HomeMy WebLinkAbout0057 CAP'N LIJAH'S ROAD - Health 57 CAP'N LIJAH ROAD ;
192=160 . Centerville
rm �
UPC 12534
No.2_153L.OR
HASTINGS, MN
_
LOCLITIOKI SEWiCtE PERMIT UO.
IMST&LLER 5 W&NAE ADDRESS
BUILDER 'S Q &MF- ADDRESS
DNTE PERMIT ISSUED '— /
DATE COMPLI &Kic'E ISSUED : 1--�6
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NO......................... FizE...................
t THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT�
r
Appliratiuu -fur Uiipuual Worko C onotrurtiuu Vrruift
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at:
..........-._.-. �- �- •------------•-------------
Lo tion-Add,
t r.. or Lot No.
..............��`Q .................... ----------------------------------------
J Ow Address
Installer Address /
Q Type of Building Size Lot../...._,$�?--- Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Atti _ ( ) Garbage Grinder ,(�9
aOther—Type of Building ��1?K No. of persons............. Showers ( ) — Cafeteria ( )
0.' Other fixtures -- ---------------------------
W
Design Flow-------------------- ......_....____._gallons per person per day. Total daily flow----------- ..............gallons.
WSeptic Tank—Liquid capacity G gallons Length................ Width................ Diameter---------------- Depth..-._____-.__...
x Disposal Trench—No_ ____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No...../---------- Diameter..zAe_e____ Depth below.inlet_________ _________ Total leachin area._-__._-__.___---sq. ft.
z Other Distribution box ( e— Dosing tank ( ) 0,6 s 1-.e S� / 2�-7
aPercolation Test Results Performed by--------------------...................................................... Date------------------------------------._..
Test Pit No. L_______________minutes per inch Depth of "Pest Pit-------------------- Depth to ground water-..___-.____._.__. --.
rZA Test Pit No. 2----------------minutes per inch Depth of Test Pit---------_---------- Depth to ground water..._.__________.-_-_...-
/ .. ¢.. a s_... �.
--
O Descript`iou,of Soil - 'Q ' � J'%'!�' rt ��.e�x. 4•. ._<�.2 2.il�,c . �.a � 21
W ------------- � ------ ----'•••••-•---_� € 'r .y , ---- -
------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------
UNature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------__-.---.------_.____. --
---------------------------------------•---•-----.._..-------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bAissuy board of healt
Signed. _
: -• -------- --• -•---------- �-
Application Approved By----- - _.._. �. ."'7
Date
Application Disapproved for the following reasons:--••---"-•-•----...-----•--------•------•--•............................•-------------------------....--••••.•••
....••....-•••---•..............•--•------•-••---•---•--------------•--•--••-•---•-•.....•-••••-----•.
Date
PermitNo......................................................... Issued........................................................
Date
`------------------------- --------------------------Fly
No......................... Fimx..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
0 .�"�._...._... .0F.............1.t� `07."--e
Applirtttiun -fur Mapouttl Works Tomitrurtion Pumit
Application is hereby made for a Permit to Construct ( )�' or Repair ( ) an Individual Sewage Disposal
System at:
5' ,1,�
Loc ion•Addr or Lot No.
O Address
---•--•-••-------------•-•--•---•---._.._..•
Installer Address
UType of Building Size Lot.. __________eol Sq. feet
Dwelling—No. of Bedrooms----------_._____._.•_J_--------________________Expansion Atti ( ) Garbage Grinder ( )
Other—Type of Building tf/!_r% No. Pf persons--------------�_______ Showers ( ) — Cafeteria ( )
dOther fixtures ---------------------------•---•---------------------------------------------------------------------- -----------------------__------
W Design Flow_______________ �J._..__._..___________gallons per person per day. Total daily flow......._.___-- .............gallons.
WSeptic Tank—Liquid capacity,,,4 allons Length---------------- Width................ Diameter---------------- Depth--_-____-_----
x Disposal Trench—No_ ____________________ Width.................... Total Length------------_------ Total leaching area....................sq. ft.
Seepage Pit No------/.__-_..... Diameter---4ee_6---- Depth below inlet__________ ________ Total leachitl area.._._.__________sq. ft.
z Other Distribution box ( Dosing tank ( ) <J, — 1� 5" / 2"�1
aPercolation Test Results Performed bY........................................................................... Date____-----------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit---_______________ - Depth to ground water........................
rxq Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
------------------------------- ---• ! '
O Description of So- ---------lf--" L �'_ -J u_�i-r% ."a=� - f >G -- -
V ---------------il-4..z-611..- -� - ._ d--Cs!� !s:_!------- ._......_.-•-•--------__.._-------
W
UNature of Repairs or Alterations—Answer when applicable._-___________________________________________________________________________________________--
----•---------------------------•------------------------------------------_._...___------•--------•-------------._....------------------------------------------ -------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu y t board of heatt
igned.. ..... -••-.... .__•••-=-'-'....--- "-••--•. ----------------
Application Approved B _-_ 2 `>t" G
PP PP Y r~ ------� ----- "- --
-- ---------
Application Disapproved for the following reasons__________________________________________________________
__________________•---------------Date-------------
_....__..---••-------------••.-••----...--------------------------------••--•----•-----•-•-•-------------...___..__..-------•------•-----•--•-----•-•----....---•--------•----- -------------------_---•-
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
--�' BOARD OF HEALTH................. ..................OF.................6' ............................................
/
�priifirttir of muntplittttre
THIS TO CERTIF, That the I ual Sewage Disposal System constructed
by --------------- U�--•-------- ............................................................................................................
/Installer
at ................
-- -/-- ------- ---•'--•------------•------•----•------------•--•-------------------•---•--•--•--•-•------••------------••-
has been installed in accordance with the provisions of Ar ' 1 XI of The State Sanitary Code cribed in the
application for Disposal Works Construction Permit No--- -_ .............. dated----------- a d ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -•••--•----••. Inspector_. �G�� -^�.... -��
THE COMMONWEALTH OF MASSACHUSETTS \
��..--� BOARD OF HEALTH
(7)2 -7l' ................
N ......................... FEE.... ..............
�i��u�ttl � rk� Chun trttrtivat rrntii
G��' __Permission is her y granted--------- ------ - �_--•--....... - _..__.-.....
to Construct or SUwr n Individual Sew D s os . System
( LP Y
Street
as shown on the application for Disposal Works Construction PoQ t No __ _.._. .. .__ Dated-------451 G
Lill. -- = ---------------------
7 `9 "7 7 Board of Health
DATE -----------------------------------------------------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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r •.., Commonwealth of Massachusetts
Title 5 Official, Inspection Form
r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name /
information is required for every Centerville ✓ MA 02632 1-10-20
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.
A. Inspector Information 614-
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving,Authority
4. ❑ Fails
1-10-20
In pector'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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
�i► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1=10-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System`Passes:-1
® 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:
System is in good working order with no sign of failure.
2) System Conditionally Passes:
❑ One or more system components as described in the "Co nditionalPass" 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
rill
Title 5 Official Inspection Form
C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r U /`r
1. ? 57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts j
r� Title 5 Official Inspection Form
! i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
s Commonwealth of Massachusetts
y Title 5 Official Inspection. Form
it
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15000 gpd.
For large systems, you must indicate either"yes" or"no;to each of the following, in addition to the
questions in Section CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
4e Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
� ws
bi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
J..
r" 57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
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
..Have
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?
® ❑ Wasthe 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, al plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
El
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
�wf'
Title 5 Official Inspection Form
'04 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:_✓ > 57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)I
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 2019
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
r� Title 5 Official -inspection Form
C�ll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
! C;11l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known) and source of information:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2411
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.):
Good condition.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
a� Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
�l
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 102632 1-10-20
page. City/Town State .Zip Code Date of Inspection
D. System Information (cunt.)
6. Septic Tank (locate on site plan):
18"
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:
1500 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
1"
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? 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.):
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
iI'► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r e </
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is Centerville MA i02632 1-10-20
required for every •
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) .
8. Tight or Holding Tank (cont.)
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
9. 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.):
Good condition with water at working level and no sign back-up from chambers.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
PI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System I(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3-500's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
4. Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is Centerville MA 02632 1-10-20
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition and empty at inspection with no visible stain lines.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —topof liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
r� 3, Title 5 Official' Inspection Form
wa
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
J'
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
a� �, Title 5 Official Inspection Form
ws
..al Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA f02632 1-10-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
H
l
1'
r
r � �
.37
V
T V 1 (T
y r to. d�/
r K
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-10-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam: e .
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with'local Board of Health - explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
II
Commonwealth of Massachusetts
r� 3 Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Cap'n Lijah's Rd
�r-
Property Address
Keith Hochstein
Owner Owner's Name
information is required for every Centerville MA !02632 1-10-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
it
THE COMMONWEALTH OF MASSACHUSETTS
BAANSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CER ,that thgg On- ' e e e Disposal Syl@fW*eted( )Repaired( )Upgraded( )
Abandoned
at S� L/ .A, ��lrvi/ TH NCB �tRS>�cc r ce
with the provisions of Title 5 and the for Disposal System Construction Permit N 'VAS 11VS c- R!TlNG `� a
Installer Designer NCE T RlCT
The issuance of s pe t shall not be construed as a guarantee that the sy m ill fu c ion as de
ed.
Date Inspector
---- --i-------------------------- -
I
No. Fee
—la?,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for 30igool *pgtem Congtruction permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. �� /1,�1�Q 1 J �/r�Q � o
lJ C�6v ry ram, r��Y�oI A Owner's Name,Address and TeL�I0
Assessor's Map/Parcel �� �
Installer's Name,Address,and Tel.No. Des is Address and Tel.N .
RM-f0�� �IP � �PP st)ewykc�
Type of Building:
Dwelling No.of Bedrooms 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
.u,p.
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: DESIGNING ENGINEER MUST SUPERVISE
The undersigned agrees to ensure the construction and maintena cn'pAt $¢iBFgMTiWssiile%641 TI osal system
in accordance with the provisions of Title 5 of the Environmental Codfdpygt$ �[b, � t til a Certifi-
cate of Compliance has been issue b VHe th. ACCORDANCE TO PUS+N•
Signed, A Date 6 7
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
0
I�_ .�--.. _' •. , w s.i.-J. .r ..i.. _ _.. .. • n a w •. ' _ y-.....;., .9 +.q,^ ..•r'-•-_�'.Y._.. ...- _.� ' f •. •�� ___.. _ . - - .. ' 1
No. a /'� �r ""• '' � � Fee
C/ 1 •
7THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for Miopo$al *pztem Con$truction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
r A Location Address or Lot No. ;�j /1�Q D�+'1/A� G��� , Owner's Name,Address and Tel No,
1.
Assessor's Map/Parcel `J 1.�-E//V,V�64,��I H0"' J�� '°
I
Installer's Name,Address,and Tel.No� Design 's Addr
ess and Tel.No.
��
nTau /vl�jJ l�nJ Clew v
Type of Building:
Dwelling No.of Bedrooms 'Lot Size sq.ft. Garbage Grinder( )
E Other Type of Building No.of Persons Showers( ) Cafeteria( )!
Other Fixtures r
Design,Flow gallons per day. Calculated daily flow gallons.
' Plan Date Number of sheets Revision Date
' Title ''
1
Size of Septic Tank / Type of S.A.S.
Description of Soil
iAll h
F rrvr
Nature of Repairs or Alterations(Answer when applicable)
II
Date last inspected: V
-, Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue ty,5hi5 Bo -��
Signed 19 Date
Application Approved by / '��. .�r1i i Date
v r
Application Disapproved,for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Y
(Certificate of Compliance -
THIS IS TO CER ,that the On-si a age Disposal System Constructed( )Repaired( )Upgraded
Abandoned )b ��/ d�� /`
at �a L9 ! /�%4'�! S 't�l /yi/�' has been constructed in acco7�dance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 3/7
Installer Designer '
The issuance of is'permit shall not be construed as a guarantee that the sys m will fu c ion as desig ed.
Date 1 i)L- . Inspector ` � �n l
No.---i —•'-- ---.—.—_--_.__—_—,� — —————— --Fee
V 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
MigpoOaf *p5tem Con0truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at L.
acid as described in the above Application for Disposal System r'onstruction Permit.The applicant recognizes his/her n ity ro _
comply with Title 5 and the following local provisions or special •otiditic l . .�F
Prc-;, :'ed:C c-nstm:,tier muse be cor Yieted within thiee year,of t .e da` of this pez,n a.
'TOWN OF 3ARNSTAB - — -
ON:
C vlef
V ,I;ACd3 c�
ANSTAL,LI ER NAME&PIEIOIdE NO r a
SBP'C TAWCAPACTT 1�
L1l;A+CIItNG`1PACII�TE"Y� {type) ��' (sve) �r'�u� S x � .
PTO;OF�31sT�1ltC1t�NS.�_.� _ �,
FSR 'T A'I' COII gC�IA�NCE
Soprarat�onMsPa 8atviean tea: :: ,
Maximo 'Ad-ISIW& the Aottntnof gibingttility Feet
rjlv�ao Wator,supiy w0-i. Pa r lao T?FOR gmi►y cells axis . .
do sstu or wEtEun:2AA feat t►�1+aacii�S filh}�). aot
i?ti r•cif W d and l oac ln� ac)11ty auy►wetl ds exist
M;tain00NeYpf , cbfng�aCFee
ill
1C�umisbed!iy
a
oa
,
�•a - y/' d- a 7'.
A,3- 41a6y
( T WN OF$ARNS LE 15--(
LOCATION 1 SEWAGE #
VILLAGE �Q ASSESSOR'S MAP & LOT 090
INSTALLER'S NAME&PHONE NO. P Ps '�- t, z�--- 160
SEPTIC TANK CAPACITY )��L 0
LEACHING FACILITY: (type) (size) t
IT
NO.OF BEDROOMS
BUILDER OR OWNER k S I
PERMITDATE: Lo 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 br,within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet 99Aeaehing facili Feet
Furnished by ,
4/
3� i
i
D
J .. --, 'A3w..
♦ ..:-Ml-:,. .T'Jffi.JiW11W.:M•.,11JR."iRMV111di1Ci''... '
GENERAL NOTES.'
1. THIS PLAN IS FOR THE DESIGN AND INVERT ELEVATIONS.' _ " . �-•_ . Ar.: ' 'IJOO, ' F;LI�'G fN 110 SAL/uAY PEA BEDROOMCONSTRUCTION OF THE SEMAGE DISPOSAL w
FACILITY ONLY. ���nb ,, ; �, ._
INVERT AT BUILDING a>r - : •- - -, , 5
2. ALL CONSTRUCTION METHODS, MATERIALS AND INVERT IN A T SEPTIC TANK °' -• ��-° `= G;Z` �l T7 lj
MAINTENANCE FOR THE SEPTIC SYSTEM SHALL?
INVERT OUT AT SEPTIC TANK U R Y
CONFORM TO MASS. D.E. 0.E. TI TL E 5 AND L OCAL - -- --- e,r F, GPjl , r0;�." J e �.,
BOARD OF HEALTH REGULATIONS. INVERT IN AT DIST. BOX �__ ._. _,. 1L� GAL.
INVERT OUT AT DIST. BOX �- ' `" A:� _.____ µPT: T/,"�' P,90VIDED• 15 D D
3. ALL SEPTIC SYSTEM COMPONENTS SUBJECT TO s ' ! == �� _ ` %00 ° _. 6AL.
VEHICLE LOADING (I.E. UNDER DRIVEMA YS, ETC.) INVERT IN A T S.A.S. J CS °�; - r i -` SIZE Of L cACHIIV: F;CIL I TY AE�UTAED
SHALL BE DESIGNED TO MITHSTAND H-20 LOADING. I i i - '�- =� %t -
BOTTOM OF S.A.S. tlti f �__J .1 T /2r i�iJ
4. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR OBSERVED GROUNDMA TER �� ` `" _ �'
APPROVED EQUAL. NTH I i �- - '�` Dr:.�rG: PAC. PATE MINUTES/INCH
C =: _ : __.� D.�.:J T. PROPGe;.-D S,s'..:,,
_____ ,•<�.....�.� ..__. � y�d_ _ GALL L'NS P.��A' DA Y
ADJUSTED GROUNDMA TER y
5. BEFORE STARTING CONSTRUCTION CALL DIG SAFE / :, L
1-800-322-4844 FOR L OCA TION OF --1 ?�4/�,'� + "' ` � ` 1� � � SIZE OF L."�v H_`'�%G F,9;^IL 1'.'Y PRDVIDtFD.•
UNDERGROUND UTILITIES. `'' _ - GO i"G; , ' 7 .
i 6. DATUM IS ASSUMED _ tic ' A .S IL}L 1v�1!.L 1 ; S.F. X 4.i L.
7. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE r� // ± V 4 r r , a a%fOTTDI� �!t 3� S.F. y 322 6PD
MITH DEED RESTRICTIONS OR ZONING REGUL A TIONS. ��'�» O f P R/C /aL
IT SHALL REMAIN THE Oh'NER'S RESPONSIBILITY TO (, _
TOTtiL� ,z S.F. 6 O 6PD
OBTAIN ALL REQUIRED PERMITS, SPECIAL PERMITS,
VARIANCES, ETC, FOR THIS PROJECT S17 ,+
B. IT SHALL REMAIN THE ONNER'S RESPONSIBILITY .. .. L rof T ` ,_ , r✓�:
! � '
z • r,
TO HAVE THE PROPOSED DMEL LING FOUNOA TION -----� ;, _ , , ' J , r
DESIGNED TO ACCOUNT FOR THE EXISTING GRAOf Depth from Surface r ,u . -f, ,NO. TL RE r,IJaGG�
AND SOIL CONDITIONS AT THE LOCATION OF THE Soil Horizon Soil Texture Soil Color ' ------� ` �'' D` Fl`�'
PROPOSED DMELL ING. (Inc h a e) ---
(USDA) r (lvlunsell)
f
p l "�A ' ��i���- �, i ` //.- I :•Lf - � � • �V I iMTE vta Y.• �" �� ,t'�
o Alp ' 111d� �A/� O��� _ TES
_
KrTNE LC/ Bt •'Ll'�`ti w�I � �,:`•i v., *v'r j�' •. " - _ _ ... ... .._ .
Point
77 ley
_� �1-" y; � ) :�� � �Y::,'�I.. ..'�it� '•.._ }"lli `.� 1N. i C
° '' �.��' it Nyps; _ �(� j/lr� ��(eSB/✓D
1 -_ �� '( � /
P Pt
�� �' Y Stoney,)
e' 141 j
? , V/l� J i(-, �yLOCU
ic"'✓V r� ! ` it t• }
i
\"__ "I� 11 1/��. G.\1�• I i'J i, i�, S t � 4- f~r ._ iL
_—.. // •/J• ..11. •� .�l� l J/ I � � .`. _ .mil
lI •% 11 \•.• I.�- •,7•J \ M// f P a Lie)Y�ay, �tt� f �'
/i / ` �: 1�, i•�/ )l ✓ "' i" - °f
/, :f k�n1 .d.1'.M /.� _�I •" �' .• _• . - ..'1 � t,.��� /./.f.. �-IIViI•
, 1,•:r� �� �� •1•• •r �i �,( a (I:� T "� '" �'
e�`_-._ A7�,IY^13
f ./ I�� I <J�.• l r� 4 ��i • y 1.
rr
'- _0r'i "� ��� �� .r �•, 1 �1:�/,�-�� � �� � rn
� �� Rrc.lypV�..
l
hvTE
PUMP THE E�'IST.ING SEPTIC T,4Nik' 4yVD
LEACH PIT AND FILL K ", CLEAN SAND. y�, ,I f
Z.u '� / �.� J�.1 y ,r "' i ! C' / f i Y 1.L {r
-7 COIL
�t APP170,1r. —,k ST. 99 +;-
LEACH. PIT � 'Q � —" � 1 .
'� tZr�,J�i�t!
lc:�) P?7r- PROFESSIONAr LAAVfURVE1T—
q
o f
. DESIGNING E t i n
i 2 f _., -__. , 6 1. �. NG"NEEr SUPF.R1i
� I -s.__._ _, _. . �, I r'�i . INSTALLATION AND MUSS ISE
r POP. ' THE SYSTEM CERTIFY H+I'"!�;}r;NG
+ �' WAS INSTALLED IN,'
N STRICT
' ROD• 1 j w
ACCORDANCE Tp p
!cry
TOP OFF FOl 10A
- !00. 00 (aSSUN�EDJJ - �'
��
PLOT PL, ' SHOY,, AIG ,4 PROP,AND �1P�R>�'��¢� OF AN PROPOSED .ADDITION
1 �_ EXISTII�'G SIJBSUAf AC "
I LOT 5A
_ __ . LPT-Z�C DISPOSAL SKSTEM
J 16606f S. F. .., � _ __ - r
i
L 0T 5,4, 5AP W L.e' AH 'S ROAL7, ,BARNSTA&E MA
42• 46 APPROX. 1 5`CALt= 1 " = 30 ' FEBRUARY 6. 2004
GAS 6 WATER .�'m��� LA/ID SURV YT�I:�i
B SERVICE f I NOTE.' EXI,97'TX .3� fYEDR00M 0Wf--1 L.:1VG 306 0�� PL �'��O;ITS' ROM �
fs�lTN AOPOSFD r�FOROGAf Ir✓
AG�MOE BEACH, MA
j At7DITI0�''. 4' BEDROOMS TOTAL PROJFECT NUMBER S-124