HomeMy WebLinkAbout0053 CARLETON LANE - Health 53 Carleton Lane
A= 190—235
Centerville
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UPC 12534
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No. � �� Fee ldo-
THE COMMONWEALYH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Bispo8al *pstpm ConeitCUttion 3permlt
Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System X Individual Components
Location Address or Lot No. 53 Owner's Name,Address,and Tel.No.
Assessor's Ma /Parcel �zGC,
P _ 0-5P'( P.(!l
Installer's Name,Address,and T 1.No.,j®!;-107—'2$17 Designer's Name,Address,and Tel.No.
M.4 t0e%— NlAk
Type of Building: /
Dwelling No.of Bedrooms N Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheet 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:ind not to place the system in operation until a Certificate of
Compliance has been issued by this Board 9,f Health.
Si / Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Z o ( � — �� �� Date Issued
No. ( J ` ` 1 Fee
THE COMMONWEAL'rH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftpliLatlon for D sposal',6pstem Construction Permit
Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System M Individual Components
Location Address or Lot No. 3j�j ��(,E(�1J (�NJ Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel (go a-3 5 3 0AVL L NVL,,q )E
Installer's Name,Address,and Tel.No. S6,9'107-88 7 7 Designer's Name,Address,and Tel.No.
NIAl G RL 5 tit,�s�f P��
Type of Building:
Dwelling No.of Bedrooms Lot Size s /.ft. Garbage Grinder
q g ( )
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)
CEP 1.a4-� 1J
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposalhsystem in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board pf Health.
y
Sign d. `S" / Date
Application Approved by L Date _
Application Disapproved by Date
for the following reasons
Permit No. z-C'{,j- Date Issued
s,
_. ,- -----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS.
Certifirate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( )
Abandoned( )by<fApGWtbR 6,,�Pt ce7S _
at 5 3 C ARLE R�kj LPJ CWr6XVI LL6� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. (S - 1( (/ dated �' I&
Installer(U(--lR)CU6 QTG&2A 6Ss5. IL-r— Designer N
#bedrooms l(���- Approved design flow 4' gpd
r
The issuance of this perinits ll not be construed as a guarantee that i he system will nction de'siign6d.
Date l - Inspector
------------------------------------------------------------------- -------------------------------------------------------------------
No. �6 S / Fee
THE COMMONWEALT%EI OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal *pstem (Construction Permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at 5A _C R(k' LA-) Ca aEvy/11
and as described in the above Application for Disposal System Constn fiction Permit. The applicant recognized his/her duty to comply with
iTitle 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. o D /P �1
Date S/ �// ,approved by
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1` lay 18 15 1-2:02a " P•1
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fortin-Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
information is MA 02632 5-12-15
required for every Centerville
cti
page. Cityrrown State Zip Code Date of Inspeon
inspection results must be submitted on this form.inspection forms may not be altered in any
way.Please see completeness checklist sit the end of the foam.
Important:when A. General information �` - / wlttumiufui
filling out forms S�. 16 ���`����,IN OFAf
on the computer, �.� �•,.-• ,•S
use only the tab 1. Inspector O��
key to move your = JAMES rt,
cursor-do not James D•Searsuse the return
ke Name of Inspector
y CapewideEnterprises,LLC '
'Q Company Name I N S 9'
153 Commercial Street �...110
CompanyAddress
Mashpee MA 02649
City/Town State Zip Code
508-447-8877 S1623
Telephone Nwnber license Number
B. Certiftcat,ion
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. 1 am a DEP approYed 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
5-12-15
ector'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 ondition,of use
at that time.This inspection does not aridness how the system wiff perform I.
®future under
the same or different conditions of use.
it S
tSlns 3113 Title 5 ORael Inspedlon Form Subsurface Sewage Oi posal y slem•Page 0 1 of 17 f�
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May 18 1512:03a p•2
Commonwealth of Massachusetts
Title 5 official Inspoction Form
Subsurface Sewage Disposal System Fomi-Not for Voluntary Assessments
53 Carleton lane
Property Address
Ruth Veilleux
Owner Owners Name
information is required for every Centerville MA 02632 5-12-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or H:/always complete all of Section D
A) System Passes:
® 1 have not Found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal.Tank D Box and Pit.
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 ❑ NO(Explain below):
l5hs-3113 TAIe 5 Official inspegton Form:Suosurface Sewage oisposat system•Page 2 el 17
May 18 15 12:03a p'3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
Information is required for every Centerville MA 02632 5-12-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cant.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpsfalarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or brec-k 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&Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not hinctioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 fleet of a surface water
❑ Cesspool or privy is within 50 fret of a bordering vegetated wetland or a gait marsh I
Mns-3113 Title 5 Offidel Inspec8on Form:Subsurface Sewage Disposal System-Page 3 of 17
May 18 15 12:03a p•4
Commonwealth of Massachusetts
RV
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
r
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
information
required for every Centerville MA 02632 5-12-15
page. City/Town 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.
0 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 60 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 iniio 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 GM1111416 is less than 6"below invert or available volume is less
Cl 0 than'/day flow /°,%7—
Is,wo•w13 TNe 5 Official Inspection Fom sA&surlsce sewage Disposal S7slem-Page 4 or 17
May 18 15 12:04a p 5
Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
information is
required for every Centerville MA 02632 5-12-15
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
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 armwonla nitrogev 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,OOOgpd.
❑ ® 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. I
Yes No
i
❑ ❑ the system is within 4110 feet of a surface drinking water supply 1
I
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes°in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department
I
Wins•3113 Title 5 WOW Ins eaan Form SuDsurfaoe Sewage posal System•Page 5 or 17
May 18 1512:04a p.6
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Dame
information
required for every Centervitte Mil 02632 5-12-13
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 systent 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 lic,iuid, depth of sludge and depth of scum?
❑ 0 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. 1
Determined in the field (if any of the failure criteria related to Part C is at issue
El ® approximation of distance is unacceptable)[310 CMR 15.302(5))
i
D. System information
i
Residential Flow Conditions:
Number of bedrooms (design): NA Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
t5ins 3113 TRIa 5 Official Inspection Form:Subaurface Sewage Disposal System•Pape 6 of 17
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May 18 15 12:04a p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Flame
information
required for every Centervige MA 02632 5-12-15
page. city/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and Pit.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes 0 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)): 2013-20,00013aIs2014-22,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Present
Last date of occupancy: Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/personslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title E system? ❑ Yes ❑ No
Water meter readings, if available:
15ins-3113 Title 6 official Inspection Farm:Subsurface Sewage Disposal System-Page 7 of 17
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May 16 1 b 11:Uba P 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
Information
required for every Centervi% MA 02632 5-12-15
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: 2010-2013
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) i(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):
45ins.3M 3 Title 5 Official Inspection Fans:subsurface Sewage Disposed System.Page 8 e 17
May 18 1512:05a p.9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
information is required for every, Centerville MA 02632 5-12-15
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1977 Permit# 77-403. New D Box 5-2015.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 26"feet
Material of construction:
❑ cast iron ®40 PVC (] other(explain):
Distance from private water supply well or auction line: feet
Comments (on condition of joints, venting, evidence of leakage,etc.):
Pipeing is 4" PVC SCH 40,
Septic Tank (locate on site plan):
16"
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1000 Gal. Precast H-10
Dimensions: j
Sludge depth:
2"
Mns•W13 Title 5 Official Inspection Form Subsualaoo Sawago Disposei Sy9tem.Page 9 of 17
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May 18 15 12:05a p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a -- Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owners Name
informationis
required for every Centerville MA 02632 5-12-15
page_ Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28
Scum thickness
1"
Distance from top of scum to top of outlet toe or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle 17"
How were dimensions determined? Astwift-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidonce of leakage,etc.):
Tank at working level. Tank and inlet cover at 16" below grade w/outlet cover at 8". Inlet baffle,
outlet Tee. No sign of leakage or over loading.
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: flare
15ins 3/13 Title 5 Official Inspection Form:SubsWa:e Sewage Disposal System-Page 10 of 17
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May 18 1512:06a p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
information
required for every Centerville MA 02632 5-12-15
page. Cityfrown State Zip Code Dale of Inspection
D. System Information (cunt.)
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
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t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Pape 11 of 17
i
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
information is
required for every Ceaterville MA 02632 5-12-15
page. Cltyrrown 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.):
fl Box iS 16"x16 14 below grade N'Tcover at Tone,line out.Box is new 5-15.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order. ❑ Yes ❑ No*
I
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
I
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:
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t5ins•3/13 Title 5 Otfidal Inspection Form Subsurface Sew"*Disposal System•Page 12 of 17
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May i o i o i z:uua p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foma-Not for Voluntary Assessments
r
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
information is
required for every Centerville MA 02632 5-12-15
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativetaltemative system
Type/name of technology.-
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. Pit w12' stone. Pit and cover at 10"below grade. 10"water in pit
w/stain line at 1'. No sign of over loading or solid carry over. No high stain line.
Cesspools(cesspool must be pumped as mart of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
I
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/t3 Title 5 official Inspection Fom[sulmirface sewage oisposai system-Page 13 of 17
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-ay t o t o i z.0 f a p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fora-Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
information is
required for every CenterviNe MA 02632 5-12-15
page. CityrT own 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.):
15ins•3H 3 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 14 of 17
i
May 18 15 12:07a p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owners Name
required
is Centerville AAA 02632 5-12-15
required for every
Page- Cityrrown state Zip Code Date of Inspection
D. System Information (coat.)
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 feel. Locate
where public water supply enters the building. Check one of the boxes below:
EQ hand-sketch in the area below
31
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13
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15 na-3N3 We S Of8de1 Form SaDWPIMM Se"Qe Olsposal Sysram•Page 15 or 17
I
May 18 15 12:07a p.16
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner Owner's Name
information
required for every Centerville MA 02632 5-12-15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑' Check cellar
❑ Shallow wells
Estimated depth toFigh'ground water 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 propertylobservation hole within 150 feet of SAS)
® Checked with local Board of Hiolth-explain:
U.S.G.S.Well SDW 252
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
U.S.G.S. Well SDW 252 at 46'w/4' adj
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Before filing this Inspection Report,please see Report Completeness Checklist on next page.
Lmn� 3 Title 5 Official hVedon Forth:SubsLdace Selvage Disposal System•Page iS of 17
May 18 1512:08a p.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonm -Not for Voluntary Assessments
53 Carleton Lane
Property Address
Ruth Veilleux
Owner owner's Name
Information
regu iced for every Centerville MA 02632 5-12-15
page_ City[rown state Zip Code Dale of Inspection
E. Report Completeness Checklist
JZ Inspection Summary:A, B, C, D. or EI: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 fie
II
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tSns•3113 TAte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
C �. . -
-' i'0....... f�� .... ...�...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
TOM......OF.....BARNS'.;CABLE.............._.----.................------------.
App iratioo -for Uwvoiittl Works Tonstrurtiou Vrrotit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
n_ arleton Lane Lot 13
•... -•--•------------------•----------------•----=--••----•--'••-•---•---••'---'- ................................................ - 's=
CCLocation-.Address or Lot No.
... ;_. _ 1.! ./ '•----'---•..................... ...................' ........................_...............--•---.
owne J g Address
W
Installer Address
Q Type of wilding Size Lot..15_,-7 Q4•--_-•_•: q• feet
Dwelling—No. of Bedrooms----__3 ............
Attic ( ) Garbage Grinder WI)
Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Pr Other fixtures ......................................................
W Design Flow_____________ _//.d................_.gallons per person per day. Total daily flow.......................330-_----------gallons.
WSeptic Tank—Liquid capacity_1000galions . ,Length$_'_-.6"___ WidtliV.-IQ."Diameter---------------- Dept115.,_-4."..
x Disposal Trench—No---------------------- Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No...........1........ Diameter.1Q_'.__-Q'_._ Depth below 'nlet.5_'-7°_.___. Total.leaching area---- ------sq. ft.
z Other Distribution box (X) Dosing tank ( ) v �"`'v ` '�''-7 7
aPercolation Test Results Performed by._Cap-e---Cod__..Surmey....0003.ultantPate......June---29_,----1.977
a Test Pit No. 12____-___•--_.f'unutes per inch Depth of Test Pit-------12.'__._.. Depth to ground water.. _ none
• ----------
Test Pit No. 2----------------minutes per inch Depth of 'Lest Pit-------------------- Depth to ground w �ZH-DF.tijAs��
---------------------------- -------------------------------..•.............................................................. -• ...........••.•.r
O Description of Soil--------- ---C.oa Be---aan-d--•----------------------------••------------ ----RENWICK---- -
(xj --•----------•----------------------------------------------------••-------------------•-•-------------•-------•---------•---------.------ v B' ----L ff
-- --------- ---------------------•--- ---------•--............................................•..... -• -•-------------------•-------------- -------•-------- -;o itloA2 65 N
V Nature of P.epairs or Alterations—Answer when applicable------------------------------__-__-__-_-_--__ -_--____.____ �'p_FE, __.__.
-----------------•------...•------•-------------....---•--..._..---•----....__.......--••-----•--------•--•-------------------------------------- --- ---- ---------- /pN
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System intlaccordanc with
the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss l y, e board of-health.
Signed_--- --- --- - --�- e✓ D
_ Date
Application Approved By---- :_/� /�'�� .-1"-=-�--- 9 D
Date
Application Disapproved for the following reasons:--------------------------------------------------------------------------......................................
--------------- -----------• •----------------••----------------------•••------•--•----....------•'-------------------------------=----•----•-----------•-----------------•.--_---•--------------
Date
PermitNo........................................................ Issued...................... .................................
Date
P .
THE COMMONWEALTH OF MASSACHUSETTS
t o» fO OARD OF HEALTH
o ..... .BARSTA
.........
TOWN ..........
..
.. „.
Appliration -for, M;ipniitti aark� Cn>an fr rtintt rrn�it
t Application is hereby made for a Permit to Construct (X) or Repair ( } an Individual Sewage Disposal
System at
• ----
., ... ......... . .let _n• Lane Lot 13
cation•. re - or Lot No
Owner : Address
w ................................................
Q Installer Address
Type of Building Size Lot....1 r 7Q4____--_.Sq. feet
04Dwelling—No. of,,Bedrooms__.____ ...................................Expansion Attic ( ) Garbage Grinder
as Other-Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
al Other fix ure
WDesign-'Flow............... . -_0..._._.._........gatlons per person per day. Total daily flow------------------------- _ .Q__.._..___gallons.
- 4 iameter---- ------ De p '----------
W Septic Tank-Liquid�capacity._1flO_�allons Length.._..-.6.n_ Width._ ..I."�,C>.°`D" - 1th.S
x Disposal Trench—No_ ________________-• Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft`'
Seepage Pit No...........1--------Diameter.10."._•-Q"_- Depth below let. �.-7°._.__. Tota eaching area--_ 2_C�_�-----sq. ft.
z Other Distribution box ( X) Dosing tank ( ) Oi '" �'� r i`'t "'77r
'-' Percolation. Test Results Performed by.__Cape---Cod S_uvey---CQ;'j$n1tAntMte..._...Aqlw...n,.-_1977
a Test Pit No. 1.2............minutes'per inch Depth of "Pest Pit-------- _'____. Depth to ground'watPr .......none
(i Test Pit No. 2........_:`.....minutes per inch Depth of 'hest Pit-------------------- Dept4'to ground water_._...__......_.._.
' ------------------ --- --------------•----------------
A -
x a� ap ` -
O Description:of Soil--------- -- ---Q_: m. s -d... .. ------- o- ---
W •----"------------------- --------------------------------------------------------------------•------------------------------------------------- ---------------- `s -----------6._..........�'
U Nature of Repairs or Alterations—Answer when applicable......_............. . CHAPMAN-
--- U
No. 27654
---------•----------------------------••--------------------------------------.---••--•-----------•--
Agreement:
The undersigned agrees to install the aforedescribec- Individual Sewage Disposal System in th
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee iss Oby. e board of health.
Signed • . ' ?`�...i.
Date
Application Approved BY----- ...-•-- -"- - Date --
Application Disapproved for the following reasons-------------------•--- ----- -••---•--•-•-•-----•-------------------•------••-----------
-------------•--------------•-------•------ -----•------ --------•------•----.---
„ Date
Permit No. ......--•-•-••--••-----=: Issued
Date:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFl HEALTH
2 ..........oF........s:.. . '�>.. ....:
0rrtifiratr of UTIMpiianrr
THIS IS TO ffRTIFYTh e Individual Sew ge Disposal System constructed(,.;.,, or Repaired O
by ..w
------ ---- =
r '
Instal ,// �J
at i✓+�! 't a�`
� ..p
has been.,lnstalled in accordance with the provisions�pefrAr 't XI of The tate Sanitary Code as described in the
a o.
application for=Dix osal Works Construction Permit '' . ^r All dated +'__� '' �•
THE`ESSUANCE OF THIS CERTIFICATE SHAL HOT BE CONSTRUED AS A G`RA TEE THAT THE
SYSTEM I L FUNCTION SATISFACTORY E
DATE. ----- ............................... hispector0 ...................................................
THE COMMONWEALTH OF MASSACHUSETTS
�4 ,
BOARD Ofj HEALTH
O F......... ...42... 9 ........................
.... (Y •.
No. � FEE--=-F! ...........
Di-watial IV kq (n,a:n rnrfinn anti#
Permission is hereby granted-------------------------- - ---------;- -----------------------_......................................'s"
to Construct ( or Repair (,p).an in vi I age'Disposal ste vr
at No...... 3 ......C� : A�s.� '� -- .•-c�-" ---
Street ,/O Q y
as shown on the application for Disposal Works Construction Permit No...._ _.____ -3. Dated.........�__lY."-__77--------
.•••-•-••------•--•••-•• - ----�"`--�---------- -------------- ..........
_
3 Board of Health f
DATE................... '---.......----7-------------------------•-•----------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
LOCATION SEWAGE PERMIT NO..
, , �a — /3
VILLAGE
q
I N S T LLER'S AM & ADDRESS
S
B 61DE R OR OWNER
I
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
i
40U � �
3�
G `
iy
SOIL LOG
2:.PEASTONE • LOAM a FILL"' 12°MAx.. '
T_
°°°'.: '° ,
+ 14�1
DIST.I. Box24°MIN.MIN. 1000. 1� 0, ° 1000— GAL.
GAL. o •• PRECAST OR
SEPTIC 6 10 ne °°, BLOCK a0 0 o
TANK I,°. °'° ° SEEPAGE PIT ° 0
(l 1
II �` .f l ° ° o °el 4
il
20° MINIMUM
FOUNDATION I
%:�° WASHED'-STONE� l /✓o [,�gac•�+L
ELEVATION SKETCH. 10° PING. RATE
TEST BY: C-K � IT'0 'y P. p'lk'Fese'
SCALE I' = 4° TOWN .INSPECTOR u - T ce
BACKHOE OPERATOR
TEST MADE ON -yi J 77 x82
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{/I��� .1 n A y _ may`• r .
ASS
6
.. ./off' - : � - � � V `o�• / / ,
lzmi
Vol
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tv
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er
`p \o �p`pal \�� ��� ��� `�'>f? `� �`� i� �-� •
/`/.-/ .,�' � r - .�, ,,.,�,. FMB _••;,,.
APPROVED. BY BOARD OF HEALTH �//// �,.�/�,,,/����•-�`- ���jN�F�RS,� �
DATE 19— ol
B.
Jam, /�� /�/'�i�� '] ,�..• "" �_ I2ENw1Cl4.: cam` �`
c CHAPMA.N y
-No. 27654
ELEVATION SCHEDULE PROPOSED SITE PLAN
_ 1a7.�a 4
I. INV. AT FOUNDATION - SEWAGE SYSTEM DESIGN
2. 1 NV. INTO SEPTIC �ANK = lo_''ZS I N ,
L od' 13 e,9-,/�7 a- 4,9 A;e
3. I NV. OUT OF. SEPTIC TANK = IO�.CQ
G6.,�'�Q.VilO� fY'fH$s .
4. INV. INTO DISTRIBUTION BOX _ w6'�� SCALE: I"= C° -Y,Ly 1977
5. 1 NV. OUT OF DISTRIBUTION BOX -
Ic�'?�? C- T 2 0
CAPE COD SURVEY CONSULTANTS s
6. INV INTO SEEPAGE PIT ROUTE 132
7. :BOTTOM OF PIT = v HYANNIS,MASS.
A DIVISION BOSTON SURVEY CONSULTANTS, INC.
B. BOTTOM OF STONE LAYER
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