST
LOCATION !J �+✓ �" �'�� SEWAGE#
VEUAGE' ASSESSOR $tPARCEL
INSTALLERS KAM dt PRONE I40.
- SEPTIC TANK CAPACITY i.6f0
LEACHING FACT[=.(tW) �t, 1d*Sim) 7LVC/,0/
NO.OFBEDROOM
• OWNER /�
PERAQITDATE: I"'b—OP COMPLIANCEM
Sepah&n Distance Between the:
Maximum AdAasted'Groundwater Table to the Bottom of Leac6mg Facility Feet
Private Water Supply Well and Leaching Facility(If any wells east
on site ar within 200 feet of leaching facility) Fed
Edge of Wdland and Leaching Facility(If any wetlands exist
within 300 Seel of leaching Facility) Feet
1
FURNISHED BY
r
i
.spa .. -------
0
Si"�to,,,1CR:.l Z)(�( .} nF{�L kr.�. � ) •
. . ,• :. � .! if 4�i.l .c lv 'FF r I>tttl •.,�^�_�_"
I ILl
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f
http://www.town.bamstable.ma.us/assessinp-/HMdist)lay.asD?maDt)ar=191123&seq=1 6/24/2014
r
No.:k'�tl�)�`✓ '� � � Fee �-
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for � gpogaf 6p9tem Congtruction permit
Application for a Permit to Construct( ) Repair(�) Upgrade Abandon( ) ❑ Complete System t Individual Components
Location Address or Lot No� n Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. �(X> rCJ [Vqj Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms ✓ Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures /� 2
Design Flow(min.required) �O gpd Design flow provided ,J3 I' gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank OD0 Type of S.A.S. n S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of itle 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by thN Boaro of Heal h
Signed Date
Application Approved by Z14 Aym A Date
Application Disapproved by: Date
for the following reasons (((
Permit No. p-0 (o — / 4P Date Issued
No. 64� �� � t �� Fee
/00
.THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:am- Yes
- PUBLIC HEALTDIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
1 application for Digogal �§pgtern Congtructton Permit
Application for a Permit to Construct( ) Repair(, ) Upgrade(U) Abandon( ) ❑ Complete System Individual Components
Location Address or Lot No �jr„S n Owner's Name,Address,and Tel.No.
VV
Assessor's Map/Parcel 123 We
w3
Installer's Name,Address,and Tel.No. 5aJ V / Designer's Name,Address and Tel.No.
�P.O. x i� �-5 ex v
4 Type of Building: 3
Dwelling. No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min,required) V gpd Design flow provided J gpd
e
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank can Ci 1 I K' Cif of S.A.S.
Description of Soil
`+ Nature of Repairs or Alterations(Answer when applicable)
-m Date last inspected:
a �., 'Agreement:
' .
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of(.Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by th• Board of Health.
Signed1W� Ci(I�/ i� Date�U
Application Approved by '/ /11 (/� _Date /
Application Disapproved by: � hB d� ' ✓N/ , Date
� following reasons for.tl�e
R 1 to Permit No. �^�� "!11— � �� Date Iussued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
1 THIS IS TO CERT,FY,that the On siteSewage Disposal System Constructed ( ) Repaired ( ) Upgraded (tv)
1 Abandoned )1-
OoC. 6 has been constructed in accordance
11,
with the pro(vip ns of Title 5 and the for Disposal System Construction Permit No. q�� dated �� (b
Installer 1✓tJ Designer�� 1,w7
#bedrooms ti Approved design flow 3 gpd
The issuance of this permit shall o(f�be construed as a guarantee that the system will f`unct n as designed. f
Date ' t' Inspector
/—, — --�--=-- -----------------------------
———No. "� L1 / Fee /0 C�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
ligogat i§pgtem Congtructto permit
'Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ) Abandon ( )
System located at l; !
r� h tA (41V
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Povided: Construction
)_mu t(be completed within three years of the date of this permit.
Date �V "' r _ Approved b
02104/20�17 01 :09 FAX Z 001/001
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
a�vsrwe�,
public health Division�
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-46 4 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 11-08-06 {
Designer: S P.C.
Environmental Services,Inc. Installer: Robert Septic Services.
,Address: Ci Box 627 East Falmouth Address: 5 Trenton Street
02536 Yarmouth, MA
On 11/4/06 Robert Septic Service was issued a permit to install a
(date) I (installer)
septic system at B86 Buckskin Path Centerville MA based on a design drawn by
(address)
Shay Environr aental Services Inc. dated 11/3/06
(de igner)
XX I certify t the septic system referenced above was installed substantially according to
the desigii, which may include minor approved changes such as lateral relocation of the
distribute box and/or septic tank.
I certify t iat the septic system referenced above was installed with major changes (i.e.
greater th,n 10' lateral relocation of the SAS or any vertical relocation of any component
of the sep 'c system) but in accordance with State & Local Regulations. Plan revision or
certified -built by designer to follow.
� �V OF MgSSf
(( s o CARMEN c` 0
E. -A
U SHAY N
No. 1181
G IS T 5-�''�10
esigner's ignature) (A p Here)
PLEASE_RETU TO BARNS',i'.ABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF-COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD.ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q.Hcalth/Septic/Desi or Ccrtification Fom
I
TOWN OF, BARNSTABLE
LOCATION �lp /� �1-"TI-� SEWAGE# t7DGa— 7�0
VILLAGE ASSESSOR' 'MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY -a\wVN—�
LEACHING FACILITY:(type) tN�f 6T/�7b(size)�
NO.OF BEDROOMS
OWNER
LV
PERMIT DATE: ��IQ —Q� COMPLIANCE DATE: ,
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any,wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
t
- F
P I
Town of Barnstable P# J/ q 7c
ogTMe
Department.of Regulatory Services
A•O .BhF : Public Health Division Date
•tile �� 200 Main Street,Hyannis MA 02601
tb MK't t'
Date Scheduled Time Fee Pd.
Soil Suitability Assessment for S a e Dis l
Performed By: �AR!'1�Ehti �-cJbkflY Witnessed B �
LOCATION& GENERAL INFORMATI N
Location Address �QI �XA ZV.1. Owner's Name
V l4 E7� Address v
Assessor's Map/Parcel: �v Engineer's Name ef a W,-F��S/y /
NEW CONSTRUCTION REPAIR X/" Telephone#
Land Use 2� Ci _G�� Slopes(%) io Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well —d4A._ft
' 1� 1
Drainage Way A ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
s �
e
'3d c`--(geologic) S� Depth to Bedrock
Parent material eolo •c f1�1.�..-�J G�
b Sweeping � bs
Depth to Groundwater. Standing Water in Hole: from Pit Ftice N d
P g �CY'P ��,.
Estimated Seasonal High Groundwater SS
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Obs6veb standing in obs.hole: in. Depth to soil mottl a:
Depth to weeping from side of obs.hole: in. Groundwater Adjustment fr.
Index Well# Reading Date: -Index Well 1 ;el P. .Adj,ttidctor__ Adj.0r0undwater bevel_
PERCOLATION TEST We '1lYme a:b�
Observation
Hole# 1 `rime at 9" 9 '.o't
n g
Depth of Perc 30 _Le Time at 6.
Start Pre-soak Time @ O'.IS .T9me(911•6") b se .
End Pre-soak O
Rate MinJlnch L2MP 1
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100'of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPfIC1PERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole# :L_
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Co istenGravel)
SL wit
—C-1 Klea Seca z46y lia. e6e 1/5%
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%
JQ 3LQ
► -
ua L s
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color. Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency. vl
• J ,
F ,
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders.
onsi t n
Flood Insurance Rate May:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No=S Yes.�
Within 100'year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? 'i�,e g __
not,what is the depth of naturally occurring pervious material? Ilk—
If .
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Env'ronmental Protection a that the above analysis was performed by me consistent with .
the required trai m expertise and a eri ribed in 310 CMR 15.017.
Signature Date O \
Q:\SEPTIC�PERCFORM.DOC
i
Town of Barnstable
oFt"E rti. Regulatory Services
•. snRtvsr�ste,.
+' Thomas F. Geiler,Director
MASS
9A : a.� Public Health Division
tFD MA'S
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
September 26, 2006.
Mr Brian Baker
67 Colonial Way
Harwich,.MA 02645
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE;Title 5.
The septic system owned by you located 286 Buckskin Path, Centerville,MA was last
inspected September September 15t 2006 by Michael Kellett,.a certified septic.inspector .
for the State.of Massachusetts.
The inspection of your septic system showed that your system"Failed"under the
guidelines of 1995.TITLE.5.(310 CMR 15.00) due to.the following:
The liquid was within 4" of the invert with staining above..
You have 90 days.from the date of the of the system failure to bring the system in to
compliance.
If there are any questions.about this.reminder,please feel free to contact the.Barnstable
Health Department.
BARNSTABLE.HEALT DEPARTMENT
I
Tho c ean,R.S., C.H.O.
Agent of the Board of Health
A
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
s
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name w ��l /,2
Owner's Address: 7
*,-rujZ6, MA Q!iR5- 3q a 5—
Date of Inspection:
Name of Inspector: lease print) f
Company Name: (e SFddl tADa•5
Mailing Address:
Vas 1-2
emlij- MA Oa6 4(
Telephone Number: Z2 gg--385--76cy
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 Further Evaluation by the Local Approving Authority
pt Fails
Inspector's Signature: -y�� . Date: J� l f
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 flowof 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.
kl
j
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: �u
Owner: p,
Date of Inspection: (s6 ,b6
Inspection Summary: Check A,B,C,D or E 1 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 to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the followin atements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the sep ' tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or ailure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as ap oved by the Board of Health.
*A metal septic tank will pass inspection if it is structur sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is av ' ble.
ND explain:
Observation of sewage backup or b ak out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,se ed or uneven distribution box. System will pass inspection if(with.
approval of Board of Health):
roken pipe(s)a:rexeplaced
obstruction is removed
distril utioti box is.leveled or replaced.
ND explain:
The system re ired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if tth approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 1 l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: !6 tI
Owner: j�1CSA
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in o er 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 accordanc ith 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public ealth,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 vege ted wetland or a salt marsh
2. System will fail unless the Board of Health d Public Water Supplier,if any)determines that the
system is functioning in a manner that protect the public health,safety and environment:
_ The system has a septic tank and soi absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s face water supply.
The system has a septic tank d SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic t and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a Sept' tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply we] *. Method used to determine distance
"This system passe if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volati organic compounds indicates that the well is free from pollution from that facility and
the presence of monia nitrogen and nitrate nitrogen is equal to or less than-5 ppm, provided that no other
failure criteria a triggered.A copy of the analysis must be attached to this form.
3. Othe
3
Page 4 of 11
OFFICIAL INSPECTION FORM--NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DDIixSPOSAL'SYSTEM INSPECTION FORM
PART-A,
CERTIFICATION(continued)
Property Address: oZ A &M"VAIA
Owner:• G
Date of Inspection: RIQLft
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
of 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.
ry Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
`1— water supply.
Any portion of a cesspool or privy is within a Zone I of a public well..
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
o 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 coMrm bacteria and volatile organic.compmmds
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.]
— 7 (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 facility with"esign now of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the.folio
(The following criteria apply to large systems in.additio the criteria above)
yes no
— _ the system is within 400 feet of . urface drinking water supply
— the system is within 200 et of a tributary to a surface drinking water supply
_ the system is locat in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a pu is water supply well
If you have answer "yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section above the large system has failed.The owner or operator of any large system considered a
significant at under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 07
Owner: G,
Date of Inspection:
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
(,'' Were 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?
P� 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
e tic tank manholes uncovered,oP ened,and the interior of the tank inspected for othjb-ahesthe condition
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
mdintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
T no
Existing information.For example,a plan at the Board of Health.
c _ 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 11
OFFICIAL_INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
ti
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): a
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):ac)po
Number of current residents: L
Does residence have a garbage grinder(yes.or no): 00
Is laundry on a separate sewage system(yes or no): M [if yes separate inspection required]
Laundry system inspected(yes or no): rl1
Seasonal use: (yes or no): 130
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):T—diti—
COMMERCIAL/INDUSTRIALLast date of occupancy:
Type of establishment:
Design flow(based on 310 CMR 15.203 . ;pd
Basis of design flow(seats/persons/ _
Grease trap present(yes or no)Ze
Industrial waste holding tank (yes or no):_
Non-sanitary waste dischar d to the Title 5 system(yes or no):
Water meter readings,if vailable:
Last date of occupant use:
OTHER(descri ):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):�Vl�
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 ag of all componend ate installed
(if known)and source of information:
i I
Were sewage odors detected when arriving at the site(yes or no):. AJd
6
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
DO
Property Address: C G(CS1a4h
Owner:• 4
Date of Inspection: 6?G k26
BUILDING SEWER(locate on site plan) .
Depth below grade. )C7
Materials of construction:_cast iron V 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: 0( (locate on site plan)
Depth below grade:
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: wo !;&
Sludge depth: ,3" aSu
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 07"
t
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee o baffle: t bk
How were dimensions determined:_IV,G45�1
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as relateg to outlet invert,evidence of leakage�jetc.): e Q
�/ 3 o tX Qj ¢ �f W T CS t �n t C K CJ�
f d
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete metal fiberglass polyeth e_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 r baffle:
Date of last pumping:
Comments(on pumping recommendations, ' and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of le tee,etc.):
7
• Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 01
w � -
Owner: gsu
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at t' of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: -gallo
Design Flow: g ons/day
Alarm present(yes or no):
Alarm level: Al working order(yes or no):
Date of last pumping:
Comments(condition o alarm and float switches,etc.):
DISTRIBUTION BOX: "(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: eVGh
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage int or out of box,etc.):
lketw 4S
PUMP CHAMBER: (locate on site pla
Pumps in working order XnnoAlarms in working orderComments(note conditioer,condition of pumps and appurtenances,etc.):
8
a Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: d04 it �t.`i'�-►
Owner:
Date of Inspection. !'X
SOIL ABSORPTION SYSTEM (SAS): pf (locate on site plan,excavation not required)
If SAS not located explain why:
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.):
i t3
CESSPOOLS: (cesspool must be pumped as part of ins ection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invertZ--
De pth of solids laver:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater ow(yes or no):
Comments(note condit' n 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 oil,s hydraulic failure;level of ponding,condition of vegetation,etc.):
9
Page 10 of I i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1%
J
Owner-
Date of Inspection: �L
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.
r4i UyVt/�7 �rv-vv
✓"
3a
'Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
'. SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: t %t
�C
Owner: G[�
Date of Inspection:
SITE EXAM
Slope t�-o
Surface water
Check cellar
Shallow wells W�
Estimated depth to ground water o2O 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:
You must describe how you established the high ground water elev tion: n
1.S�`�IPA�r.Q�S S 1 a d 4c c�s- -P �etl�i�t� U � �O
11
TOWN OF BARNSTABLE
LOCtATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
O.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: &1tVCOMPLLkNCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
Fss. ..... .....-....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF (HEALTH
...................O F.....I .Ce.t'v1 s`�4 a......................----------------------•-_ I I
Appliratiun for Diopustt1 Works Toustrnr#iun Farm#
Application is hereby made for a Permit to Construct ( ) or Repair (Y(.) an Individual Sewage Disposal
System at:
-------------- ------------------
� --------------------------------------------------------------------------------
,�.g�.---u-- --gin.- -. ...---�--...�:�-------------------
Location-Address o t N
. 1� gKE2t r:!r afar ------ ---------------------------------------------- Ge.. Gt iH._h� - .__x v���¢:-----•---.....----
Q Owner ddressk f/
a /Y Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.................A.......................Expansion Attic ( ) Garbage Grinder ( )
Other—Type 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........................................
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........................
pd •-••--••••••••••-------•••--••••-••••-•---••••----•-••••.............•--•----•-•--•-----•----•-•---...--•---•-------...------•----....-•-•....._._...._.--••-
0 Description of Soil..............................................................................................4•------••-•-•-••---•--•---•-----••--••---••-••-••----•••--------•--•...
U ------------- ------ -----------.....------.-----
----••------------------------------------------------------- ------------------------------------•-----------------------......--•• ------------------------
mhen ---------Nature of Repairs or Alteratipns-O��r uvhen pplicable. Fu�n_4_I'±z s ____/D oc� __�Q t_---------
Agreement: 6
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the board of health.
4...................................... ....4.. -t...............
Application Approved By..............7• .........-- ------------ -----• �
--
Date
Application Disapproved for the following reasons---------------•------------•---•------------------...--•------•-------------•---•---------............••----....
......---•............................•-•-•-•---------------•---.......----------•---•--•--•---•----•-•------.......------••---•----••...-•-•-•---•--•••--•---•-----•-•-•-••---•• ......................
Date
Permit No...4 __.. ..... .... Issued...... -
Date
���
.�� - 1���
^ ,�,�p,,p�,,, � � � b
r
1 - w
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF `HEALTH
c,w.►t......................OF -�Urvj s�r- Kj e—
Appliratiun for Disposal Works Tonstrur#ion reruti#
Application is hereby made for a Permit to Construct ( ) or Repair (t• ) an Individual Sewage Disposal
System at {
i'Yl1 tt t Location-Address C 1 Yl
tJ�1=E2 r .2 S(o t ir�r ferUt f�e
.......................__..._....................................................._............ ------•------------•-------------•--•--•--....:---..Pf,..............
Owner ) I t dresh
aA . dGt....... . .................. ..................... � .: f�!1. strLet:........ ! U Ct Y v17o cc h..........---.....
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............... Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—T e of Building No. of ersons..------•-•-•-•-----....... Showers
YP g ..................•--------- P ( ) — Cafeteria ( )
dOther fixtures ........................•------•----•----------...........-----......--------•-----------.....-----••---........._.....•• •---•-._..............
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Or Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Dept h................
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........................................
0.4
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
LLI Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
A+' -••---••-•--••••••••-•--••••--•-•-.........•--.._..•-••••---------•-•.........................................................•---.........------.......--•--
0 Description of Soil...............•--------•---....................-•----••-...............................................................................
=.....
x
UW .......---•••--•--•--------••-••........-••••--• •-••••••••••-•-•--••••-•-•-••......._...••--•--•-•---------•---••••••-••••----••..1 �__.......-.. J_.._....r........ .......•-
Nature of Repairs or Alterations—Answer when applicable..' ........�'n�Tu,FC! /a oo cPc�(� C fiClt pr f
w srrte cs rec-,u,irer
.................................. •-- ._ .....••-••••••--•-••-•......-•-•---••---------------•----••-••••......--------• ......•• •-•-••• •----•.._ ......... .......• ---•-.....
Agreement: qq
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of TITI.I 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has begin:issued y the board of health.
�j
Signed---.'1..:.Icc........��c? jGt�J� �.
.......
Application Approved B .:t�t--�: .! ?/✓�"J-.--r-� C_ ..._ /...
PP PP y............... - ....... - - - 1
Date
Application Disapproved for the following reasons:...........................................................................................•..............---
.................•••--...........----.._...----••---••-•-•-••-----.........---••------...-••-•----..............-•----..............................••••.....------•.................•--•-•••----........
Date
Permit No '....
---.. ....-•.............. Issued.................................................-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
4 BOARD OF HEALTH
..........ca�n o I
......................O F....N Uri s�..lo:......................................................
f9rdifirate of Tompliana
THIS IS TO CERTIFYThat the Individual Sewage Disposal System constructed or Repaired �.
by................... rQ.► !......:.............`._.........- g p - :.-- .................................................. (..._.
nst I
has been installed in accordance with the provisions of T-I_-� Fg State Sanitary C de as d cri in the
application for Disposal Works Construction Permit No........................ ............... dated.... . f, _._..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE THAT THE
SYSTEIar!! WILL t�C.T LRY.
DATE...... .... ..........-- Inspector....
-----�-..........-•"-•--•------------•---............---------......._..
/1 THE COMMONWEALTH OF MASSACHUSETTS
BOARD - OF !:PEA TH
CctY!z c
N :: Fas.......................
Disposal ko Toiiu#rn tion rrrntit
Permission is hereb anted.....
to Construct (-) , ,r Re r ( f ) anedividu r!5*age Disposd System
Street
as shown on the application for Disposal Works Construction Permit-No..................... Dated..........................................
.... .... .....................
:......................................._
Board of Health
DATE.. 1*..1..........................
r
FORM 1255 A. SULKIN• INC.. BOSTON, ._
4
L-
-ASSES� 'S MAP NO. PARCEL
LO CAT ION � SHWA C E PERMIT NO.
VILL GE
to yt�L <�
INSTA L R'S NAME i ADDRESS
(f0
e UILOER OR OWN EN
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED rd23
_ t
���� � .
I� �'C
.. �� I'I
� �
a
�,
'�
�10' min. from 'NOTE ALL PIPES ARE TO BE a SCHEDULE 40 P.V.C. SECTION A A
Existing Foundation I ho++se to septic tank PROFILE VIEW OF ADDITION TO LEACHING SYSTEM
D-BOx cover must be
Septic took covers must be
TOP OF FOUNDATION = ELEV. 100.00 (Assumed) S"Ptiwithii vlltlrin to GRADE -/steel Corer
a in. of fir>ished grade
r,Tade over 0-Boa-99.25 aver SAS-f19.25 3' of 1 8' 1 2' Washed Peostone 2 6 6 B u cfles Ic"r> Pat h
Credo over Septic Tank- W75 / - /
3 HOLE H-10 Y:
3/4' to 1 1/2 Washed Crushed Stan
S 0.02 4•PVC(CAPPED)NSPECTIOII PORT 10 BE
_ 3. 1100"eo/Cover Tap OF Ststvn-aer =96J6 MSTALLED AND 7D BE,r,1F#N 6'OF tGRAMGl
0 12 EXIST. S>0.0, or oater
EXIST_PIPE - N 1.000 GAL o ts' S_ o.ot-Per toot A (rErt.atr»Depth
'�ao
FROM EMT. Fana►ATTn+ a, Co SEPTIC TANK o
" au ev�ev in to 5' y'tmg� fly : 's} ✓f !'�. Rf
> " H-10 a0 5 Unfts @ &25' 30 x v `
CONCRETE FULL FDU1�A o _ " r- 0) 0.83' (10 inches) �
a o o °i " 0 3 1 3' �2006'MM.osK OeiO�2001f N8V7e/�,snAJorO�i,lno.
SYSTEM PROFILE O 6 roof 3/4--1 IIr 7U " o n Eff wen 31.25 -
5 ccmpocted atone c c e " rn 37.25'
I� GENERAL NOTES
Scale Not to ,
- 1
i Effective L th
V �+9
3 5' >n 1. Contractor is responsible for Digsafe notification, Verification of Utilities
v 5p SOIL ABSORPTION SYSTEM (SAS)
s In of 3/+-1 1/2' 0 10' o and protection of all underground utilities and pipes.
compacted stone 0 Qo 5' STRIPOUT ALL �; INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE ❑'BRIEN 2. The septic tank and distribution box shall be set
NOTE. ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE -1 AROUND m level on 6" of 3/4"-1 1/2" stone.
i o TO ELEVATION 95.75 (OR EQUIVALENT) Not to Scale 3. Backfill should be clean sand or gravel with no
w Bottom of Test Hole 2 Bev.- 89.00 NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10' stones over 3" in size.
4. This system is subject to inspection during installation
PERCOLATION TEST 5' SEPARATION PROVIDED FROM GWI TO BOTTOM OF SAS- by Carmen E. Shay - Environmental Services, Inc.
5. The contractor shall install this system in accordance
Date of Percolation Test: OCTOBER 25, 2006 vObs. Groundwater - Test Hole 1 Elev.- 89.00 (Adj. Per CAPE COD COMMISSION - 2.8' s ELEV. 91.80) with Title V of the Massachusetts state code, the approved plan
Test Performed By. CARMEN E_ SHAY, R.S., C.S.E. v PROJECT ADJ. Groundwater = ELEV. 91.80 and Local Regulations.
Results Witnessed By. DON DESMARAIS (BARNSTABLE B(Xi) soil conditions or site conditions that are different
EXCAVATOR: Shay Env. Svcs. ALL ounrt FM FHd1 THE
Percolation Rate: Less Than 2 MPI 0 24" as,reeUTM Baer STALL BE 12.. CONCIEIE 00W1t from those shown on the soil log or in our design
sEr r>rvEL fee AT LEAST 2 Fr. installation must halt & immediate notification be
`�� .,,.-> r Kitchen Bath Bath Bedroom made to Carmen E. Shay - Environmental Services, Inc.
Test Hole Test Hole oaaa;;t-,
NO. 1 No. 2 =! GARAGE Dining 7. No vehicle or heavy machinery shall drive over the
Vr 1r MET septic system unless noted as H-20 septic components.
DEPTH SOILS ELEV. DEPTH SOILS ELEV { _ +o ss o0 0 ss ao 8. Install Tuf-Trte gas baffles or equals on all outlet tee ends.
Sandy Andy - ;� Living Room 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
Loam Loam + e - y� 40 T +�. ]B:edroTomedroorr10. All solid piping, tees do fittings shall be 4" diameter
'°,R 3/2 10""n PLAN SECTION CROSS-SECTION pipes g
A. 98 0"-12' A, 98 Schedule 40 NSF PVC r with water tight joints.
11. Municipal Water is Connected to ALL OF The Residence and Abutting
Sandy Sand Loamy
3 HOLE H-10 DISTRIBUTION BOX Properties Within 150 Feet.
10 YR 5/6 10 YR 5/6
12"-24' B, 97.00 12"-24' Be 97.00 THE PROPERTY LINES ARE APPROXIMATE AND
Wed Wed Note: Remove soil down t el. 95.75 (Esti d) & COMPILED FROM THE SURVEY PLAN BY BAXTER do NYE, INC. ENTITLED
�„d sand rep c with clean o se sand w�p rc. a less an CERTIFIED PLOT PLAN OF LOT 42 BUCKSKIN PATH, CENTERVILLE, MA
25 Y 7/4 2.5 Y 7/4 DATED JULY APRIL 13, 1973
z or equa to 2 m' ./in. efore & of r place AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
4"- 120
C+ s.Do 24'- 120 r" 89.00 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
THE SEPTIC SYSTEM INSTALLATION.
100.08' EXISTING LEACH PIT TO BE PUMPED OUT AND REMOVED
NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
FROM THE EXISTING LEACH PIT TO BE DISPOSED
OF AS PER BOARD OF HEALTH SPECIFICATIONS.
,Perc #1 / -
Depth to Perc: 30" to, 48" ,
,
/ TFi u,c-r,i2[-h ..C� oJ'JS-ARE-. l2ESERIT_WITHIN 200 _-f?F._THE..PROPERTY
Perc Rate- 2 MPI , ASSESSORS MAP 191, PARCEL 123
SDW252/ZONE D INDEX = 47 for 11/06 LEGEND
ADJUSTMENT = 2.8 FEET TEST HOLE #1
OBSERVED H2O Elev. = 120" or ELev. 88.00
ELEV.-=
99.00 � , TEST HOLE #1
0.5 ELEV.= 99.00 104X1 DENOTES PROPOSED
Failed SPOT GRADE
=t �•��= Le ch Pit
2-18'dAL1 ACCESS YANIIaES T`L� "�1E.t";;: .<!ss, r Q y
g 1 -4 DENOTES EXISTING
41_ -��; :�-_�: _ - i z'y£;?s•'� =`- �.=;:Ems '`_ } o Box X 104.46 SPOT GRADE
- = = 1
Fr'
PL PROPERTY LINE
""ETOUT ET io EXIST. PROJECT BENCH MARK 9r PROPOSED CONTOUR
-- 1000 l. TOP OF FOUNDATION -- -
THE ACCESS COVERS rat THE SEPTIC TAT«, o5 g ' -97 EXISTING CONTOUR
as,RIeuna, BOX AND LFACHMG Ca1PONEW of / 1)] Septic Tank ELEV. = 100.00 (Assumed)
. . - SET DEEPER THAN 6 MCHES BELOW F1N15IED
�- -'�� " GRADE SHALL BE RAISED TO M7HM r OF
STEEL REINFORCED PRECAST CONCRETE Fa65Hm MADE i Su400m' DEEP TEST HOLE &
PLAN VIEW MSTALL n'r-WIE GAS eAFRES OR EQUALS % On Sonotube's. PERCOLATION TEST LOCATION
03
/-3-24• REMOVABLE COVERS f .---. 6 FOOT STOCKADE FENCE
i
I
y
ER
_ =� 4" - r:` i EXISTING REV. 1 1/03/06 Revised elevations
n�E7 6'miWF r mh Mdett to outlet 'r i1INGLETEXISTIN3 BEDROOA[10 e+L � OUTLET ; GARAGB HOUSE- P LOT P LAN
4'W tll ; #28G
oUWId I OF PROPOSED SEPTIC SYSTEM UPGRADE
PREPARED FOR
-��- 4'-10rr l MR. BRIAN BAKER
t
CROSS SECTION END-SECTION i
AT
TYPICAL 1000 GALLON SEPTIC TANK a LOT #42 � #286 B U C K S I N PATH
NOT TO SCALE `� I 0 1 15,000 Square Feet
--- -------; ----------- ---9s CENTERVILLE, MA
_--=----------------
Design Calculations
I I
Number of Bedrooms: 3 Bedroom EXISTING I i i f 00.00' I ���p OF qss E/P�ARED BY: C u v
Garbage Grinder: No Cl RH�/�N E. IV l A l
Leaching Capacity Required: 330 Gal./Day (MIN. PER TITLE V)
Septic Tank : - 2 x 330 Gal_/Day = 660 USE EXIST. 1,000 GAL Septic Tank. -----�--------------- 0= A � ENVIRONMENTAL SERVICES, INC.
Q
SOIL ABSORPTION AREA: Using percolation rate of min./inch
Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons ------------------------- -------------------J-
-------------- --------------
1 a P.O. BOX 627
Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gallons CB D_H. FG►ST1 a� EAST FALMOUTH, MA 02536
Providing: = 331.80 gallons B UCK.S'�1IN PA TH FND s R�1�1�N
EL/FAX 3
Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, (40 FOOT RIGHT OF WAY) � SCALE_ 1"=20' DRAWN BY:7 CES DATE: OCT. 26 2006
TO BE USED WITH 3.5 OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE
ON THE ENDS. NO STONE UNDER.
. PROJECT#SD981 FILENAME: SD981 PP.DWG SHEET 1 OF 1