HomeMy WebLinkAbout0108 CEDRIC ROAD - Health 108 Cedric Road
Centerville F/
172 135
IN
UPC 12543
No
APO r1YQC �/y
x - Commonwealth of Massachusetts
- _-- Title 5 Official Inspection Form
- Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important: 1 ��
When filling out 1. Property Information:
forms on the
computer,use 108 Cedric Road
only the tab key Property Address
to move your Today Real Estate
cursor-do not
use the return Owner's Name
key. 1533 Falmouth Road
Owner's Address
Centerville MA 02632
�-- -� Cityrrown State Zip Code
Date of Inspection: 12/15/07
Date
2. Inspector:
MR. ROBERT A. DRAKE
Name of Inspector f3 _
KCJ ENGINEERING
Company Name c
66 GREENVILLE DRIVE n
Company Address <I —
FORESTDALE MA �2- 02644'
City/Town State o`.} Zip Codem Z,
� � f r,
508-477-5048 r
Telephone Number •- ,
G7 r—
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 ❑ H OF M4S
S� S9C
eds Further Evaluation b the Local Approving Authori ROQERTA. y
Y PP 9 ty L DRAKE m
A e o CIVIL
I MMM���-- I p No.41642 C11)
Inspector's Signature Date 09
The system inspector shall submit a copy of this inspection report to the A F�sg� F� (Board
of Health or DEP)within 30 days of completing this inspection. If the system Is 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.
his 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.
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/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:
All components appear to be structurally sound and working properly. No signs of leakage or
blockages.
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:
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
Citylrown State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cunt.)
108 Cedric Road
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cunt.):
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:
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
' M
A. Certification (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
Cityrrown State ZipCode
Today Real Estate 12/15/07
Owner's Name Date of Inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® 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.]
Yes No
❑ ® 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.
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
YES NO
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
108 Cedric Road
Property Address
Centerville MA 02632
City/town State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
YES NO
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(3)(b))
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Not for Voluntary Assessments
y� Subsurface Sewage Disposal System Form
C. System Information
108 Cedric Road
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 200-7 a 11,aet ;P- 107 gpd
ZOoG : �D1ooao�oQ .
Sump pump? ❑ Yes ® No
Last date of occupancy: a couple of
months ago
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'M
C. System Information (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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:
House built in 1974. Septic tank is believed to be original tank. Leaching pit was upgraded in 2005.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: approx. 2'
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Joints appear to be structurally sound, no signs of leakage.
Septic Tank(locate on site plan):
Depth below grade: 1.0
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Tank appears to be structurally sound and functioining properly.
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 1,000 Gallon
Sludge depth: approx. 1-inches
Distance from top of sludge to bottom of outlet tee or baffle approx. 33-inches to pipe invert
Scum thickness approx. 1 inch
Distance from top of scum to top of outlet tee or baffle approx. 11-inches to pipe invert
Distance from bottom of scum to bottom of outlet tee or baffle approx. 12-inches to pipe invert
How were dimensions determined? MEASURED IN FIELD
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10of16
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'4 M
C. System Information (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
All components appear to be structurally sound and working propedy. The existing outlet concrete
baffle are in place and appear to be in good working condition.
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
^M Subsurface Sewage Disposal System Form
C. System Information (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
Cityrrown State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Tight or Holding Tank(cunt.)
Dimensions: N/A
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.):
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No
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.):
Appears to be sound and working propoerly. No evidence of carryover.Water level at invert of outlet
pipes.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
4M
Sy`e
C. System Information (cunt.)
108 Cedric Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 gallon
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching field everything appears to be working properly. No signs of hydraulic failure or ponding.
Lawn area appears to be fine.
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
,M Subsurface Sewage Disposal System Form
C. System Information (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: N/A
Dimensions.
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Sketch Of Sewage Disposal System: 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.
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108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
,M Subsurface Sewage Disposal System Form
C. System Information (cont.)
108 Cedric Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Today Real Estate 12/15/07
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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:
Barnstable GIS Groundwater Maps indicate high groundwater elevation is at approx. = 36', GIS
Contour Maps indicate ground elevation is at approx.66', approximately 30+/-feet to groundwater.
108 Cedric Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
Town of Barnstable
OF THE 1p�
Regulatory Services
BA"STASLE ; Thomas F. Geiler,Director
'&
Public Health .Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving,this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
r,
No. �S Fee 160
/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Migpogal *pgtem Com6truction 3permit
Application for a Permit to Construct( . )Repair)Upgrade( )Abandon( ) O Complete System>ndividual Components
Location Address or Lot No. C€0?j C iI.-, Owner's Name,Address and Tel.No.
Assessor's Map/Parcel S
fi
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
� `� �ktG �C• '��AY �t�te�tsMi�'�t_ S.CS.
-�310 51q- CQ
Type of Building:
Dwelling No.of Bedrooms Lot Size 16.04k sq.ft. Garbage Grinder(AJAA-
Other Type of Building Mer g No.of Persons 2)- Showers(s/j Cafeteria( 01"
Other Fixtures f_Aui:3-, _y_ I ercaar-4 Sf#,l , Lwvyy_:�Y
Design.Flow 3,60 gallons per day. Calculated daily flow e gallons.
Plan Date 1 i3 b S Number of sheets �'�• Revision Date
Title s?e\ 5epAjr K,EAQdy-- up.
Size of Septic Tank X t S 9,n ;Axn k Type of S.A.S. &r_ �&s
Description of Soil. ` G,— A D�M
t
Nature of Repairs or Alterations(Answer when applicable) 4_ p\btl
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 sued of
gned Date
Application Approved Date
Application Disapproved for the following reasons
Permit No. Od -���'� Date Issued
Fee /60
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: kef
Yes
r' PUBLIC HEALTH DIVISION -TOWN OF B�ARNSTABLES MASSACHUSETTS
01ppYication for Diopozal *pgtem Con!5tructiou Permit
Application for a Permit to Construct( . )Repair)Upgrade( )Abandon( ) E Complete System 1�dividual Components
Location Address or Lot No. I b 1 C C pe+c Iz-v. Owner's Name,Address and Tel.No.
e2c">4ecV%\N-e- MP., MO-Q-'y WAU50 L-VOLEY
Assessor's Map/Parcel
Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No.
�ab��j �1C_ �� • �NA�I �NUI`2.C7N�nc*T'r4+.. SACS.
c�ti�-53�d 539 - �-9CQt�
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size_1 S,o4U sq.ft. Garbage Grinder(NM_
Other Type of Building \)0CV_ No.of Persons 3 Showers(v-) Cafeteria( rg
Other Fixtures L-AVp)-TpZY k,-rcNEJ S��k � 1<wvryl�y
Design Flow U gallons per day. Calculated daily flow �J 3 •S -gallons.
Plan Date 13 4 S Number of sheets 1 Revision Date
Title 'ecOrrC� G� c i C lsu U DC,�
Size of Septic Tank Type of S.A.S. v a_._'ov GCt P)C.(rA6&5
Description of Soil _ p 4t
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance hasboenks of ealE
igned Date
Application Approve y Date
Application Disapproved for the following reasons
Permit No. c OC3 CD Date Issued
-- _ . ____ . ____
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance �
THIS IS TO CERTIFY 4at the On-site Sewage�Disposal System Constructed( )Repaired( )Upgraded(v )
Abandoned( )by a s� Tt\C
at ,0 y 6G-E- r I C NAN6 reK'fzw+ -C— has been constructed in accordance
with the provisions ofgige 5 and the for Disposal System Construction Permit No. dated
Installer Designer 5;/114'-/ �.
The issuance of this permit shall/not be construed as a guarantee that the system wi_1 funct�on as designed.
Datey�o Inspector
. v
No. ------------------—-------Fee /60
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
r
=i5po5at *pg;tem Construction Permit
Permission is hereby granted to Construct( Re air )Upgra,�jq( Abandon( )
System located at O �r" �dL TLC►o't
Z `e
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 conditiioo�n$.
Provided:Construction ust be completed within three years of the dat' of this p i
Date:_ � � � Approved by
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
* BARNSrABM
MASS. Public Health Division
rEn 39. 0. Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 5/04/05
Designer: _Shay Environmental Services, Inc. Installer: Robert Septic Services.
Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street
MA 02536 Yarmouth, MA
On 4/27/05 Robert Septic Service was issued a permit to install a
(date) (installer)
septic system at#108 Cedric Road, Centerville, MA based on a design drawn by
(address)
Shay Environmental Services, Inc. dated 05/02/05
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
---- - '(`,\OF Mgssgcy
o CARMEN �s
aller's Signa E.
SHAY
No.."1181
0
�FGISTe
(Designer's Signature) (Affix p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
r _
TOWN OF STABLE
LOCATION 10 SEWAGE #
VILLAGE SSESSOR'S MAP & LOT fps
r
INSTALLER'S NAME&PHONE
SEPTIC TANK CAPACITY G 5 00 C>
LEACHING FACILITY: (type) (size) Z'`a�, �r
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: -5;fT-6- COMPLIANCE DATE:
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 facility) Feet
Furnished by
�P
L-:i A-y-
fq2A q3'
TOWN OF STABLE
LOCATION
1 �� SEWAGE #
SSESS� & LOT
VILLAGE
INSTALLER'S NAME&PHONE
SEPTIC.TANK CAPACITY c
� G
.� size
LEACHING FACII.I-rY: RY1x,
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 2t:5 COMPLIANCE DATE:
Separation Distance Between the: Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Famished by
r
Q
,
A 31 y �
�-672) C�
FAILED INSPECTION
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPAR MEAT 9MIR 1NMENTAL PROTECTION
9 2004 4AP --�.--.�'
i uv.—yr tiARNSTABLE �/iRC`�,
HEALTH DEPT.
Lai -
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 108 Cedric Road
Centerville, MA 02632
Owner's Name: Ed Woollev
Owner's Address:
Date of Inspection: _ September 20, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
ct� Aix:.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the.iriformatio"eported
t
below is true,accurate and complete as of the time of the inspection. The inspection was perforpi d based on my -'-
training and experience in the proper function and maintenance of on site sewage disposal system,sl. I am DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: a
r—
Passes rn
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: September 22, 2004
The system inspector shall sub 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 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 108 Cedric Road
Centerville, MA
Owner: Ed Woolley
Date of Inspection: September 20, 2004
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
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 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 108 Cedric Road
Centerville, MA
Owner: Ed Woolley
Date of Inspection: September 20, 2004
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 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 108 Cedric Road
Centerville, MA
Owner: Ed Woolley
Date of Inspection: September 20, 2004
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.]
Yes (Yes/No)The system fails. 1 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
Page 5 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 108 Cedric Road
Centerville, MA
Owner: Ed Woolley
Date of Inspection: September 20, 2004
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.
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 108 Cedric Road
Centerville, MA
Owner: Ed Woollev
Date of Inspection: September 20, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n1a [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: Never pumped-per owner
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:
Installed in the 1970s-per owner
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: 108 Cedric Road
Centerville, MA
Owner: Ed Woolley
Date of Inspection: September 20, 2004
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 Qal.
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: 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.):
Cement baffles were present. The liquid was even with the outlet invert. There did not appear to be any 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
I
Page 8 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 108 Cedric Road
Centerville, MA
Owner: Ed Woolley
Date of Inspection: September 20, 2004
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: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
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: 108 Cedric Road
Centerville, MA
Owner: Ed Woolley
Date of Inspection: September 20, 2004
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 leach pit was full. Liguid was above the inlet and up into the riser. The leach pit was in hydraulic failure. The bottom to
grade was 9'. The cover was 15"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: 108 Cedric Road
Centerville, MA
Owner: Ed Woolley
Date of Inspection: September 20, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
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.
P
nT �
I I d I$
a 3a a9
0
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 108 Cedric Road
Centerville, MA
Owner: Ed Woolley
Date of Inspection: September 20, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30 +/- 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 Barnstable topographic maps and water contours maps the maps were showing approximately 30'+/-to ground water
at this site.
This report has been prepared and the system inspected and failed 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 108 Cedrick Rd.Centerville
Owner: Jerry Sheffield
Date of Inspection:1115197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
V
A A 31 to P�
��► aye
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
i
*RAND ALLT
" SECTION A A
10 min. from..
NOTE. ALL PIPES ARE TO BE 4 SCHEDULE 40 P.V.C.PVC D Box cover must be
within 6 in. of finished rode ALL W TLET PIPES FROM THE
9 DISTRIBUTION BOX SHALL BE
Existing Foundation house to septic tank PROFILE VIEW OF LEACHING SYSTEM SET LEVEL FOR AT LEAST 2 FT. - t2 CONCRETE COVER
TOP OF
FOUNDATION = ELEV. 100.00 Assumed Septic tank covers must be
within 6 in. of finished grade _ �.+a...
Grade over Septic Tank - 99.(Rl Grade over D-Box - 99.(xi ode over SAS - ElEVe'99.00 -,.:. �� �.� � 3 - 5 OUTLET - E �',-...,2
f!
n. •f I A a /�• m r 1/2 i►..R�d CYv�As[SY.ee '.W r/s•_ r/r'W..e.t p.,.ao. ; '� _ KNOCKOUTS
/ INSPECTION cover must be
. - ` 5.5 OUTLET 72' INLET
1 within 6 in. of finished rode
S 0.02 3 HOLE H-10 9 r s
DIST. BOX 3' Maximum Cover Top of SAS-Elev.=96J5 .• '
O is' EXIST. S=o.01 or Gr S- 0.010" per toot 1 . f
r. 2 ., 108teM>c Itr
EXIST PIPE U) 1.000 GAL. eater P 1 15.5•
FROM EXIST, FOUNDATION t- O 15 O M O O O O � 4 - SCH; 40 Te 1.75"
rn SEPTIC TANK in
ai eD 20, p0 Om '.Effective Depth O O O
r;
/1 > li H-10 0..een. rn r�i rn o 0 2 Units 2 8.5' 17
PLAN- SECTION CROSS-SECTION'
CONCRETE FIAT FOUNDATION--' y ,O •.•a ,.y i f - t <
Or)
e > 3.5 5 -► 3.5 a
6 in.of 3/4-1 1/2 v :> :� 3 HOLE H-10 DISTRIBUTION BOX
SYSTEM PROFILE "•
compacted atone a) 0 12' II 25
c > a a - Effective Length NOT TO SCALE 4150
00N
Not to Scale - c o Effective Width 5 �:Woh
C�:a7Q'a RmA4t kN�:E�er.'garyO�+NAvTE: : s
SDIL ABSORPTION SYSTEM (SAS)
/ / 0 500 C H 10 LEACHING UNITS / WIGGINS PRECAST GENERAL NOTES
compacted stone m
N NOTE. ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6 BELOW GRADE Bottom of Test Hole 1 Elev.= 87.00 of to Scale 1. Contractor is responsible fOf"DigSafe notification
---------------` ------------ = and protection of all underground utilities and pipes.
v Obs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED 2. The septic tank anq, distribution box shall be set
- level on 6 of 3/4 -1 1/2 stone.
3. Backfill should be clean sand or gravel with no
stones over 3", in size:
4. This'system is subject to inspection duringinstallation
PERCOLATION TEST ST by Carmen E. Shay Environmental Services, Inc.
5. The contractor shall install this system in 'accordance
Date of Percolation Test: JANUARY 12, 2005 with Title V of the Massachusetts state code, the approved plan
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations.
Results Witnessed By. Waiver per BARNSTABLE B.O.H. 6. if, during installation the contractor encounters any
Percolation Rate: Less Than 2 MPI ® 30" soil conditions or site conditions that are different
N%F JAMES from those shown on the soil log or in our design
-- installation must halt & immediate notification be
Test Hole made to Carmen E. Shay - Environmental Services, Inc.
No. 1 7. ,No vehicle or heavy machinery shall drive over the
DEPTH SOILS ELEV. 96
J septic system unless noted as H-20 septic components.
P Y P � P
0 99.00 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends.
Sandy n. - 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
Loam .` 100.00' 10. All solid piping, tees & fittings shall'be 4" diameter
Schedule 40 NSF PVC pipes with water tight joints.
0"=8" A 98.30 �� 11. Municipal Water is Connected to The Residence and Abutting
Sandy
Loam �� Properties Within 1.50 Feet.
B. THE PROPERTY LINES ARE APPROXIMATE AND
8"- 30" 96.50 6
9 COMPILED FROM THE SURVEY PLAN GENERATED BY
Fine
Sand LOT #15 DES LAURIERS & ASSOC. OF WALPOLE, ,MA, ENTITLED
"CERTIFIED PLOT PLAN OF LOT 14 CEDRIC ROAD, CENTERVILLE, MA"
30"-144" Ct 87.00 SHED LOT # 14 DATED 03/13/92
15,040 Square`Feet +/- & THE DEED DESCRIPTION ( BOOK 2024 PAGE'47)
IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
THE SEPTIC SYSTEM INSTALLATION.
PROJECT BENCH MARK
TOP OF FOUNDATION
__.9$ EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE OR
ELEV. _ 100.00 (Assumed) ,. REMOVED TO FACILITATE NEW SEPTIC SYSTEM INSTALLATION
NOTE. ANYSTRIPPED E OUT SOIL .CONTAINING LEACHATE
CIO
FROM H EXISTING
_ THE EX G LEACH PIT, TO BE DISPOSED
__- OF',A PER_ S E BOARD OF .HEALTH SPECIFICATIONS.
t n - l. - __ N0 WETLANDS ARE PRESENT
r De Depth to Perc. :32 to 50
lA E ESE T 200 OF 'THE PROPERTY
LOT
er °R e- P � # 3
P c at Less :Than "2 M I ,
I
ASSESSORS MAP 172 PAR 1
Groundwater Not Observed $
., CEO 35
No Observed HW 9 Screened
e d ES T I LEGEND
ADJUSTED H2O Elev. = None Porch
2-18- DIAM. ACCESS MANHOLES DENOTES PROPOSED
6 A 104X1 SPOT GRADE
EXISTING I
3 BEDROOM ' DENOTES EXISTING
x 104.46
1
flo�sE SPOT GRADE
-- �- #108 PL PROPERTY LINE
INLET 1 - -
OU .T
-- i-------i _ P PROPOSED CONTOUR
THE ACCESS COVERS FOR THE SEPTIC TANK,.
l DISTRIBUTION BOX AND LEACHING COMPONENT
. •'�" .3 , :�� SET DEEPER THAN 6 INCHES BELOW FINISHED
I I EXIST. 1000 al.
• GRADE SHALL BE RAISED TO WITHIN 6. OF g 97. EXISTING CONTOUR
STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. I I 20' Septic Tank
PLAN VIEW
INSTALL TUF-TITS GAS BAFTZES OR EQUALS :::0 DEEP TEST HOLE Uc.
3-24• REMOVABLE COVERS PERCOLATION TEST LOCATION
6 FOOT STOCKADE FENCE
C IN
ASPHALT I
_ 3" min, clearance f IYf
INLET'T I I �'s'= REA
8' min.
DR VEWAY
INLET _ -_ 1��2" min. Inlet to outlet 8 min. ._� � I I I Z :
u4id ievel I I OUTLET TEST HOLE #1 ----- -
A lo•f min- is mY. I I !.
5 -r ---- L-- I 5' -r I ELEV.=' 99.00 1. 25'
�:
r 4'-0" mina. I I Faded
P LOT PLAN
D
G..Do% Liquid depth I I
r
•i� . •. ..: I I 100.00 � Leach Pit _
OF PROPOSED SEPTIC SYSTEM UPGRADE
a a
_ ... ._ :
8,-0, 4' -10- ll I\ PREPARED FOR
{ CROSS SECTION END-SECTION
--------- ------� _ MS . MARY WALSH WOOLEY
TYPICAL 1000 GALLON SEPTIC TANK U-V-d� RI U , OA D
AT# 108 CEDRIC ROAD
NOT TO SCALE
• (40 FOOT RIGHT .OF WAY) CENTERVILLE MA
,
Design Calculations s
PA
Number of Bedrooms: 3 Equivalent to 330 Gal: Da 330 Gal./DayMina er ,Title V o`, R yG E RED BY.
q / Y { P ) � u,
Garbage Grinder: No
LeachingCapacity Proposed: I Minimum ,i
C P Y P ed. 330 Gal./Day./Day M n mum (Min. Per Title V) SH rn 1 1�1 it �1 Y F. SHA Y
Septic Tank - 2 x 330 Gal./Day 660 USE EXIST. 1,000 GAL. Septic Tank
ENVIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch �Q p
Bottom Area: 0.74 gal/sq. ft. x 300sq. ft. = 222.00 gallons STERN P.O.
Sidewall Area: 0.74 gal./sq.. ft, x 148 s . ft. = 109.50 gallons 0 20 40 50 Sq Fa BOX 627
9 q q 9 NI TARS
Providing: = 331.50 gallons
EAST FALMOUTH, MA 02536
- - TEL/FAX : 508-539-7966
Use: (2) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH,
To BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND SCALE: 1 =20' DRAWN BY: CES DATE: JANUARY 13, 2005
4' OF WASHED STONE,ON THE ENDS. SCALE: 1 "=20'
. PROJECT#SD680 ` FILENAME.- SD680PP.DWG SHEET 1 OF 1