HomeMy WebLinkAbout0077 CAP'N LIJAH'S ROAD - Health LA7 CAS ?-# LIJAIIS RD, CEN76RVILLE
. 192-162
No. 42101/3 ORA
ESSELTE
10%
0 0 0 0
c � Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f t
77 Capn Lijah r +
Property Address
Arnold&Sharon Clark -'
Owner Owner's Name
information is {
required for every
Centerville Ma 02562 4-24-19 `*
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information 67-tr
filling out forms
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
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. 0 Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey 4-24-19
''Oee:At8.0e1503'1 t:J5-0aO0
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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
r
� t
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
v�
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
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: . ,
❑■ 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 system was in working order at the 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
�s ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capri Lijah
v
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for 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
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
?' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
V
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every --
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ or Cesspool privy is within 50 feet of a surface water
P P Y
❑ 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
, f
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for 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
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ O Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 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.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ 0 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 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsuf'ace Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
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
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
0 ❑ 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?
O ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ R Was the facility or dwelling inspected for signs of sewage back up?
E ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
0 ❑ 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?
Th
e size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
El ❑ Existing information. For example, a plan at the Board of Health.
0 ❑ 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)]
t5insp.doc-rev.7/26/2018 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
77 Capn Lijah
v
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
No design plans 3
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA
Description:
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes El No
Does residence have a water treatment unit? ❑ Yes 0 No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes El No
Seasonal use? ❑ Yes Q No
See below
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
2017- 48,000gallons 2018- 55,000gallons
Sump pump? ❑ Yes ❑■ No
Current
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface -Sewage Disposal System Page 7 of 18
P Y 9
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
,
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p .Y rY
U
77 Capn Lijah
Pr Address Property dd ess
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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- last pumped 3 or 4 years ago
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
0 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:
1995
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑other(explain):
Town water
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
c Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capin Lijah
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: fee r
et
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
1
Dimensions: 500gallons
411
Sludge depth:
3219
Distance from top of sludge to bottom of outlet tee or baffle
0if
Scum thickness
NS
Distance from top of scum to top of outlet tee or baffle
NS
Distance from bottom of scum to bottom of outlet tee or baffle
measured
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.):
The tank was in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
t5insp.doc•rev.7l26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�n p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
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):
NA
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
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):
0"
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.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�o Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
v
Property Address
Arnold&Sharon Clark
Owner Owners Name
information is Centerville Ma 02562 4-24-19
required for 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.):
NA
" 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:
El leaching pits number: (2) 6'x6' pits
❑ 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
77 Capn Lijah
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
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.):
The SAS was in working order at the time of inspection. Both leach pits were 1/3
full when viewed .
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
w1
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 77 Capn Lijah
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
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
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
v
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for 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
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t5insp.doc•rev.7R6/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
c� Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Capn Lijah
v
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
■❑ Check Slope
❑0 Surface water
❑■ Check cellar
❑■ Shallow wells
Estimated depth to high ground water: No GW @ 5' below SASfeet
Please indicate all methods used to determine the high ground water elevation:
n Obtained from system design plans on record
PERMIT dated 11-15-95
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:
A permit on file at the local Board of Health was used to determine high groundwater.
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
77 Capn Lijah
Property Address
Arnold&Sharon Clark
Owner Owner's Name
information is Centerville Ma 02562 4-24-19
required for every
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:
3
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
ASSESSORS MAPNa�. ,LOq No. w
PARCEL N0- k l n a Fee -30
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
application for Oigpool *pgtem Congtruction Permit
Application is hereby made for a Permit to Construct( )or Re`p )an On-site Sewage Disposal System at:
Location Address or Lot No. 7 Owner's Name,Address and Tel.No.
-� 7 C AP'N L Sak b R3 Acc-okd ck"Ik
Ins<staller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 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
Description of Soil 11;t4 n� Cs_s'r ,J c
Nature of Repairs or Alterations(An wer when applicable) 1 6V Co L C.C�CXA PIA W\t"k
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 Certifi-
cate of Compliance has been issued&this Board
Signed Date 11
Application Approved by
Application Disapproved for the following reasons
Permit No. Date Issued "r �
`'. , +: , a . . ...any r. Vy � 1 ^� y� ds•a.r„°.a . .M+r..4.w+ :'!�, )s �w�k '
No.
/ lD FeeY� �/ r
THE COMMONWEALTH OF MASSACHUSETTS-
V PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Mig aal *pztem Cow6truction Permit
Application is hereby made for a Permit to Construct( )or Rc g 4 )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
"7 � CAP N �o �csLc
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
g g
Dwelling No.of Bedrooms 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
Description of Soil Ct"
Nature of Repairs or Alterations(AaWer when applicable) M a I 6Y�k � L c c,_c & PIA
C ��t
BTU-^-JL. \ � 1A- Sr{!'V-C A
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 Certifi-
cate of Compliance has been issued this Board t
Signed t Date (1 1
Application Approved by
Application Disapproved for the following reasons
/ -/ ! Date Issued Permit No.�.
1
THE COMMONWEALTH OF MASSACHUSETTS
1
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance -
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced on
by �r rN , c z.�.li .for A r r\oj a C c A r V.-
as `° N`` has been constructed in accor ance
with the provisions o Title 5 and e for Disposal System Construction Permit N �+ dated r
Use of this system is conditioned on compliance with the provisio se forth below:
----^ No. f.✓ " �N � Fee V"�-��
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mq;paal 6pgtem cou5tructiou Permit
t
Permission is hereby granted to
to construct(. )repair(V1 an On-site Sewage System located at cG om L AL'S R LVi Qk I
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be com ted within two years of the date below.
Date: /� Approved '�2%���%�e/ /�
r -
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LOCATION r SEWAGE # 'w
VILLAGE ASSESSOR'S MAP & LOT o LG
INSTALLER'S NAME&PHONE NO. ,�� SZ21
SEPTIC TANK CAPACITY �toix� -G4L � �c� V"1" ®Y��x��°°-- L
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS -1
BUILDER OR OWNER _
PERMITDATE: 0 I0 I SF COMPLIANCE DATE: / M S
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist ,
on site or within 200 feet of leaching facility) �/�,'i Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of 1 jjh''in; facility) Feet
Furnished by .X-�
A ri
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V
T-J
fry`]
C/ G=
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No.._....--•1j�'_--. ...........
THE COMMONWEALTH OF MASSACHUSETTS
,,-----BOARD HEALTH
. /
Appliratinn -fur Uhip ial Vorks Cnnnitrnrtinn Vrrnitt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst t
-_ .................•••...... .
Location-Address �� / or Lot No.
:.
Owner --•--------•..............•----•-•----•-•---Address
Installer Address
Q Type of Building Size Lot--- feet
Dwelling—No. of Bedrooms--------c__�-.......................Expansion Attic ( ) Garbage Grinder { ®
Other—Type of Building _.___, -------- No. of persons........... Showers ( ) — Cafeteria ( )
W Other fixtures ------ ----------------------- -
W Design Flow...........5-'............ ...:....gallons per person per day. Total daily flow____-_-___--;�40 -------------------
WSeptic Tank—Liquid capacityAGW_gallons Length---------------- Width................ Diameter---------------- Depth..__----_---
xDisposal Trench—No,J .................... Width-------------------- Total Length.................... Total leaching area---_____:._-_.------sq. ft.
Seepage Pit No-------,l.-_-------- Diameter..,O��_C____ Depth blow in�y________ _________ T otal leaching area------- ----------sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) �e-, 2- `
aPercolation Test Results Performed by........................................................... __.. Date----._---------.-----------------------.
a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water---------------.._.___--
G%, Test Pit No. 2----------------minutes per inch Depth of 'Pest Pit.................... Depth to ground water------------------------
'.j 1------- 1 ,? ..................... _ ?--------------- ��
O Descrt tton of Soil = �-- .C-.. lG'`I' G� �I � �' �� `- r' nr
x
- off. . --------------------------------
----------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 NI of the State Sanitary Code�ed
ndersigned fur agre of to place the system in
operation until a Certificate of Compliance has been i the boar alth.
igned.--- -• . ...........:.••--...--•---.•-•-•- ----------• -- ---------
Application Approved By.......... ... .. �!._..... --•--•--- -------------'L./ -4_+-
IDate
Application Disapproved for the following reasons:----••---------•--•-------------•---- -------------•-•-•-------•-•-••-•----------------------------------------
••••--•......•-•••--------------•---....-•••-.........---•-----•-------...-•------•---••••-•-••--••--.....•••--•-----•----........••.._........_........--------••---•----•--••--------------------.-•---
Date
PermitNo.......................................................... Issued........................................................
Date
No..---...... lk... FEx.. . ....................
THE COMMONWEALTH OF MASSACHUSETTS
,—BOARD OE HEALTH
rf w
Appliratiort -for 43i.ipaaiitt1 Works Towitrortion Vrruift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System t: c
Location.Address or Lot No.
011 Owner Address
a ................... -------------------------------------------------------
-------------------------------------------
Installer Address
Type of Building Size Lot_---�'�`.'°.f.Sq. feet
o
.-, Dwelling—No. of Bedrooms____________ ___________________________Expansion Attic ( ) Garbage Grinder
Other—Type of Building -_-__ _�u__.____ No. of persons...................... Showers ( ) — Cafeteria ( )
a' Other fixtures ________________ ______________ __ _
W Design Flow_--_--_---.5_ ......................gallons per person per day. Total daily flow------------- 9_.................gallons.
WSeptic Tank—Liquid capacitvf ''_4gallons Length---------------- Width---------------- Diameter................ Depth.__.____-.----.
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...............-----sq. ft.
Seepage Pit No......../-------- Diameter...I ..6--- Depth below,inlet _._. Total leaching area--__._-_---.._--_sq. ft.
z Other Distribution box ( ) Dosing tank ( ) d16 -� Z 3 - �- -7
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date-•-•-----------------------------•--._..
Test Pit No. 1----------------minutes per inch Depth of Test Pit_.................. Depth to ground water..__---._----._-.-.._..
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_.-.__.--..--..-_-..__
O Description of Soil------.e7- -_ ---- �1� r°--7(' �Ze
& - !'
1- -----------------------------
U �-�rh � �d a "^ A' .-..__�.'../. = --��?-----------------------------------
---------------{1 ---------------------------------------------...---------------------------------------------------------------------------------------------------------------------------
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— T ndersigned fury to place the system in
operation until a Certificate of Compliance has been is he boar h lth. �agreeDot
gned '' r -
Dat
Application Approved By.......__.___ _
Date
Application Disapproved for the following reasons:-----•---------------------•----••-------------•--------------•------------------••-------•_--------•-----------
---------------------------•-•---•---------------------------------------.•-•----------•------------------•-------------•-------•-•------•---.-----•------------•----------------------•----------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD , HEALTH
1
......�......,�'!-1 �_.........OF........... ........f,� ?.'t.................
C.Irrtifiratr of (T.Toutpi attrr
T T' IF i 0 RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
/ _ Ins�l�er �L/% A �/
has een installed in accordance vdith the provisons of Ar/ficlb XI of The State Sanitary Code as descri ed in the
application for Disposal Works Construction Permit No---l7.41_�__J�.�_________________ dated.....�1---------------------------------------
THE
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.......... FEE.---- (�,
�i��o�tti-� ka3 �YtStrltrtta�It �arrottt
Permission is hereby granted I^...t---- ------ r s i ---•---_---
to Construct f r_R yair ( ) an I cT�idua S>"ewa e�Disposal Sys elm-
7 /
�•-_`�j ' ��' ------ lam'"'---------------'�,----- ............
Street
as shown on the application for Disposal Works Construction Perm f/No._._. __J_ ___ . Dated_________ ____�_�7---____'----_-__.---
ti/ f.--... -----
Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Cam'' l !
_LCaCT_ION :cc� 5EW D,C4E_PERMIT k10.
VILLAGE _
L L-
--IMST_ALLER S IA&ME-
BUILDER-5-
D47E__PE.RNA1T_ _15SU.ED
_ _ DATE COMPLI.A1,10E
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