HomeMy WebLinkAbout0074 CAP'N LIJAH'S ROAD - Health 74 Cap'n Lijah Road
A= 192- 181
Centerville
SMEAD
Na 24WWR
UPC 12
Commonwealth ofMassachusetts
1d IR Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 p Y Y
74 Capn Lijahs
Property Address
Owner Tarr
information is Owner's Name /
required for Centerville ✓ Ma 02632 10/5/2020
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: Ins. ector Information
When filling out A p cs/ #' 114 910
forms on the
computer,use Douglas A Brown
only the tab key Name of Inspector
to move your D.A.Brown Inc
cursor-do not Company Name
use the return
key. P.o Box 145
Company Address
" Centerville Ma 02632
City/Town State Zip Code
508-420-4534 S14297
'B1O0 Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title
5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property 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
10/5/2020
Tn—spectooVSignature 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
4 '
Commonwealth of Massachusetts
ig Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Capn Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every page. Cityrrown 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:
® 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:
At time of inspection this system met all minimum passing requirements. This report can not predict
the future performance under the same or increased usage. This house has been occupied by 2
people for the last several years. The septic system appears to be original. There were no as-built
records at the town so we were only able to report on what was found at time of inspection.
2) 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):
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
fv p Title 5 Official Inspection Form
11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4�
/ 74 Capn Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every 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
�n I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Capn Lijahs
v
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every 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
4 �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
>r
74 Capn Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every 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 1/2 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 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.C.4.
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
t /
Commonwealth of Massachusetts
�,-F Title 5 Official Inspection Form
�1° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ 74 Capn Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every page. Cityrrown 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
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5ins .doc•rev.7/26/2018
p Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^ � 74 Capn Lijahs
Property Address
owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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): 330
Description:
A septic tank that on previous inspection report was stated to be 1000 gallons was found and a leach
pit was also found and located. No D-box was located.
Number of current residents: 2
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.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Readings were not available at the time i completed this report.
Sump pump? ❑ Yes ❑ No
Last date of occupancy: currently
occupied
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
74 Capn Lijahs
Property Address
owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every 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: owner stated pumping in March of 2019
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: maintenance
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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Capn Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every page. Cityrrown 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):
Tank and pit previous insp report stated d-box but gave no measurements to it and
there was no as-built card available.
Approximate age of all components, date installed (if known) and source of information:
1977 off previous inspection report. ( State recommends pumping every 2-3 yrs for maintenance)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L 74 Capn Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallon per previous insp
report
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
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 was functioning properly with a wall type baffel on the inlet end and concrete regular baffel on
the outlet end. inlet had riser and plastic cover and outlet had riser and concrete cover.
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
V
74 Capn Lijahs
Property Address
owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every 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
I
Commonwealth of Massachusetts
�v Io Title 5 Official Inspection Form
Ib
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
74 Capn Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
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
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�v ltR Title 5 Official Inspection Form
il�1
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
L � 74 Capin Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every 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 (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1 found
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Capn_Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every page. Cityrrown 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.):
A leach pit was found with a heavy 36 inch cover about a foot down and 4 ft of concrete block risers
.The top of pit had a hexagonal opening typical for its age. At time of inspection there was approx 2.5-
3ft of liquid in the pit with no signs of failure or surcharge.
12. 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
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Capn Lijahs
Property Address
owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�. �P Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form Not for Voluntary Assessments
/ 74 Capn Lijahs
Property Address
Owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every 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
7q Capto L-k* N\S
A
10
3
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
cam, Commonwealth of Massachusetts
iiP Title 5 Official Inspection Form
11.� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L � 74 Capin Lijahs
Property Address
owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: greater than 5
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. see attached proposed septic plan
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:
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u � 74 Capn Lijahs
Property Address
owner Tarr
information is Owner's Name
required for Centerville Ma 02632 10/5/2020
every page. Cityrrown 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
AsBuilt Page 1 of 1
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PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No.P� � ��'�)� J' Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel -'Ra —
Installer's Name,Address and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 6_rz r, 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)
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 of H c�
Signed Date
Application Approved by ec Date
Application Disapproved by Date
for the following reasons
Permit No. �~ Q Date Issued r �,
U
e- �
No. a � � 30� `.. Fee
THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0(pplicatlon for Disposal *pstem Construction Permit
00
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System individual Components
Location Address or Lot No.�f'j Cs�4��'' G�,J�/v Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel ✓9eZ "✓p/ G� T
Installer's Name,Addres§ and Tel No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building lor". No.of Persons Showers( ) Cafeteria( )
Other-Fixtrnres •g
rr
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) ® "^�� ��®���� �•T
F Lei"//+�'�L'y `/'Y��'`�d .e��`�o,X � �'�✓��� ��,.•tom C v v�''dl . ''
Date last inspected:
7'
Agreement-:tr *-. f• �` 3:4
F
The undersigned agrees to ensureAl e•conssttr�uction 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 of H �' q
Signed Date
Application Approved by Date14
d b(
Application Disapproved by Date
for the following reasons
Permit No. J j— Date Issued U ��
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
X � u V+ � BARNSTABLE,MASSACHUSETTS
h
� o
f Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired /�U raded
g P ,Y ( ) P (�) Pg ( )
Abandoned( )by
�)..Q/l �04191 iAA0ro has been constructed in accordance
with the provisions of Title 5 and the for Disposal SystemConstruction Permit No. �d( Grated 9 d-
Installer��j� Z��G'�&.0al Designer /1/
#bedrooms Approved design flow gpd
Ak
The issuanc of this pe `fit sh 11 not be construed as a guarantee that the system will fi
as designe .
Date /�� / Inspector ctio 1 ,
11 i
No. Fee / a&
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Nsposar *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(kil" Upgrade( ) Abandon( )
System located at
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 completed within three years of the date of this permit. P)�V_C4
Date /O r / Approved by
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� A
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 74 Ca 'n Leijahs Centerville
Property Address
r�
Beth Anne Papasodora C/O Beth Anee Hanley k
Owner Owner's Name
information is Q1
required for every Centterville MA 02632 September 9, 2015
page. City/Town State Zip Code Date of Inspection
r.�
nu
rNo
Inspection results must be submitted on this form. Inspection forms may not be altered in kny
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, /}f I��17
use only the tab 1. Inspector:
key to move your
cursor-do not David B. Mason
use the return Name of Inspector
key.
David Mason
r� Company
Name
4 Glacier Path
Company Address
East Sandwich MA 02537
City/Town State Zip Code
508-367-1617 S1287
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
Z Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4 September 11, 2015
Inspector's SignatuM 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.
YS
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Dis 2ys �emPage 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 74 Capin Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is required for every September Centterville MA 02632 9, 2015
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:
The observations noted in this report represent the condition of the system only on this date of
inspection and the information contained herein does not guarantee the continued operation of the
system.
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
c Commonwealth of Massachusetts
F Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is Centterville MA 02632 September 9, 2015
required for every ��
page. Citylrown 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 ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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
74 Capin Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is required for every September Centterville MA 02632 9, 2015
page. CityFrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 1/day flow
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 M , 74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is P required for every Centterville MA 02632 September 9, 2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cost.)
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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
: W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4.174 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
informrequired
is Centterville MA 02632 September 9, 2015
required for every p
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
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is Centterville MA 02632 September 9, 2015
required for every _ p
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
2
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 Yes
9 ( Y 9 (gp ))�
Detail:
2013; 12,000 gallons and 2014; 11,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
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 Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Cap'n Leijahs, Centerville_
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is Centterville MA 02632 September 9, 2015
required for every P
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: Board of Health
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley _
Owner Owner's Name
information is e Centterville MA 02632 September 9, 2015
required for every p
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1977
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Typical
Sludge depth:
3"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is P required for every Centterville MA 02632 September 9, 2015
page. CitylTown 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 47
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Scour Stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Effluent level with outlet invert. New riser added to outlet of septic tank.
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is p required for every Centterville MA 02632 September 9, 2015
_
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 74 Cap'n LeUahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is Centterville MA 02632 September 9, 2015
required for every P
page. City(rown 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 effluent level with outlet invert
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.):
condition of distribution box warranted replacing with a new H2O distribution box with riser.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley _
Owner Owner's Name
information is p
required for every Centterville MA 02632 September 9, 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching pit was to deep during inspection so a camera was used. Use of camera indicated
approxiamately a foot of effluent and no staining in the leaching pit.
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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Capin Leijahs, Centerville _
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is Centterville MA 02632 September 9, 2015
required for every p
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.)-.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is p
required for every Centterville MA 02632 September 9, 2015
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is P
required for every Centterville MA 02632 September 9, 2015
_
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: 15'
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:
Groundwater Contour Map
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater Contour Map
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Cap'n Leijahs, Centerville
Property Address
Beth Anne Papasodora C/O Beth Anee Hanley
Owner Owner's Name
information is required for every September Centterville MA 02632 9, 2015
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
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION - `{ 33 Ll !`5 SEWAGE ' 7 -
.VILLAGE ASSESSOR'S MAP & LOT 1 9Z —lift
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) K (p (size)
NO. OF BEDROOMS .. VATE WELL WAT PI
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No Vl�
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THE COMMONWEALTH OF MASSACHUSETTS
1� �\ BOfRD OF HEALTH
_.V...-Ow/)................OF......Ad Q.e'.P.l-.. ..... ..............................
Appliratiun -for Di-4poiittl Works Tomitrnrttnn Vrrm t
Application is hereby'made for a Permit to Construct (C-) or Repair ( ) an Individual Sewage Disposal
System at: r
CCU%�k L tC ��
¢ _ ti ------.----•-- ems_ ___._......_--•---
{`� Locali Address or Lot No.
�er Address 04/11
Installer Address
d Type of Building Size Lot_%.'�/6 40._._Sq. feet
Dwelling—No. of Bedrooms/_�____._-___�__________________________Expansion Attic ( Garbage Grinder (MO
Other—Type of Building /c/ No. of ersons--______/_'_ Showers Cafeteria
g .e��� p 1 .............. ( ) ( )
dOther fixtures --•-------------------- ---------------------------------------------------------
W Design Flow.......cS ____________________________gallons per person per day. Total daily flow...........&5Q_0..............._~__--gallons.
WSeptic Tank—Liquid capacityf O_gallons Length________________ Width_.__.--.------- Diameter---------------- Depth---------------
x Disposal Trench—No_ ____________________ Widtl _________..____-____ Total Length.................... Total leaching area-----.--------.-----sq. ft.
Seepage Pit Noa___________/...... Diameter___ _.._ Depth below inlet____________________ Total leaching area------------------sq. ft.
z Other Distribution box (1,4- Dosing tank ( )
Percolation Test Results Performed bY------- ------•----- ----------------------•---••--------- --- Date____-----------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit......-------------- Depth to ground water--------.-_________-----
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------------._____---
a' ------•----------------------------------------•------------•-------•------------------------------•-••--------------•-------------•------------------_------
0 Description of Soil - , ��«/
v ----------------------------------------------------------------1&1,e 7K.........5�f= ------ �°y---�_---- ----- --------------------- -------_____------------
W ---------------------------------- --------------- ---------- -------------------------------------------------------------------------------------------------------- ------ --------------------------
UNature of Repairs or Alterations-Answer when applicable._-___________ ......_----------------------------------------------------_____---------------
---------------------------------------------- --------------------•------------------•----•------••----------------------------------•-----•-•-----•--------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The signed further a of top a the system in
operation until a Certificate of Compliance has be n i:at oard of heSigned - - - ------ --- .............
^ / Date
Application Approved BY----- =1 ------------------------------------------------------------------------------
Date
Application Disapproved for to following reasons:----••------------- --•---------•----------------------------------------------------------- a.t e..............
•--•--------••-••-__--•---•••--•---------•--•-•---•-•-..._----••--------------------•---••-------•-_-- --------•---------------------
Date
PermitNo------;L3..............................•--••---••- Issued...................... .................................
Date
�-- — -- -- -- ----��...
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
.(�.W./) ........... ..OF...._'l.' n..S.. ! .L..C- ......
Applirtt#iun -fur 43i"oiial urkii Tomitrur#tun Vrrnti#
Application is hereby'made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal
System
1at:
-3 ...... Cr y. ---
Location�Address or Lot No.
_.........T Pf�� ................ -----------------------------------------
f� �vner Address..................
--••--•---•-^ ---•---�w-� s
--•---......-- ...G....--•--------•----••---------------
Installer Address
d Type of Building Size Lot.) --------------------Sq. feet
U Dwelling—No. of Bedrooms. __-__-.---�-----_. ...__---_Expansion Attic (��) Garbage Grinder ( 9
Other—T '-
a YPe of Building --, -?�-�'�I---�y�=j-- No. of persons-------�/----------------- Showers ( ) — Cafeteria ( )
QOther fixtures ---------- -----------------t_-- ----------------------•---•----- ............. ----.-__...-----------.....--••---------------------•----------
W Design Flow.._....s._O________•________ _________gallons per person per day. Total daily flow...........4290a....................gallons.
1:4Septic Tank—Liquid capacity,/000-gallons Length---------------- Width.-___--_-_-.- Diameter....------------ Depth..-.------.-----
W 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 (4,,)- Dosing tank ( )
Percolation ,Test Results Performed by.......................................................................... Date---------------------------------------
W
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
LT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ------------------------------------------------------------------------------------------------------------------------------------------------------•----
D Description of Soil -�.ii. ------------ -- -----------------------------
--
U -------------------------------------------------------------------�-------------------=f---------------------------------- --------------------------------------_.--------------------------
W
U Nature 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—Th signed further a ryes`nOt to I the system in
operation until a Certificate of Compliance has been issue, y t card of he -----~
-7
Signed-- ------ --- ---- - 1- 7 /
Application Approved B .. �L . Da� ?
Date
Application Disapproved for t�lie following reasons:................................................................
-------•------------------ -- ......
.....--•----••----•-------------•---.........._.....-----------•-•-••-•----------------------------..................................................... -----------------------------------------------
Date
PermitNo.-----='.. 3......................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH //
.......... S�cl.
..c>w✓/.........OF.............. f_e� �z-r.p/p
Tntif irate of T"'oM rliaurr
THIS Ik�14:t�
TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------- --------00-J^------.. -----------------------------•--•-------•-------.
J /1 ` Installer
at.............. p r' L. Viz. �'' Q-----------------•----•.
has been installed in accordance wit the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.........;.,.:...................... dated-----
..._...._..._..______._____..__....__...__.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY r� `1
DATL._ t - ...... Inspector...............
l�s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1...o.W ................OF..... l� � �..5. :.6 P..------------------...............
No......... - ....... FEE------fS ...%
�i��u�ttl u k,� Cnun�#rnr#i tt �rrmi#
Permission is hereby granted_-------------------- -641..------.... e�------� "7 �--------•--.......--------•-•-------------............---
to Construct ( G) or Repair ( ) an dividyal Sewage Disposal System �.
at No.. />,t-f ?�..3� ------.... � ` ....../V 4=---J --------- ---------------------'-Il e
---------- - ---- -
street
as shown on the application for Disposal Works Construction Permit No--------------------- Dated------------------------------------------
-------------------------------------------- -----------------------------------------------------...._
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) �� (size)
NO. OF BEDROOMS _ PfVATE WELL R PUBLIC WAT
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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