HomeMy WebLinkAbout0051 CARRIE LEE'S WAY - Health 51 Carrie Lee's Way
Centerville CP/R
A = 168 008
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UPC 12543 % o
No.._..._53_LOR
HASTINGS, MN
Commonwealth of Massachusetts /&9- 009—01al
1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments fit
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name Jr_
is
required for every Centerville ✓ MA 02632 8-29-19 f
page. City/Town State Zip Code Date of Inspection j
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.
\,`vUuutuulup�
Important:When p\� N OF M I //z,
filling out forms A. Inspector Information
on the computer, �g�:' JAMES u'
use only the tab James D. Sears = m
key to move your Name of Inspector
cursor-do not Capewide Enterprises
use the return
key.
Company Name
153 Commercial Street ry+Sy��� 5 I N SPa"`�pv
,Q Company Address
Mashpee MA 02649
City/Town State Zip Code
� 508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
xt 8-30-19
pector's Signature
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
isrequired for every Centerville
MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 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.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
�m ,�p Title 5 Official Inspection Form
�io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Disposal Sewage Dis g p System Form Not for Voluntary Assessments
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is
required
uired for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I.I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Carrie Lees Way
�V
Property Address
Fannie Mae
Owner Owner's Name
information is Centerville
required for every MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in is less than 6" below invert or available volume is less
than '/z day flow A/;'
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
., 51 Carrie Lees Way
�u
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
I
Commonwealth of Massachusetts
,1P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Carrie Lees Way
u-
Property Address
Fannie Mae
Owner Owner's Name
required for
is every
Centerville
required for eve MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Description:
1000 Gal. Tank D Box and pit.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
I,
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 2017- 0 Gal's
Detail: 2018 -0Gal's
Sump pump?
❑ Yes ® No
Last date of occupancy: NA
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Carrie Lees Way
V�
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
YI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is
required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 23"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.):
Pipeing is 4" PVC SCH -40.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I,o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�v
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is
required for every Centerville MA 02632
8-29-19
page. City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade:
1'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
El 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 Gal. Precast
Sludge depth:
2"
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 tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
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 at working level. Tank and outlet cover at 1' below grade. Inlet tee w/outlet baffle. No sign of
leakage or overloading. Note: Large bash over inlet cover. Bush should be moved
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is Centerville
required for every MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
,e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is
required
wired for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-30" below grade w/cover at 1'. Box is clean and solid w/one line out. No sign of
over loading or solid carry over.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
II
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
,�p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is
required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. precast pit. Pit and cover at 36" below grade. Pit is dry w/no sign of over
loading.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
,A Title 5 Official Inspection Form
f). Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
0 51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Aug 2219, 12:16p Capewide Enterprises 508-477-4977 p.3
. a
Page 10 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Sl Carrie Lee's Wav
Centerville. MA
Owner- -
Date of lnspection: _
Map: J 68
Parcel: 008
SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 15
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within t00 feet. Locate where public water supply enters the building.
i
l
1
i
a A
1 a� yl
3� 57
10
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
0
Estimated depth to high ground water: 30+
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 well 30'+to G.W..
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I
_ r �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u51 Carrie Lees Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 8-29-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
ad A
40
Gw
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for igpool *pgtem Construction Permit
Application for a Permit to nstruct( . Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
e /7
Assessor's Map/Parcel ,A,. � L'Ve—ol'E, wee4wj
Installer's�Nam ,Address,and Tel.No, Designer's Name,Address and Tel.)))No.
n ►�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil: /) Ilk
Nature of Repairs or Alterations(Answer when applicable) fL 0 xC
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has behth-
y this Board of ealth.
Signe d Date 03
Application Approved by Date
Application Disapprovedowing real s
Permit No. Date Issued 3
No. CG J Fee O
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
7""
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplic4tion for Zi5pool *pgtem Construction Permit
Application for a Permit to nstruct( . Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. //i' L�
•�Gu �l/G (� ;Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 11M/'ye,fir:F
f
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil; 9 J A
Nature of Repairs or Alterations(Answer when applicable) C OCLLA.. e 6 0 1<
Date last inspected: ,
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has be ssued by this Board of Health.
Signed��� m jo vn Date 9 blo-3
Application Approved by Date
s
Application Disapproved for the`following reaso�t�
Permit No. `Z-O 0 3 Date Issued -�
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( )
1 Abandoned )b
9/O at Q- 12 5- I AV
Abandoned
has constructed in accordance
with the provisions of Title 5 and the for Disposal System Co struction Permit No. 0 ated
Installer
The issuance of this erm/Ii11t hall not be construed as a guarantee that the system will¢f� 'o d
Date `7 �_ Inspector
--------------------------------------- - -
/ J Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Xkg;pogar *pgtem Conotruction Permit
Permission is hereby gran d to Constrrr/�uc�,�� Re air )Up ade )Abandon( )
System located at 1��K_� C� --, / —V
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Co con st bmpleted within three years of the date of n \
Date: Approved by-", '
L 14-9
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PRO I TEdiW41VED
AUG. 2 8 2003
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 51 Carrie Lee's Way
Centerville, MA 02632
Owner's Name: Margaret Reeves
Owner's Address:
Date of Inspection: July 27, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Map: 168
Mailing Address: P.O. Box 49 Parcel. 008
Osterville,MA 02655-0049 Lot. 15
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
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
N Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: M
Date: July 31, 2003
The system inspector shall sub 't 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page I
f
-Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 51 Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27, 2003
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 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.
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
✓ distribution box is leveled or replaced
*The D-box was broken down structurally and roots were growing inside. The D-box needs to be 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-
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 51 Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27, 2003
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.
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 and volatile organic compounds indicates that the well is free from pollution from that facility 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:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 51 Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
No (YesfNo)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
f
Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 51 Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27, 2003
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:
Yes No
✓ 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(3)(b)J.
I
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 51 Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27. 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 1
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):.
Approximate age of all components,date installed(if known)and source of information:
Sep. 13178-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 15"
Material of construction: ✓ concrete _metal _fiberglass polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring 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.):
Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27, 2003
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
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 D-box was broken down structurally and roots were growing inside. The D-box needs to be replaced
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 gal.)
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.):
The pit had 4'ofwater on the bottom. The scum line was at the same level. There were no signs offailure. The cover was 40"
below grade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27, 2003
Map: 168
Parcel. 008
SKETCH OF SEWAGE DISPOSAL SYSTEM Lot. 15
Provide a sketch 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.
3 a 30. y
p y 3 3g S'o
37 s7
10
Page I 1 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: SI Carrie Lee's Way
Centerville, MA
Owner: Margaret Reeves
Date of Inspection: July 27, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30' +1- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximate
30'+/-to ground water at this site.
This report has been prepared and the system inspected and conditionally passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
1-rr 1 6� TOWN OF BARNSTABLE I .
LOCATION SI CA60 e- /te¢, SEWAGE #
VILLAGE C46T1/'yl k ASSESSOR'S MAP & LOT/ " 00 FJ'
INSTALLER'S NAME&PHONE NO. L-� r C
SEPTIC TANK CAPACITY l /fib
LEACHING FACILITY: (type) bX G p, 1 (size) C A
NO.OF BEDROOMS
1 BUILDER OR OWNER ✓VI/a r S AI�- n-2J-uts
t- PERMITDATE: COMPLIANCE DATE:
2,
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility. (If any wetlands exist
within 300 feet of leaching acility) Feet
Famished by /?s I D -7 For
i
a � �
_y
3 �
a 3Q6 y
S'o
17 57
No.----- ��..... Fss....as._............._
THE COMMONWEALTH OF .MASSACHUSETTS
BOARD OF HEALTH
....... O.IN V.-----------OF........ .........................
Appliratiott for Dispaii tl Works Tomitrurfiott rantit
Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal
System at:
CAME....4.CE.YI.......QAy....-GEI.14.[ej?VO4fir-.......................-."Q-7........--•5...........................................
Location-Address or Lot No.
3 Ja .........................................................•-•------------•. •••------•----------•---......•-----.....
Owner Address
W Vetorino Brothers Barnstable
Installer Address
d Type of Building Size Lotl_7.2.7.....Sq. feet
Dwelling—No. of Bedrooms._....................................Expansion Attic (Na) Garbage Grinder (No)
P4 Other—Type of Building .... ...... No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures .................................................... --
W Design Flow.....�`?....ZZ-6.........gallons per person per day. Total daily flow-------M;�rD.......................gallons.
WSeptic Tank—Liquid capacityLA.,er�.gallons Length8.�t6_�.. Width.Y Vie.' `�. Diameter________________ Depth..95.. �
x Disposal Trench—No. .................... Width......._............ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......`-._...__._ iameter-----99. ..... Depth below ir}let�.. ____.... Total leaching area.vQ_Q.0...sq. ft.
Z Other Distribution box ( ') Dosing tank ( ) D "—
`" Percolation Test Results Performed by___k6A14cb__.. !.S------ Date.J'.!?A.>'....1,j1Y.M...
aTest Pit No. LA�..Zt...minutes per inch - Depth of Test Pit../Z_..._.__.. Depth to ground water.-
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ri ----•------••••-------------------•----•-----•-•--•••--••---•.......-•••...........------....................................................................
u
Description of Soil............f..n..a y OR/!2 AAI•,b..... •�U�S-Gt1ls-------------------•-------------------------
W ............................................................------•---•------------------•----••.
UNature of Repairs or Alterations—Answer when applicable...:............................................................................................
----------------------------•----•--•--------------•--------------------------------.......-•-•---------•--------------------------------------•-----------------------•---------------......--••----•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sigd...................................................................................... ................................
Date
Application Approved BY----`-- ....&,44 !_ . <----•----------- - -7
Date
Application Disapproved for the following reasons:..................................................=-----•-----------••--------•-------------•-••---------------
................................................. •-••---•---•------------------•-•----------•-----------------•----••-•----------•--- .................................--------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........T.Q .P....................OF...............Aarns..table...........................................
Currtifiratr of TootViitttta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( )
Vetorino Brothers
Lot 15 Carrie Lee's Way, Center'#Ifte
at................... .......................................-----------------------------------------------------------------•-------------------------•------------------------.--------------------
has been installed in accordance with the provisions of T� ` of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.., _...... . .............. dated-._9'_1 _V__7 ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. -••-DATE.....,/.. Inspector..... :.
_•-L�1�L-- ...............
Fn
No.....ki� ...... $............... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............OF....... fQ.:>�5. �.C..��� . t.�•�w.........................
i
Appliration for Disposal Works Tom3trurtiou Prrutit
Application is hereby made for a Permit to Construct ( too
or Repair ( ) an Individual Sewage Disposal
System at:
..../.:.....E .••..t-) .. c'��sa�"���ic�;F.......................•'=�=(1Z *5 ----------------------------------------
Location-Address or Lot No.
J= James K Smith ..._..-Barnstable
- ---•---- -•----_.....-- •----...... ............................ ..................
W Vetorino Brothers Owner Barnstable Address
a . ---------------.........-----------•----------......... ...._...... .....-----••-•-• -------•------..........----......------------._.....--•---••----•-----
Installer Address
of
d TypeDwelling No. of Bedrooms______________________________ Size Lot.____...____._.t�.__._____Sq. feet
U g— ^' Expansion Attic (tay�) Garbage Grinder (NO)
-------------
p•, Other—Type of Building ..-A?.419._...-._____ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ------------------------------- --
Design Flow.... )....11. g p p p y y gal
W +'"� __gallons per arson per day. Total daily flow....._ ��....................... �lon�s/
WSeptic Tank—Liquid capacityZ?A4?A.gallons Length .9_'�.y. Width_ ' ._'.. Diameter---------------- Depth--.�`-'.--.R -...
x Disposal Trench—No.................... Width.................... Total Length.................--. Total leaching area.............._.....sq. ft.
Seepage Pit No..----/.......-_-. Diameter..... .�..... Depth below i let__?'?_. ._. Total leaching area_�_ _ .._sq. ft.
Z Other Distribution box ( Dosing tank
'-' Percolation Test Results Performed :�-_ J�� a'c. .-_.-t =�_ ---- Date._+n?r9_ '____ !�_e! ± '_..
Test Pit No. 1.-4:..9...minutes per inch Depth of Test Pit..?4.'N'---- Depth to ground water_.N-.o_?.v..e......
(s, Test Pit No. 2................minutes per inch . Depth of Test Pit......... :.r Depth to ground water........................
--•--------------------------•----------•--•----------------------•------•=----..............................................................................
O Description of Soil------------ gip... `--`•24.x`t........ I.)!'N----------�'-Via- ', _ ?.e! r.............................................
�2 r/`- �����'�' /+fir�`"l'!''� �'�'�------!" ----.�.'/_.M..L-a-------------------------------
V --------------------------
••--
W ------------------------------------------------------------------------------------------------------------------------------------------- ---------------•-------
UNature of Repairs or Alterations—Answer when applicable............._`.
------------------------•----•-•-------•----••-•----------------------------------..............---•--------.....--------------------------------------------------------------•---.._........------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig2d.............t _.....................................................................
r � Date
Application Approved By._-
-------------------------
,z
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------•-................
-•----------------------------------------------------------------•---•--••---------•...-•-•------------------------------••--------------------------•---•-•-•------------------:..----...------•-----.
Date
PermitNo........................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........Tom..................OF...............Barnstable...........................................
Trr#ifiratr of Toutpliattrr
THIS U TO �ERTIFY That 'the Individual Sewage Disposal System constructed ( x) or Repaired ( )
•VVetor no Brothers
by--•..............•--•-----....._...................--•--••-•-....__..............---•-------•--------------------•--•-•---•-•------.....--•--------------.......---...............•-•........_....
Lot 15 Carrie Lee's Way, CenterIA41te
at.............................................................................------------------.........---•--........-••-•-•-------------------------------...----------------..__.........-----•---
has been installed in accordance with the provisions of TI?T � j of The State Sanitary Code as descr•bed in the
application for Disposal Works Construction Permit No.--�;�..--- ............. dated----- �'' .~_. ° ..................
THE ISSUANCE OF THIS CERTIFICATE-SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
�.. 7 ';�
DATE......... -1 Inspector..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
O�' Town Barnstable
, ,. ......................................OF.................................................................................
No......................... FEE........................
Disposal Works o t ion rruit
Brothers
Permissionis hereby granted..............................................................................................................................................
to Construct X or RR�e it n I div dual ewa a D' sal System
( Lot l5pear�i� ee s Way, en erv' ��e y
atNo. -----• ••-- ---•----•-
Street
as shown on the application for Disposal Works Construction Pert No�_.f.�.../.�_�-- Dated..._...../����.................
'•=!l-! ................................._
Board of Health}
DATE.... ....71f.---------•--•..........................•-----
,.°" FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
C-- 5^q�
LOCATION �( SEWA PERMIT NO.
LET
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INSTALLER'S NAME & ADDRESS
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BUILDER IR OWNER
DATE PERMIT ISSUED Ly
DAT E COMPLIANCE ISSUED
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