HomeMy WebLinkAbout0363 BUCKSKIN PATH - Health 363 BUCKSKIN PATH
CENTERVILLE
A = 191 117
�lll__I �� ,�0.ECYCCFOCQI
llll m �3 Z
UPC 12534
No. 215�3L`OR T-coNS°`�
HASTINGS, MN
.�_.�.. vim..... ,..n.....�,.,a.a.....�............ ,... �,.__....,._..:x...w,. _-_. ..., ,,,,�.............. �_. —
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
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 filling out A. General Information
forms on the
computer, use 1. Inspector: v
only the tab key
to move your Brett Hickey
cursor-do not Name of Inspector
use the return
key. B&B Excavation r
Company Name
ffi 14 Teaberry Lane
Company Address
Sandwich Ma. 02644
�n Citylrown 4§ State Zip Code
(508)477-0653 S1-13747
Telephone Number License NumberJzm
f ;
B. Certification ---
1 certify that I have personally inspected the sewage disposal system at this address and tliaf the
information reported below is true, accurate and complete as of the time of the inspection. T-pe inspection
was performed based on my training and experience in the proper function and n4aintenaneetof on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section-'h5.346of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8-15-14
InspyVes Si attire 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.
l
t5ins•3/13 Title 5 Official Insp c on rm;Subsurface Sewage Disposal S stem• age 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°y 363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N FIND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ .ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
Rc
{
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The f;
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , ' 363 Buckskin Path
.Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. Cityrrown 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
El ® 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
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
E] ® 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 11 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
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for. Centerville Ma 02632 8-12-14
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?
❑ E 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)
1'
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
g
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every, page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® . No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2012- 103,000 2013-122,000
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection, Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18feet
Material of construction:
t
❑ 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.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal.
Sludge depth:
2"
t5ins.•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. Cityffown State Zip Code Date of Inspection
D. System Information (Pont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
34"
Y
Scum thickness
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
15"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):.
At time of inspection septic tank appeared to be in working order,Tees present no sign of back-
up.Liquid level equal with outlet invert.
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (Pont.)
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.):
At time of inspection d-box appears to in working order no sign of deteration, or carryover.
E
I
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.);.
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain.why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Lnspection Form
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3-500 gal.
(10X2X30)
❑ 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.):
At time of inspection leaching appears to in working order no sign of hydraulic failure. Water level 14"
below invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker _
Owner Owner's Name
information is required for Centerville Ma 026.32 8-12-14
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.):
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately ;
A Q
0 0
2
O O O
- Al q!e 131 21'
A.3 " 51' 63 ' 39'
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
�_ r
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
Z Check cellar
® Shallow wells
Estimated depth to high ground water: 26
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: permit dated 11/14/2000
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:
permit on file at BOH
r
r'
e I
Before filing this Inspection Report, please see Report Completeness C . ecklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface swage Disposal System•Page 16 of 17.
• t
1l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
363 Buckskin Path
Property Address
Wayne Baker
Owner Owner's Name
information is required for Centerville Ma 02632 8-12-14
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
r
No. Fee$5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIPPrication for Migogal *pgtem Conmruction Permit
Application fora Permit to Constnict( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's 444arAuckskin Path, Q ntervi
Ile Lauree Baker
4
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Ser.
Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system
consistina. .of a tank, D-box and 3 concrete chambers
with stone' J all around.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance o the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code d not to pla a system in operation until a Certifi-
cate of Compliance has been issue by thi�B and of ealt
Signed Date
Application Approved by Date
Application Disapproved fo a following reasons
Permit No. Date Issued#/
_ fir
' rY No. Fee$5 6
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Miopotal *potem Construction Permit
App li!lion for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
ocation Address or Lot No. Owner's Name,Address and Tel.No.
ssess,sA.a� r,Auckskin Path, In
tervill Lauree Baker
'
Installer's Name,Address,and Tel.No. Designer's Name,�kddress and Tel.No.
ru Wm. E. Robinson Septic Ser.
1,
• Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms n Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
,t
... S a
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system
consistin :,,pf a 'Dank D-box and 3 concrete chambers
with stone all around.
Date last inspected: ?
i
'- Agreement:
The undersigned agrees to ensure the construction and maintenance o the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code d not to PI
the system in operation until a Certifi-
cate of Compliance has been issu d y thi �B and of Healt
Signed — Date
Application Approved by ' Date
Application Disapproved fo a following reasons
Permit No. Date Issued
--------------------------- — --------
THE COMMONWEALTH OF MASSACHUSETTS `
BARNSTABLE, MASSACHUSETTS
%3 ,
Baker Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal.System Constructed( )Repaired( X)Upgraded( )
Abandoned Q )by Vm. E. Robinson 'S4:ptic Service
at 363/Buckskin Path, . Centerville la_s hoq constructed in accordance
with the provisions of Title 5 and the for Disposal System Cons ction Permit N ated
Installer Designer
The issuance of.this.permit st',allinot be cons a as a guarantee that the s Re 11 uneAio as Mn F \✓
Date! I t- Inspector
V
_ / — --
No. � , 47 Fe
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Baker wigo.5al *p5tem Construction Permit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 'Af;3tJ Rrr4a_kin Path, Centerville
i
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local'provisions or special conditions.
Provided:Cons ctio st be completed within three years of the date o t ' e i
Date: Q Approved by
G C,
TOWN OF BARNSTABLE )'
LOCATION 363 OULkSk n PA44. SEWAGE # IWO 673
VILLAGE Ce441 P.r-v e 1 I @, ASSESSOR'S MAP & LOT p
INSTALLER'S NAME&PHONE:NO. RLO1-i-,J go►J SUd i L 7 7 5-F 7 7.6
SEPTIC TANK CAPACITY S CJ
LEACHING FACILITY: (type) '3 le2 6U (size) /OX 2 x 7d
NO.OF BEDROOMS
BUILDER OR OWNER (?3Pk6 X
PERMIT DATE: 1111460 COMPLIANCE DATE: I(I 1 D04161
T i
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
' I
�iEck '
I 1
l� 4
V I
l
0 Q
Q TOWN OF BARNSTABLE
LOCATION 3b3 �Suc.ZL�IC�n Pl�>N` SEWAGE # ;2= G
VILLAGE CeA e ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 2-12�-i !orJ 7 7 5-F 7 7 4
SEPTIC TANK CAPACITY L 1 S<)o
LEACHING FACILITY: (type) 3 Dta &rjS (size)
NO.OF BEDROOMS
BUILDER OR OWNER CbAK&(�-
PERMITDATE: I 1 li}I00 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
p
D pl
M"
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF.SKETCH AND APPLICATION FOR A DISPOSAL —
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, Will iain E. Rob ins on,Sz eby certify that the application for disposal works
construction permit signed by me dated /�`s�6 O -� . concerning the
property located at 363 Buckskin Path, Centerville meets all of the
Mowing criteria:
• The failed system is connected to a residential dwelling only. 'there are no commercial or business
uses associated with The dwelling.
The soil is- as CLASS I and the percolation rate is less than or equal to i minutes per inch.
There are no ands within 100 feet of the proposed septic system —
• There arc no rivate wells within 150 feet of the proposed septic system
There is increase in flow and/or change in use proposed
• 'There no variances requested or needed.
• The m of the proposed leaching facility will ngt be located less than five feet above the
ma ' tun adjusted groundwater table elevation.-f Adjust the groundwater table using the Frimptor
od when applicable)
• the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
t thing facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A). Top of Ground Surface Elevation(using GIS inforniation) �j
B) G.W.Elevation +the MAX High G.W. Adjustment.
DIFFERENCE BETWEEN A and B
SIGNED : DATE:
{Sketch proposed plan of system on back).
q:health folder:Len
�, ..
r .. ,�
t. .- r ,
... .'4.: .. .. .. t•:
t`
J
' J '' � '
�✓,� - r
I + I , ' k,
1
ri. � ._ a ., a ,..... .6 e:i ... ..
} � k. .. r . .. �>> - � -
�. .
` r�. a �. ,.:�� .,s ._. , , �} � - ... r s ' ••
} r � . .�.�.`i�l DEL.t..k � • - � , ,. �.. � "
' s .. M. 1 � r..
�G .. �
U-3 3 0
LO 'CATION SEWAGE PERMIT NO.
/*��t
VILLAGE
I N S T A LLER'S NAME i ADDRESS
1ZraQ ll" o Q � C,
/-?it,6T��L�
0 w N ER
�icc,i19Af caeol",
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED r/�
t