HomeMy WebLinkAbout0017 CHEQUAQUET WAY - Health 17 Chequaquet Way
Centerville p
A = 191 008
llll OxcLco�gy
UPC 10259 o-
No.H_30R
NASTINOt,. UN
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !rT'-,
V
M 17 Chequaquet Way
Property Address
William Price s-'-y,
Owner Owner's Name
information is
required for every Centerville ✓ MA 02632 9-6-17
page. Cityrrown State Zip Code Date of Inspection �•
a«
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms 0-
on the computer,
_�H OF
use only the tab 1. Inspector: .�` � `• s11
51
key to move your - • y
cursor-do not James D.Sears _�: JAMES :E.
kee the return Name of Inspector
Y
Capewide Enterprises •. CA-
Company Name ., � �.•
153 Commercial Street p�4�F,5 i N SP G�```\7
Company Address
Mashpee
MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
9-6-17
spector s-Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information isequired or every
Centerville MA 02632 9-6-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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 main block pool w/two over flow's. Note: Main block pool and overflow pool old
system at time of inspection working.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass..
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is required for every Centerville MA 02632 9-6-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is
required for every Centerville MA 02632 9-6-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*'This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in IMEM is less than 6" below invert or available volume is less
than Y2 day flow J-9AcH/N6
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is required for every Centerville MA 02632 9-6-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section.D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
_ . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
informationis
required
wir for for every Centerville MA 02632 9-6-17
page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the EMMEM manholes uncovered, opened, and the interior
inspected for the condition of the ONE=tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NA Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information isequired for every
very Centerville MA 02632 9-6-17
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Main Block pool w/two over flow's.
Number of current residents: 2
Does residence have a garbage grinder?
❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected?
❑ Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 2015-25,000Gals
Detail: 2016-40,000Gal's
Sump pump?
❑ Yes ® No
Last date of occupancy: Present
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present?
❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 17 Chequaquet Way
Property Address
William Price
Owner Owners Name
required for
is every Centerville
required for eve MA 02632 9-6-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 600 Gal.
gallons
How was quantity Pump Truck
q y pumped determined?
Reason for pumping: Part of inspection
Type of System:
® a soil absorption system
® MAW IMcesspool
I
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6116 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is required for every Centerville MA 02632 9-6-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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
Building Sewer(locate on site plan):
Depth below grade: 3'
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 and orange bur a see asbuilt
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Che ua uet Wa
q q Y
Property Address
William Price
Owner Owner's Name
information is
required for every Centerville . MA 02632 9-6-17
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Su
bsurface Sewage Disposal S -
g p System Form Not for Voluntary Assessments
17 Chequaquet Way
Property Address
William Price
Owner Owners Name
information is
required for every Centerville MA 02632 9-6-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is required for every Centerville MA 02632 9-6-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No Box
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(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
I
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is required for every Centerville MA 02632 9-6-17
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 1
❑ 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 is a old block pool and precast H-20. Pit 6'deep over flow. Block pool at 3' below
grade w/cover at 10"dry. H-20 precast over flow . Pit at 3` below grade w/cover at 17",6"water. No
sign of over loading or high stain line.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth—top of liquid to inlet invert
6"
Depth of solids layer 411
Depth of scum layer 211
Dimensions of cesspool 8' Deep
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is required for every Centerville MA 02632 9-6-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Main block pool w/cover at 10".One inlet w/two outlets. Main pool at working level
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
' Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is required for every Centerville MA 02632 9-6-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
A o,vT
O � �
i
� 3
1 =alp 13-3 =-317
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,•''y 17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is
required for every Centerville MA 02632 9-6-17
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth tofhigh ground water: 50'
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:
U.S.G.S. Well at 50' Bottom of pool and overflows at 9'-10'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Chequaquet Way
Property Address
William Price
Owner Owner's Name
information is Centerville MA 02632 9-6-17
required for every
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No-Z (7 7 11 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppliLatlon for MispoBal 6pstrin Construction J)ertmt
Application for a Permit to Construct( ) Repair( ) Upgrade( } Abandon(X ❑Complete System Individual Components
Location Address or Lot No.191 CWMLfAQL JE- WAJ Owner's Name,Address,and Tel.No.
C'ViLL15 f.1 I LI-104"4 $ C_'1iL®t, PU�IC�
Assessor'sMap/Parcel I (� h CHC O 1VA\4 av1Irk
Installer's Name,Address,and Yel.No. S pf5—4"7'l—8%T1 Designer's Name,Address,and Tel.No.
CAPeW Dc 6)JT9<P"L-S A
Type of Building:
Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) s� gpd Design flow provided N& gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 4FjA?a--)w &Xa-,rw&
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of
Si H
e Date `� "{"��17
Application Approved by G- Date ( � `
Application Disapproved by U Date
for the following reasons
Permit No. 7sa— Z)f191 Date Issued ( 701
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
9pplication for Disposal *Ps temk Cons trUction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon()< ❑Complete System gindividual Components
Location Address or Lot No.Ih CJ4CG%jAAJ€-c Wo , Owner's Name,Address,and Tel.No.
� .i~6 WI (.4.6a"A + CA�d� Pry lGE'
Assessor'sMap/Parcel �GZ� �(�g 4 1-1 G14C6LU U&••r•• K/M i(s rUti.t.�
Installer's Name,Address,and fel.No. 3708_411- 8'9l1 Designer's Name,Address,and Tel.No.
CAae)lDe: 6V1WkKe S
GUK�c•fif 1w,#.l lilt. �, 04 kSI4 p6f
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) x
Other Type of Building r No.of Persons Showers( Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided ' a gpd
Plan Date' Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -AA.il
r ,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of ;
Compliance has been issued by this Board of Health.
Sign- Date ` {
Application-Approved by Date1
i
Application Disapproved by Date
for the following reasons
Permit No.74 M- .7-q L4 Date Issued -/ 1♦ 1 1 ?:(1 1
_,.,..
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( } Upgraded( )
Abandoned X)by LIMQ 4R'I D i15 GX~k(<95_y
..at /*7 4N-M JAQ Qa r- W -C t- L44r-has been constructed in accordance-
with the provisions of Title 5 and the for Disposal System Construction Permit NoR)Y-M dated 1 (l
Installer(1AQ9jW1,,b 15 &)Z-�PALJ<;SC Designer kf
#bedrooms Approved-design o � gpd
The issuance of this pe• 't shall no be construed as a guarantee that the syste( will fiin tion `Jigm .
Date / Inspector
--------- --------- ---------------------- ----------
No. A( 7 Z 1 q Fee 02 7160
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon�A
System located at. 1 0_44 5Q OA O U r W A 9 (!Nt rmky((.ZC �
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. _
Date I� Approved by
..A
b020�'
r
DATE: 12/17/01
PROPERTY ADDRESS:Willaim Price
__ 1 7-Chequaquet-Road
Ceaterville,Mass. ,.,02632
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1 -6 ' X6 ' cesspool in rear for the kitchen & laundry
2 . 2-6 ' X8 ' block cesspools.
3 . 1 -1000 gallon precast leaching pit. ( 6 'X10 '
Based on my Inspection, I certify the following conditions:
4 . This is not a title five septic system.
5 . This is a sewage system. ( Does not have a septic tank )
6 . The sewage system is in proper working order
at the present. time.
7 . Pumped the main cesspool and the grey water cesspool
at time of inspection.
SIGNATURE:'
Na me:
_ ^�_ Macomber Jr�______
Company: JoseI)h_P_ Macomber_& Son , Inc .
Address: Box 66
Centerville , Ma . 02632-0066 ®EC 2 ilk
U 2001
-- TUlN7u ,
Phone: 508_775_3338 �EAL7HDep-r.
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
•
1 .
I
►., �--\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Sj&_..OE
DEPARTMENT OF ENVIRONMENTAL, PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:17 Chequaquet Wad
eC ntervi e,Mass.
Owner's Name: William Price
Owner's Address: Same
Date of lospection: 7 01
Name of Inspector: (please print) J.P. Macomber Jr.
Company Name:Joseph P. Macomber & Son Inc
Mailing Address: P=0Q= $.ox F�_
rpntprvi lla Ma 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is rme, 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. l am a DEP
approved system Inspector pursuant toSection 15.340 of Title 5 (310 CMR 15,000). The system:
r/y/Passes
_ Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authoriry
_ F i l s
Inspector's Signature,?mitda
Date: / ✓/'��
P g
The system inspector shall 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
r ""This report only describes conditions at the time of inspection and under the conditions of use at that w�f.
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
Page 2 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:1 7 Chequaquet Way
Centervi e, ass.
Owner: William Price
Date of Inspection: 12/17/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S stem Passes:
I have not found any �ex7ist.
ation hich indicates that any of the failure criteria described in 310 CMR
15.303 or 15.3 ny failure criteria not evaluated are indicated below.
Comments:
The sewage system is in proper working order
at the present time.
B. System Conditionally Passes:
VO 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.
�J eptic tank s metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, e i its su stantial infiltration or exfiltration or tank failure is imminent. System will ass inspection if the
Y P P
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:
4)6Ve- Observation of sewage backup or break out or high static water level in th distribution bo�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:
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 Chequaquet Way
Centervi e,Mass .
Owner: William Price
Date of Inspection: 12/17/01
C. Further Evaluation is Required by the Board of Health:
4�0 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:
AID 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:
AVD 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.
NP The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
.Ulf The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
A)d The Svstem has a septic tank and SAS and the SAS is less than 100 feet but 5 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. 49)The
sewage system exists of. 1 -6 ' X6 ' cesspool
or the kitchen and the iaundry.
2- X8 ' biock cesspools wi a 1000 gallon precast
. leac ing pit as an overflow. ( All in series , ) '
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 Chequaquet Way
en ervi e, ass.
Owner: William Price
Date of Inspection: 12 7
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no" to each of the following for all inspections:
Yes No
_ ackup 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 th distribution box bove outlet invert due to an overloaded or clogged SAS or
/cesspool
t/ iquid depth in cesspool is less than 6"below invert or available volume is less than h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
�off times pumped�.
y portion of the SAS, cesspool or privy is below high ground water elevation,
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
ater supply.
y portion of a cesspool or privy is within a Zone 1 of a public well.
_L/ Y portion of a cesspool or privy is within SO 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.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now 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
�th system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—iWPA) or a mapped
Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with`310 CvfR
15.304. The system owner should contact the appropriate regional office of the Department.
4
lit Page 5 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:1 7 Chequaquet Way
en ervi e,Mass,
Owner: William Price
Date of Inspection: 12/17/01
Check if the followine 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?
ZHave 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, cluding the SAS, located on site?
Were the e tic taAconstruction,
anholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees, matena dimensions, ,depth of liquid,depth of sludge and depth of scum ?
P 9 P g P
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
Ekisting 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))
5
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 17 Chequaquet Way
Cen ervi e,Mass .
Owner: William Price
Date of Inspection: 12 17 01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): C
DESIGN flow based on 310 CMAI 5.203 (for example:110 gpd x# of bedrooms): ly
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no): 5;[if yes separate inspection required)
Laundry system inspected( es or no)��
Seasonal use: (yes or no)W �.
Water meter readings, if available(last 2 years usage(gpd)): `��T
Sump pump(yes or no): •Ud j�ia•— iA S''� ��
Last date of occupancy:
COMM ERCIAL/INDUSTRIAL
Type of establishment: z0f
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):&14
Non-sanitary waste discharged to the Title 5 system (yes or no)�/9
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): F✓
If yes, volume pumped:aZgall ns -- How w s quantity p ped d ermi ed? yYJNr951//>�,/
Reason for pumping: ley hrc'�S �` 5, r
TYPE OF SYSTEM
A,D Septic tank,distribution box, soil absorption system
X_Single cesspool
7 Overflow cesspool
,6b Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
VO) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
Vt ined from system owner)
Tight tank Attach a copy of the DEP approval
•� Other(describe):
Ap xf to a2 0 1 components, date installed (if known) and source of information:
Were sewage odors detected.when arriving at the site (yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Chequaquet Way
Centerville,Mass.
Owner: William Price
Date of Inspection: 12/1 7/01
BUILDING SEWER (locate on site plan)
Depth below glade: 1p
Materials of construction: cast uon 40 PVC_other(explain) J.
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage. SysteW is
vented through the house vents.
SEPTIC TANKt&,'C(locate on site plan)
Depth below grade: VX
Material of construction:,"concrete metal,1�1, fiberglass444polyethylene
Ir4other(explain) 44
If tank is metal list age:.Jji is age confirmed by a Certificate of Compliance (yes or no):�4(attach a copy of
certificate)
Dimensions: 4"W
Sludge depth: AJ�
Distance from top of sludge to 'oonom of outlet tee or baffle:
Scum thickness: A)1`7
Distance from top of scum to top of outlet tee or baffle: llc�
Distance from bonom of stuns to oonom of outlet tee or baffle:
Now were dimensions determined: .i✓��
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet inven, evidence of leakage, etc.):
Septic tank is not present.
GREASE TRAI)Ajkt(locate on site plan)
Depth below grade:
Material of construction.: GG concreteAmetal�fiberglasuc polyethylene other
(explain):
Dimensions: ,✓�i9
Scum thickness: 6,�
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bosom 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 inven, evidence of leakage, etc.):
Grease trap is not present -
7
i
Page 8 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:1 7 Chequaquet Way
en ervi i i e,M'as s
Owner: William Price
Date of Inspection: 12/17/01
TIGHT or HOLDING TANK 1' (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: V t
Material of construction: ajl concrete 4ometal fiberglass .L'J9 polyethylene42
1_other(explain):
All?
Dimensions: .d4
Capacity: .4)4 gallons
Design Flow: h14 eallons/day
Alarm present(yes or no): h
Alarm level: 1?R Alarm in working order(yes or no):
Date of last pumping: 4),4
Comments(condition of alarm and float switches, etc.):
Tight c)r hn1 cling tanks are not present.
DISTRIBUTION BOXti�/-c4. (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 4q
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.):
nist-rihution box is not present.
PUMP CHAMBER.rlJWe (locate on site plan)
Pumps in working order(yes or no): 4,iq
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump chamber is not present.
8
r
Page 9 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Cheguac[Ue Way
Centerville,Mas,G..
Owner: William Price
Date of inspection: 1
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
3- 6 ' X8 ' block-
1 -1000 gallon precast leaching pit as an overflow off of the two
If SAS not located explain why: septage pools.
Located• See page 10 �
Type _leaching pits,number:
_,tZDleaching chambers, number:()
�>leaching galleries,number: O
leaching trenches,number, length: �T(
oaching fields,number, dimensions:
verflow 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.):
0
as re or pon in . of s are .
Waste water as 66" below the invert pipe of the leaching pit. -
CESSPOOLS: � (cesspool mus e 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: .D�✓CiIY%�e
Indication of groundwater inflow(yes or no): W-10
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.
Same as have
PRIVY?r 6, e(locate on site plan)
Materials of construction: NA
Dimensions: NA
Depth of solids: NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Privy
9
Page 10 of I I
.., w •
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address) 7 Chequaquet Way
en ervi e, ass.
Owner; William Price
Date of Inspection; 12 17 01
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 fect. Locate where public water supply enters the building.
!d
O
0 ,
• at 1
• o�� 1
1
10
OIL Page 1 I of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Chequaquet Way
Centerville,Mass.
Owner: 12 17 01
Date of Inspection: 12 17 01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 6� feet
Please indicate (check)all methods used to determine the high ground water elevation:
X? XXObtained from system design plans on record- If checked, date of design plan reviewed: 1 2/1 7/01
XXXXQtserYed sje(abutting property/observation hole within 150 feet of SAS)
_Checked with local Board of Health-explain:
XXXXChecked with local excavators, installers-(attach documentation)
XXXXAccessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used Gahrety & Model Grond water above sea level
USGS Observation well data Tune 1992
USES 92-000-1 Plat-e #2 - ,TAnThar= 1 q9?
Tup of un
Leaching
i
Pit /6; ;eet
Groundwater:��f Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom >
Of the leaching pit and the adjusted goundwater table is 1p �
feet.
11
,
A
y+•rrn rw.—nl•rs+—.•rr- rn—mr•nts+rrr-+.n rsn.mm:•.•*++-r�.rr+r.-+.wm nera�u r.s-�r�vtlrn .�.�.T�T..-._r...1
TURN OF Barnstable BOARD OF HEALTH
SUI)SURFAU SEHA(;F DISPOSAL SMF,M -IN9PFCTION FORM - PART D .- CERTIFICATION
...t..•l.T•••••.-T.III.�.�TT1,T rT1'R.'f1f1TR'RTIT.TI'r-•.I TITf1iRlIf�TTRR'�OrR�tT'1'Rt TflI1 ..�I•T'I�••�• �.
-TYPO OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS17 Chequaquet Way Centerville,Mass .
ASSESSORS MAP , BLOCK AND PARCEL # 191 -008
OWNER' s NAME William Price
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME Joseph P. Macomber & Son Inc
COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632
Street Town or Clty State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578
CERTIFICATION STATEMENT -
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Ch//e one :
V '
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 - 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED* \
The inspection which I have con ircted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 151303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
"r
Inspector Signature �. Date
On
e copy of this certification must be provided to the OWNER, the BUYER
where applicable ) and the DOARD OF HEAL'I'1l,
* If the inspection FAILED , the owner orl'*o` orator shall u P pgrade ' the ayetem
within o'ne year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CMR 151305 ,
partd . doc
TOWN OF BARNSTABLE
LOCA IRON 17 C 14 eig //,A_ea ,e f w SEWAGE #2 l- Y G
VILLAGE ASSESSOR'S MKP"&tLOT
INSTALLER'S NAME &-PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ` J (size) coo Z
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC'WATER
BUILDER OR OWNER �&,U. � v
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
,,VARIANCE GRANTED:.xYes No, '
"k,, ,
TOWN OF BARNSTABLE
LOCATION.,"07 ��e SEWAGE # ,
VILLAGE • G%�' ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 111W (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the-Bottom of Leaching Facility Feet
Priv.a!P_Water Supply Well and Leaching Facility (If any wells exist
on sit or within 200 feet of leaching facility) Feet
i�.ag""se 83'11'Vetland Le ng Fa ility.(If y wetlands exist
within 300 fee I le ility) Feet
Furnished by ✓ �'
. � (�� e
�% i�
i �� � a
��.t
1 ��o
1 �� ,
� � \ ` r � �
` � `� � � , i
�,� �
�..� 0 p
��
�-
t� C,he�,�q��.� ��
$ 20 00
No..Qf:.. ... FRs.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF` 6-1EALTH
.......... own....................OF...........Barns table
AVVIlratilan for MsVaa of 10orkii Tnnstrnrtiun amit
Application is hereby made.for a Permit to Construct ( ) or Repair XX ) an Individual Sewage Disposal
System lat� C.h. ec�uaquet Centerville,Mass
.............
Way --•-I•----------- •......----•..............•-•----••-••-•---•---•---••---•-----•-•----•----•---....................
oca�tion-Address or Lot No.
William rice .
......................... .•-•••-•••...---.....----••-•••-•.........-•--••---•................... .........................................................
W J.P Macomber nJr Address
Installer Address
Type of Build�•'gT, Size Lot............................Sq. feet
U Dwelling Mo. of Bedrooms................a.........................Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ............................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.............. Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.-------_--------- Depth to ground water..-.-.-.---.-.--.._--...
44 Test Pit No. 2................minutes per inch Depth of ,Test Pit--.................. Depth to ground water...-.------.-.---------.
9 --•••------•-•----------•---•••-••--••-••-•---••----•••--••-••••------•-•..........................•••-----------••••-.....--•---.................-••••---•=-
0 Description of Soil.............................. •--- -- ....---• -----------------------------------------------------------------------------------------------------
x Sand �CraveT
W •---••-•----•-- -----•--••-•------•----•-•-••-------•-••------•-•--•••-••---•---------•-•----•--•••----•-•............. -
Z I-- x 1 J---Z e a c yi---i t------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.--.............................................................................................
....-...................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en issued y e b and of hea
Signe = ---•-8/29/89• - - -----•--
----- -----••--•
Date
Application Approved BY ... d'" ---------- P_^. ..
Date
Application Disapproved for the following reasons------------------------------------------------------------------------ ---------..........
---------••----------•............................•----------------------------------------•----------------------------------------------------------------------------------------------------•---•---
y� Date
Permit No.----- ,'..:.......1...5&-.............. Issued.........---•-----
bbL Date
� A
No..s..t......I FEs.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Diiipwi al iVork,5 Towitrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or RepairX(X ) an Individual Sewage Disposal
System at:
....:
Location-Address or Lot No.
------------------•.•--::.._...................................... ........ ........................•......._.................................................---•_•..........
yyOwneryy Address
W c.l_f_ _.1_..0'.:... ..:.:..:.l.._. .i_./......................................
--•-------••-•-•..............................•---•---••---------••-•----•---•---.._...------•-
Installer
Address
Type of Building Size Lot............................Sq. feet
Dwelling=+No. of Bedrooms...................
_____________------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons_._______________.______--__ Showers ( ) — Cafeteria ( )
a' Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity..........__gallons Length________________ Width-----------_--- Diameter.__---------- Depth._.__--_-_____
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet-----_.............. Total leaching area----..............sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by..................................................... .................... Date---------------------------------------
Test Pit No. 1________________minutes per inch Depth of Test Pit_--________.-_______ Depth to ground water-_-__-__-__________--.
w Test Pit No. 2....._..........minutes per inch Depth of Test Pit.................... Depth to ground water_._-_-__-____________-_.
---------------------------•--------------•--------------------•--------------------••---•-----••---........................................................
0 Description of Soil........................................------••---_-_-------••-•-•--------•--•-----------•----•-----------------_ ................. ..................................
x Q—
v - -----------------=-------------------------------------------------------------------------------------------------------
W
x -------------------------------------------------------------------- ---------------------------------------------------------------------- --------------------------------- -•----------•-•--•--•----
U Nature of Repairs or Alterations—Answer when applicable.__--_-_._._-_�-- :_.:_:'---__- i __''_
•-. . ,
..• •-••----•---•--------•------------------•----•-------------•-•----------•----------------•--------------------------------•------••-••-----•-----.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 71T.LE,
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued,by,the board of heath.
................
.+
r/1 Date
Application Approved B I-,___._.]_„ _,< _--- _:=y__________________ 1 PP PP y-----•---------• J J Date
.:...1<
Application Disapproved for the following reasons:-------••------•••-------------------------------•----------••---------------------------•----------•---------
-•---.._...---•-------------------•-•----••---•-----------•---•-••---•--••-•-••--•-••-••----•-----•-•-••.--------------- -------------------------------------------------- ------------------ --------
Date
Permit No. --'> f..._.....`--f---._441.---------••--- Issued.........---...........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(Inrtifiratr of Tomptianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at____ _S_______________rt..__.__1_L._.�...__....._.._..t,.;:.:,_,,..,,t_.___..4�_y�..t_,;Y�...�i�.r-----------------------------------------------_----------------------------------------------
has been installed in accordance with the provisions of T17: ] _j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......... __.t^ } _. dated_....--.-----------------.---____________._..
THE ISSUANCE OF THIS CERTIFICATE S L NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................................................................... .._. Inspector----------------------------------------------------------------------..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,..
No..- .....1.
Miposal ork� ion rnr#ion rani
Permissionis hereby granted--------`-._-='. :................ :...JX--.------------- ----------_--- --------------------------------------------------------•---
to Construct ( ) or Repair_L, ) an Individual Sewage Disposal System
.��,��- l.r, ,
Street ,y
as shown on the application for Disposal Works Construction Permit No._, _36. mated___________________-_______-_________.__,
Board of Health
DATE--------------- ...... ----- 5.l--.•4.1(
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS