HomeMy WebLinkAbout0420 CAP'N LIJAH'S ROAD - Health 420 Cap'n Lijah's Road,Centerville
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UPC 12534
No.2_ 1_53 OR
HASTINGS, MN
No. Fee 2,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for MispoSal *pstrm Construction 3pPCmlt
Application for a Permit to Construct( ) Repair(<Upgrade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No ���'�"�`i�jd/f f' Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
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 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 B f lth.
oop
Signe Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. rJ " l Date Issued
' I
r i r
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
`PUBLIC HEALTH DIVISION. TOWN O-F BARNSTABLE, MASSACHUSETTS Yes
ZIPP4 tion,for -Misposal *psttm Construction permit
Application for a Permit to Construct( ) Repair(<Upgrade( ) Abandon( ) [:]Complete System ndividual Components
Location Address or Lot No.T O G�P'�'' �.l�d//✓' Owner's Name,Address,and Tel.No. /
op
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
(5�)
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building lr4dr--'• 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) &Or<4e.Z ' e !�7 ".Cj'O,X
Date last inspected:
Agreement:
The undersigped 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 B lth. 000,
Signe, Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. � Date Issued I v
THE COMMONWEALTH OF MASSACHUSETTS
F' BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(1 Upgraded( )
Abandoned( )by
at , ✓ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No__/W /5.�I—dated
Installer r� .4,ewpeao— Designer
#bedrooms Q—&ox C;.A--4y Approved design flow A gpd
The issuance of this permit shall not be construed as a guarantee that the system will f+tm�c A)as designed.
Date l I v Inspector �� hJ /--
--------------------------------------------------- -----------------------------------------------------
No. C �` — `� --__.______.___._.Fee 7
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction �ermit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at 5penZ O C�� �^� /Ji�..y✓� �,d C �`.�T
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 co pleted ithin three years of the date of this permit.
Date �} Approved by \
3q5-
142 94,
PROP.
GARAGE
DWELLING E /
C/) TAN Lpe Lp
N BM (
/10.
MBLU 194-034
420 CAP'N LIJAH'S WAY l
CNTERWLLE, MA l
FLOOD ZONE X
LOT AREA 18,473 SF
EX. DWELLING AREA— 1.780- SF
SEPTIC SYSTEM PLOTTED
FROM INFORMATION PROVIDED
BY OWNER. BUILDER TO CONFIRM
R T1 F IED PLOT PLAN
ANDERSON RESIDENCE
I CERTIFY THAT THE IMPROVEMENTS SHOWN Of w 420 CAP'N LIJAH'S WAY
HAVE BEEN LOCATED BY A FIELD SURVEY. Ass�o CNTERVILLE, MA
9 ROBE. DATE: JUNE 15, 2016 DRAWN: RBS
SYKES SCALE: 1"=40 JOB t S246DWG.-CPP
-- No. 35418 y EASTBOUND
6-15-2016 ssF��S �����'� LAND SURVEYING, INC.P.
Na 0. BOX 442
ROBB SYKES, P.LS DATE FORESTDALE, MA 02644
505-477-4511
Commonwealth of Massachusetts
Title 5 Official Inspection Form ®Q
Subsurface Sewage Disposal System Form - Not for Voluntary Assessme s/
^M 420 Cap'n Lijah's
Property Address W
Robert and Barbara fougere �..
Owner Owner's Name
information is
required for every Centerville MA 02632 January 22, 2016
page. City/Town State Zip Code Date of Inspection
4+D
Inspection results must be submitted on this form. Inspection forms may not be altered in any'
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, 6/4f 'I e3 Z
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
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
;-- � January 28, 2016
Inspec or's Sign—a-Qe • Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
ko& A
1 i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every rY
page. Cityrrown 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):
IF
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
,i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every Y
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every ry
page. Citylrown 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 '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every y
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•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
420 Capin Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every y
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 420 J
CaP'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every ry
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑, Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): Yes
Detail:
2015; 85,000 gallons and 2014; 79,000 qallons
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22 2016
required for every ry
page. Cityrrown 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•3/13 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
420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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: 8 inches to top of tank
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:
2"
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
^M 420 Capin Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every y
page. Cityrrown 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. PVC tees in place
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 420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is y Centerville MA 02632 January 22 2016
required for every ,
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
H W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every rY
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.):
No evidence of solids carryover. d-box is 18 inches below grade
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
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 420 Cap'n Lijah's
Property Address
Robert and Barbara fou ere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every ry
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
Unknown
❑ 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.):
2-6' leach pits 24 inches below grade. No risers in place. effluent is 40 inches below inlet invert on
each pit. There is evidence of staining that indicates the effluent level has been within 30 inches of
the inlet invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every ry
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
420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every y
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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 Janua 22 2016
required for every ry ,
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: 20
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
c,M 420 Cap'n Lijah's
Property Address
Robert and Barbara fougere
Owner Owner's Name
information is Centerville MA 02632 January 22, 2016
required for every ry
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
JAN-22-2916 09a43 From:BARNST HEALTH 15087906304 To:5082760001 P.1/1
Commonwealth of Massachusetts
Title 5 Officia] Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'�'��-_,w 420 Captain,t.ijahs Rd .-__._•_ ...,.. ...__ _____._.__
Property Address
_ FOt.GERE, R085RT F BARBARA
Owner dwneVs Name
information is Centerville Ma 02632 902013 _
required for ovcry --•'--...._----- ----.:.... »:......._
page, Cdy/Tcwn State Zip Code Date of Inspection —~D. System Jnforlmation (cunt)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system„ including ties to
at feast 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
l0 Q L
� 3
-t i`f
Ob
4rz 2.a
:33
S-3 3b
t5i�s-3r13 7'111e R Qffidnl Inspedion Form:utsurmcs tirvrs:Uispossl syslenl-Pair 7n of t7
i
F / Commonwealth of Massachusetts
Title 5 Official Inspection Form
�a e'-.'I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
420 Captain Liiahs Rd.............................
_.___ .._..-_ ___--
Property Address
FOUGERE, ROBERT F & BAR.BARA
Owner _.. .. - ----
Owner's Name
information ie Centerville Me 02632 9/6/2013
required for every -- -._ _.__..._._. .. ........
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection.forms may not be,altered ira any
way. Please see co pleteness checklist at the end of'the form.
--._-_-:_.............
Important:When A. General Information
filling out forms
on the computer; U
use only the tab 1. Inspector:
key to move your .
cursor-do not Seari M. Jones'
use,the return
key' Name of Inspector
C pewide Enterprises . .:...
r Company Name
153 Commercial St.
Mashpee Ma _. 02649
__ _ ........ .... .._ ..__—. __ ...... .. . ..__....
Cityrrown State Zip Code
508-477-8877 SI 4522
._.... _.. _ ..... -
Telephone Number License Number.
B. Certification
l certify that l 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 aril maintenance;of on-site
sewage disposal systems. 1 am a DEP approved system inspector pursuartt fio Sec#ion 15 340--f
Tit
le 5(310 CMR 15:000). The system:
Passes ❑ Conditionally Passes [] Fails
[] Needs Further Evaluation by the Local Approving Authority
9/6/2013
.... _._._. ..__._ ......... ..... ..... ...... .._..___
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)'within 30 days of completing this,'inspection. if the system is ashamed systerrm':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 tfx.ap WiNle, and the approving authority.
�-
� a
****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 udder
the.same or dtffcrent conditiotls of-use.
v cF `Gi �JJ
V
bins-3713 title 5 Official!nspaction Form:Subsurface Sewage Disposal System-Page of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
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 dwelling located at 420 captain Lijahs Rd Centerville is served by a Title V septic system
consisting of a 1500 gallon septic tank, distribution box and 2 1000 gallon precast leach pits. The
system was found to be in proper working condition at the time of inspection.
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
I
Commonwealth of.Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. City/Town 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ .❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is Centerville Ma 02632 9/6/2013
required for every
page. CitylTown 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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
420 Captain Lijahs Rd
Property Address
FOUGERE,,ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® 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:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A.system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
original system 1981, leach pit added 2/24/1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: 10"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallons
Sludge depth:
6"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is Centerville Ma 02632 9/6/2013
required for every i
page. City/Town 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
3"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers, took
measurements
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 should be cleaned soon and again every 2 years for proper maintenance. water level was even
with outlet, tank was not leaking and was structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments
�M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes, ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was video inspected and was in good condition, no rot, water level was even with
outlet invert.
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c,M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2x1000 gals
❑ 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.):
Vegetation was normal, soil was dry with no sign of past saturation. No sign of hydraulic overloading.
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,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. Cityrrown 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
Toltle 5 Official Inspection Form
Subsurface Sewage Disposal System Fora - Not for Voluntary Assessments
%I 420 Captain Liiahs Rd_Property Address
FOUGERE, ROBERT F& BARBARA
Owner Owners Name -
information is
required for every Centerville Ma 02632 9/6/2013
-...... .. ...... - . .._ - . - .........— - -- - ..._
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
-. } -
t
' �"
.
t-3
e.- 23
t5ins•3113 Title 5 Gfdal Inspection Form:Subsurface Sewage Disposal System Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
page. Cityfrown 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: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable 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
wM 420 Captain Lijahs Rd
Property Address
FOUGERE, ROBERT F & BARBARA
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2013
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
Commonwealth of Massachusetts ¢"
Title 5 Official Inspection Form C" "
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required for Centerville MA 02632 05/01/10
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.
Important: A. General Information
When filling out B f '
forms on the �Il/11I
computer,use 1. Inspector:
only the tab key
to move your Michael Kellett
cursor-do not Name of Inspector
use the return
key. Aardvark Environmental Inspection
Company Name
P.O. Box 896
Company Address
East Dennis MA 02641
City/Town State Zip Code
508-385-7608 S13742
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.Theinsp Ion
was performed based on my training and experience in the proper function and mairitenance`of on sr
sewage disposal systems. I am a DEP approved system inspector pursuant taSection 15 340 69
Title 5 (310 CMR 15.000).The system: 1J,
® Passes ❑ Conditionally Passes ❑ Fails ' "=a
❑ Needs Further Evaluation by the Local Approving Authority °
I �
TG ,� 05/05/10
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
5 �
� D
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required for Centerville MA 02632 05/01/10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the❑forthe 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 exliiltration 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.
ND Explain:
❑ 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
❑ obstruction is removed
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is Centerville MA 02632 05/01/10
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
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
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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is Centerville MA 02632 05/01/10
required for
every page. Cityfrown state Zip Code Date of Inspection
B. Certification (cunt.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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 Y2 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. _
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required forCenterville MA 02632 05/01/10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No :
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—iWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required forCenterville MA 02632 05/01/10
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
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)]
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required for Centerville MA 02632 05/01/10
every page. City/Town state Zip Code Date of Inspection
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
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Tale 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required for Centerville MA 02632 05/01/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (f yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date'installed (if known) and source of information:
03/07/94 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes 0 No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required for Centerville MA 02632 05/01/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1.9
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.):
Septic Tank(locate on site plan):
Depth below grade: 2.2
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: 1500 gal
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 28"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
' Distance from bottom of scum to bottom of outlet tee or baffle 16"
How were dimensions determined? measured
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information-is Centerville MA 02632 05/01/10
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (coot.)
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 sound and tight with tees in place and liquid at outlet invert.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom,of outlet tee or baffle
Date of last pumping: Date
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):
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required for Centerville MA 02632 05/01/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Tight or Holding Tank(cont.)
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert even
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 box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
G1 420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required for Centerville MA 02632 05/01/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 2
❑ leaching chambers number.
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number
i
❑ innovative/aftemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
The system has two 6'x6'precast pits one was half full while the other had two feet of liquid with no
sign of staining or ponding.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required for Centerville MA 02632 05/01/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
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.):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
420 Captain-_U)ah
Property Address
Robert Fou ere
Owner Owner's Name
information is Centerville MA 02632 05/01/10
requuedfor
every page. Cityrrow n State Zip Code Date of inspection
D. System Information (cunt.
Sketch Of Sewage Disposal System: vide a sketch of the sewage disposal system including ties
to at least two permanent reference IE ndmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply ent rs the building.
3w`
YS 3�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
420 Captain Lijah
Property Address
Robert Fougere
Owner Owner's Name
information is required for Centerville MA 02632 05/01/10
every page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet
r �7
t + I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PO vQ lj
&WIQ JLI3'A(-s At
Address of property 420 Capt Lijah Rd Centerville, MA 12
Owner's name Richard Landers
Date of Inspection 5-28-95 M4
PART A �,3
CHECKLIST
:y.ec if the following have been done:
Pumping information was requested of the owner, occupant, a of
Health.
__�e_/None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
__ZAs built plans have been obtained and examined. Note if they are not
available with N/A.
/The facility or dwelling was inspected for signs of sewage back-up.
V The was site inspected for signs of breakout.
1 P 9
All system components, excluding the SAS, have been located on the
site.
The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
--,/ sludge, depth of scum.
—,-The size and location of the SAS on the site has been determined based
Yon existing information or approximated by non-intrusive methods.
The facility .owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
3 number of bedrooms
_ number of current residents
�o garbage grinder, yes or no
laundry connected to system, yes or no
o seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information: _
System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Typ 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)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: /
• ��: 6 is y � i l i S�
Sewage odors detected when arriving at the site, yes or no
1
I
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:-J S6-0
(locate on site plan)
depth below grade• /=
material of construction: _zconcrete metal FRP other(explain) -
dimensions: �,��Q 612"
o�
l_ sludge depth
1-5 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
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
��s i a. P a-�41 G a �o,A, .�i i�/�'s ►� r:-, C _ .
DISTRIBUTION BOX:
(locate on site plan)
p depth of liquid level above outlet invert
Comments:
.(note if level and distribution is equal , evidence of solids carryover,
evidence of leakage/ into o�r/ out of box, recommendation for repairs, etc. )
d
PUMP CHAMBER
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, -
recommendations for maintenance or repairs,etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : Z/
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
TYPe bIst
leaching pits and number 9
leaching chambers and number
a �" " �'��'��
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
CESSPOOLS (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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. )
lI
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH. OF SEWAGE L=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
f�a
DEPTH TO GROUNDWATER
_ depth to groundwater
method of determination or approximation:
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C !
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
. Backup of sewage into facility?
surfaceDischar eg or ponding of effluent to the surface of the round
aters. 9 or
,.,,A� Static liquid level in the distribution box above outlet invert?
AZ-6— Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
C
J✓ Is any portion of the SAS, cesspool or
below the high privy;
g groundwater elevation?
within 50 feet of a surface water?
ILI within 100 feet of a surface w
water su 1 ater supple or tributary to a surface
PP Y•
Al— within a Zone I of a public well?
I
within 50 feet of a bordering vegetated wetland or salt ma
(cesspools and privies only, not the SAS)? rsh
within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private
wat
supply well with no acceptable water quality analysis? If thee well
has been analyzed to be acceptable, attach co
PY of well
. for coliform bacteria, volatile organic compounds, ammoniater nitrogenslL
and nitrate nitrogen.
s
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
ame of Inspector 6,,1, o�� 1� �� 6 J� ,S if R,, �"14�
ompany Nameb�i.�..go S� l'
ompany Address $6 )z 10
ertification Statement
certify that I have personally inspected the sewage disposal system at
his address and that the information reported is true, accurate and
omplete as of the time of inspection. The inspection was performed and
ny recommendations regarding upgrade, maintenance and repair are
onsistent with my training and experience in the proper function and
snitenance of on-site sewage disposal systems.
-zee. one:
I have not found any information which indicates that the system fails
to adequately protect y
q y p public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
ispectorIs Signature
ate S,P-F-`7 '
=iginal to system owner
Dpies to:
Buyer (if applicable)
Approving authority
03 �
e 30 00
No.. 7y='.4 Fss............._...............
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
Barnstable Conservation Q BOARD OF HEALTH
-LY�' TOWN OF BARNSTABLE
x Appliration for Di►ipwial Wnrk.6 Tomitrnrtinn jJrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
420 Capt Lijah Rd
--------------------------•-•-•---•---.........--•-------•-••-------••-••-••----.........._.------ ------------•--•-----•---••••--•----•---•-----....-••...---........---•-------•--...........---••-
Location-Address or Lot No.
R. Landers ;
......................-.......................................................-----•------------ --••-•---•-----•-•--•----••---------..........--•-------•-------...__.._.....------.......----..•.
Ow"' Address
W.E. Robinson Se tic Servi �____-�______
.................... p --• ------------- P o Box---1•Q-8-9._.Cea:.exv._llPa.-----------......---------
Installer Address
UType of Building 4 Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.--.....................---- Showers ( ) — Cafeteria ( )
Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width.....-.--_---.-- Diameter--..--_-.------- Depth................
x Disposal Trench-- No. .................... Width......-------------- Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter-------_............ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed b ................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.--..................--.
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.---.---............ Depth to ground water........................
a
ODescription of Soil............ ravQ.l..•-••-•...••-•-------------------------••-•--••---•••-----..••---•----.....-----•-------•---•------•---------••-----------•...........-----
x
w
------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------•--
M. Nature of Repairs or Alterations—Answer when applicable.----- ...............................
Precast...overf low
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—;he dersy
edersi d fur er agrees not to place the
system in operation until a Certificate of Compliance has teen ' ed unh rd o ealth. t�
Signed /�yl ...... .. �.......... ....... .. .......... .r24
Dace
Application Approved By ................ ...... .- ... - L/
Application Disapproved for the following reasons: .......................... . ... .................................................................................---.......--....
.................... ......................................... . ... ............................................................... ..-... ................................ ..................................
PermitNo. ..........r�. ..�................... Issued ....................................................................Da.
Date
n
f/ TOWN OF BARNSTABLE �
L AnON _ vZ 9t'�, 444 SEWAGE #
VILLAGE /+�T~� E'P �' ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.WA Ko6i�vso Y'
SEPTIC TANK CAPACITY ,,/S®
LEACHING FACILITY:(typ0 h)a E_ c� s T (size) /n oo G -t,
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER/�'.,�
BtWHOER OR OWNER , ��
DATE PERMIT ISSUED:'a A 5/
Y r
DATE COMPLIANCE ISSUED: 7—
VARIANCE GRANTED: Yes No
r
fi tx,sri�y
d
� yr _
No.. f..-y. 30 00
Fzx............ ...............
THE COMMONWEALTH OF M.ASSACHUSETTS
BOARD OF- HEALTH
x r�� LY-:�TOWN'.OF BARNSTABLE
/�- �-"
Appliratiou for Dili.pnial-1vork.6 Cnowitrurtiou Vrrmi#
_ Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
420 Capt Lij ah Rd
.....---••................•------------............_........--------....---•--•.........---•---•-• ----••--•---•---•-•-------.....---•••••--....----------•----------•--------------....._.....-----
R. Landers Location Address or Lot No. i
......................_.......................................................................... -..............................................--•................................................ f
owner Address
w.... RobinsonSent cS 089-- .. ... ... .. ------------- - - -..Centergillf............................
Installer Address
d 'Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.-..4--------------------------- _.Expansion Attic ( ) Garbage Grinder ( )
0`44 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
0.1 Other fixtures ------------------------------ - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons' Length................ Width-.-.- .------ Diameter................ Depth................
x Disposal Trench--No- -------------------- Width.................... Total Length..................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter............---..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.................. ----•--------•-••-••--•-----•------••---- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ `
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:4 -------------------------------------------------------
----•.......................
-........
....---.......................
.---•----- -------•--
DDescription of Soil gravel•----•--•----•-•............................•-----------•--------•------•••--•--------.......---......------------•-•---..........--••...---
x
U
W -----•••---------------------------•----•-•----•-------•-•-------------------------------•---•••••------•••••--•--------•.....-------•--------------•--•--------••-------•-••-•-----------••-------•----
UNature of Repairs or Alterations—Answer when applicable_..install--- n-__adds,tiara-al...............................
preaast everflow
. --•------•------•----•-•-•..................•••--••----•---•------••----•--••.....---•----------•---•------•-•-----•-•------•••--•-•--...----......--•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The unders�d furtjier agrees not to place the
system in operation until a Certificate of Compliance has Len 's ed y,vh and of Health.
Signed . .... .... .......... . ..........................,......... r .-Cj�......e
� - -- DaceApplication Approved By ..............( ....., z . . ..-.1...1.<..---.._...L/...................................................................
Application Disapproved for the following reasonr: ................................. . ........................ . .... ........ ........................................... .
... .......... ................................................... ........................................... -- . -- --...............................................--- ........................................
Permit No. ......... 1...... ._.-L/— ................... Issued fe......
- Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
CZelrtifirate of CZomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x )
~. by ----W—E.......Robinson...-Sept.i_c- -S-ervice---,;---� r.........-------.........------------........................... . ........................................
420 Capt Lijah Rd Centerville
at ..... ...... .......... ...................... .................-------- ------------.--------------..............---..------------------ ----.--------------------------....... ................-----
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ---------j�_....-7... :------- dated -----...........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. ._.....t��. ... ..... ........-.-- ----- -- -------- Inspect.................- ---------.---.......------
--------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
q TOWN OF BARNSTABLE 30 00
Permission is hereby granted-- -----------------------------------------------------------
to Construct ( ) or Repair ( X) an Individual Sewage Disposal System
atNo..........4 2® Capt Llj. l?. d---------.........................................- ---..............................................................................
Street q
as shown on the application for Disposal Vl'orl:s Construction Permit No./.._ -7 Dated.._-- ..� -- �/
C -----•----------..........
- :_----------------------
•-- Board of Health
--------------------------
DATE.................. � ' ------------------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
No........�` ....... _ Fps...... .®...............
THE COMMONWEALTH OF MASSACHUSETTS ~
BOAR® OF HEALTH
................ ......__....-.OF...........-......-..-.......-.....,... ...._...........................
Appliratinn for DWposal Works Tnnitrnrtinn ramit
Application is hereb made f a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at• .'
` L atio -Addres / ,C or I �r1to y/-
1Z ���4 ..... t' ........................ �C S� ./�i iV•.(:'���"eX.......................................
----
Addr ss
Installer Address
Type of Buildings Size Lot_ �'P.7 . Sq. feet
DwellingLNo. of Bedrooms_______________aj.............................Expansion Attic ( ) Garbage Grinder--(--�---
04 Other—Type of Building ____________________________ No. of persons............................ Showers (L) — Cafeteria ( )
Q' Other fi tures ••--••-••-•--••••--••••-••--••-•••-•••••---•-••-•••-••••._._...-••--•---••••••--------................ .
W Design Flow.............. __ ..�t>"gallons per person per day. Total daily flow_________________ _______________________gallons.
�--
WSeptic Tank—Liquid'capacit}b_._._____gallons Length................ Width................ Diameter________________ Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length............ Total leaching area....................sq. ft.
Seepage Pit No.................... Diameter.......yld_..... Depth below inlet....... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by....... a
........................__ ---••-•--•--
Date__ a8 ...........
Test Pit No. 1_t__Z.____._minutes per inch Depth of Test Pit____________________ Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........_...............
----------------------------------------------------------..................----........•--•_---
---------- ...
O Description of Soil...............0-_.:- y
---------------
•----------
•----------------------
----------
•--------------
--------
-_ ___----------------•--___--------------•----------------------- ------------.----_ -------------
•---------------
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 TIT'.;•
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issNe3l by the boar /ealth.
Z�GG�� ,
Signed.......X �G: .L 1rf.
y Dat
Application Approved BY _�� � -----2------ ''- `���
Date
Application Disapproved for the following reasons----------------------------------•----------•-------•-----------------------•--•--------.-.----------...--••----
---••••-----•-•••••-••-•-•....................••••.....••------•---••-•-_.._..•••.........----•••--•-_-•-
Date
PermitNo....................................................... Issued.......................................................
, Date
J " w
No....... ....... FEs.....��. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F............................---............---------•----------..I..._.._......_......_...
Appliration for Disposal Works Tonstrurtiinn Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--•• - -•-----•• • ............... .......... -.._......-•-----•.... ---•-
Location-Address or Lot No.
......................---......................Owner Ad-- --•---•--..........••-•--..._......---...... .........-----------.......__......_..........Ldress•••--...........................................
W
a ............... ..........
........
Installer Address
Type of Buildi Size Lot............................Sq. feet
U Dwelling L No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( )`k Other—Type T e of Building _______________ No. of ersons___.._.____._____._.___.._._ Showers — Cafeteria
C4 YP g ------------- P ( ) ( )
QI Other fi tures ----------------••---------------• - - --
- ---------
Design Flow............... _____................gallons per person per day. Total daily flow......................!.....................gallons.
WSeptic Tank—Liquid'capacity_.__________gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length........... ...... Total leaching area....................sq. ft.
Seepage Pit No.._ .... _. Diameter.__.._ .. Depth below inlet....... ....... Total leaching area...................sq. ft.
Z Other Distribution box ( ) Dosing!oOk ( ) ��
Percolation Test Results Performed by....._ ..0-?:........� �------------- ------------- Date.,/ -/A...��._______...
Test Pit No. 1.<_2-.......minutes per inch Depth of Test Pit____________________ Depth to ground water........................
Iz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground{'water........................
M ...........................................................W -- ---......_ ._.. .._----•
O Description of Soil---------------0......2!/..-- .�.->at:...�?.-----��/:,��e�_2...----.�_..� -----.....------
x
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 T IT:_. y g g p y
5 of the State Sanitary Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed....:.::::::.:.: :.::.: _ • _ ._,_ -
Da
Application Approved By.._..___ :_4r .._ __'__�`_ �
Application Disapproved for the following reasons:�_____________________________________________________________________________________Date
.................................•--------------------------....--------...---------------....--------------._.._...._....-••----•----------•----••---•----••••-••--•-•-•-------••-••••---••---------•--
Date
PermitNo....................................................... Issued----------•--•-•--....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!.M................OF..... e. ............................
.........-................
Q'I"'rrtifiratr of ToutpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by �........ .1 µ........... . ...........
44*&W
Installer ,%7 '
has been installed in accordance with the provisions of T ) j� The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ �_________ . dated_.............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...... °t ' /----•--••-••-------•------------------- Inspector........�"�� ---------------•--------•-•-----•------•-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..d-k-Irv............OF........� ._._.._..... J ,rat`
NFEE........................
Disposal Works Tnnutratrrtion Vprrmit
Permission ' hereby granted......... --------- ._._._.
to Construct_�')S or Repair ) an Indivi �1,Sev�ra a Disposal S stem -
Ter
Street
' as shown on the application for Disposal Works Construction Permit No...................... Dated..........................................
= ' -------------------•._.__.._........_.._...
k6ard of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r ---t
G644�-wT 2.�2
L. SD.� �S6wgE� �q^j�►1
TOP OF FOUNDATION
CONCRETE COVER
• CONCRETE COVERS
. • nrn+rsyr My►
•• 12"MAX. WA2"MAX.
PIPE (ORIRON '
•. 4"ORANGEBURG(OR EQUIV.) -�
• EOUIV.)- MIN. PIPE- MIN. I LEACH
.. ' PITCH 1/4"PER, PITCH 1/4"PER.FT. PiT
VF4ECAST
.'� NV�gT aACHING
`•• EL. IN INV T INV�Ejib e . T OR
SEPTIC TANK EL. 1,28. DIST. EL6� 1 , • W EGUIV.
BOX INVERT - .. GAL. INVETaEL.47¢S ELY'/CAB INVERT •,. WWTOII/2EL. ..... ASHED
W TONE
WDIA. -+-� �
PROR LE OF GROUND VATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
0 L LOG WITNESSED BY :
p
DATE ./ �d. TIME. /.�-30 / �! / ,�O,�BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 ENGINEER
EL.EV. . . . . . . . . . . ELEV .. .. . . . . . .
LAM DESIGN DATA :
L4 NUMBER OF BEDROOMS . . . . . .
l TOTAL ESTIMATED FLOW . �D. . . GALLONS/DAY
{� BOTTOM LEACHING AREA 01 . SO.FT. /PIT
SIDE LEACHING AREA SO.FT./ PIT
54"Lb GARBAGE DISPOSAL .4CO. . .(50% AREA INCREASE)
TOTAL LEACHING AREA
.J-�,T . . SQ.FT
���.� ��� •i PERCOLATION RATE (94� Z MIN/INCH
��yy
e l-� LEACHING AREA PER F►RCOLAi' �N HAiEIZ,0� SQ.FT.
AAPWATER ENCOUNTERED y
NUMBER OF LEACHING PITS"./;.+�4. .4-As ��
APPROVED . . . . . . . . . . . BOARD OF HEALTH
,.,eye; rs: s�
DATE . . . . . . . . . �T�D � �OV�•
AGENT OR INSPECTOR °
OFIy
�T� ,('7`�• THOMAS E.KELLEY'CO• - a ELLEY y
ENGINEERS-SURVEYORS ,Q Na 24260 Q
.LET. '������ T��� � 346 LONG POND DRIVE .090��.G/ST��t�,���,�
/�Q SOUTH YARMOUTH,MASS. FSS/ONAL�a�
PETITIONER : ����,��-� oz664 /
�7
� I
>� T.H.92 ' t�
I � ' C41
I Mpg O� ��� OFs
I T.H,a/ o`'� THOMAS �yG
C3KEUEY y
No.242*
I \ � T �o�fss/sTEQ`6�`�`�`
/p41� / O� THOOdAQ I : E.
KELUVci
w
Z 43 .
cr�d3��4R�
CEP sF INE 'LOT mPw A!t"17
LOCATION 4:�V
SCALE .
PLAN REFERENCE �.�� . . . . .. . .... .
EYCO. ,�sA'� rr�
THOtviAS E.KELL / �� l�4 Z/J. ./. of 9
ENGINEERS—SURVEYO
346 LONG POND DRIVE ,�f.�e �: •af• •z�. •/��
SOUTH YARMOUTH, ` ��ow
02664
I CERTIFY THAT THE .. " ....
SHOWN ON THIS PLOW ` ED 0 GROUND
AS SHOWN o AT IT FORMS TO THE
C /,:�,t�CG'� /:� •�4�Lf� SET 8- a` NTS HE TOWN OF
. . . . . . WHEN CONSTRUCTED.
DATE . . . . . . .. .
PETITIONER: REGISTERED LAND SURVEYOR
�0 t
LICA'TION 1- ' SEWAGE PERMIT N
VILLAGV, Pjl�- L
INSTA LLER'S NAME i ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED A/
DAT E COMPLIANCE ISSUED
L
I
6DO C-&L r ooc
JA W<
LO AT10N %_1
L nOSEWAGE PERMIT N .
VILLAGE
IINSTA LLER'S NAME i ADDRESS
i
I
B U I L D E R OR OWNER
eV/wrr.
DATE PERMIT ISS,V E D � � ej
DATE COMPLIANCE ISSUED
SID
000 l 729®09/
2E ,® '
R'