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Commonwealth of Massachusetts
Title 5 Official Inspection Form COPY
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Conners Road
Property Address
Anthony Martin
Owner Owner's Name
information is _
required for every Centerville MA 02632 _ June 1, 2015
page. CityRown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Patrick_T. Sullivan _
use the return Name of Inspector
key.
Ready Rooter Excavating _ _
Q
Company Name
P.O. Box 89
Company Address
Forestdale MA
City/Town State Zip Code
508-888-6055 S112843
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 functioryarm ! nit ,parc _ on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
- June 2, 2015
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�n
t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Conners Road
Property Address-- - ---- - --
Anthony Martin
Owner Owner's Name
information is required for every Centerville MA 02632 June 1, 2015
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:
B) System Conditionally Passes:
❑ One or more system components as des bed in the"Conditional Pass" section need to be
replaced or repaired. The system, upo completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not d termined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 0 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infi ration or exfiltration or tank failure is imminent. System will pass
inspection if the ex/pss
eplaced with a complying septic tank as approved by the Board of
Health.
* A metal septic taspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicank is less than 20 years old is available.
❑ Y ❑ NND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
:6 Title 5 Official Inspection Form
j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�a
7_0 Conners Road
Property Address
Anthony Martin
Owner Owner's Name
information is Centerville
required for every _ MA 02632 June 1, 2015_
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (coat.):
❑ Observation of sewage backu or break out or high static water level in the distribution box due
to broken or obstructed pipe( or due to a broken, settled or uneven distribution box. System will
pass inspection if(with appr val of Board of Health):
❑ broken pipe(s) arr replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution b x 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 Requied by the Board of Health:
❑ Conditions exist which requi e 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 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•3113 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
�,. 70 Conners Road
Property Address
Anthony Martin _ _
Owner Owner's Name
information is Centerville MA 02632 June 1, 2015
required for every _
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 a d 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 wat r analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent a d the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided tha 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
i ❑ ® 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
15ins•3113 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
70 Conners Road
Property Address
Anthony Martin _
Owner Owner's Name
information is Centerville MA 02632 June 1, 2015
required for every _ _
page. City/Town 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 eithe/feetf
" t \each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within surface drinking water supply
❑ ❑ the system is within tributary to a surface drinking water supply
❑ ❑ the system is locaten sensitive area (Interim Wellhead Protection
Area—IWPA) or a m II of a public water supply well
If you have answered "yes" to any ques> 'on in Section E the system is considered a significant threat,
I or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Conners Road
Property Address
Anthony Martin
Owner Owner's Name
information is required for every Centerville MA 02632 June 1, 2015
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
t5ins•3113 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
70 Conners Road _
Property Address
Anthony Martin
Owner Owner's Name
information is Centerville MA 02632 June 1, 2015 required for every -- .___.._._._.__
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 2013= 367 GPD*
g ( y g (gp )) 2014= 520 GPD'
Detail:
"Almost all water use during summer months. High usage due to irrigation__
Sump pump? ❑ Yes ® No
Last date of occupancy: Oct 2014Date
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. ., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank pres nt? El Yes ❑ No
Non-sanitary waste discharged o the Title 5 system? ❑ Yes ❑ No
Water meter readings, if av lable:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
-F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Conners Road
Property Address
Anthony Martin
Owner Owner's Name
information is Centerville _MA 026_32_ _ June 1, 2015 required for every _ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Ready Rooter records: Pumped Au . 2014
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: -
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
�\ Commonwealth of Massachusetts
a : Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_ 70 Conners Road
Property Address --- -- ---
Anthony Martin
Owner Owner's Name - —"
information is
required for every Centerville MA 02632 June 1, 2015 _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
System installed June 3, 1994. Owners records. Installed prior to current owners purchase of
property. Certificate of Compliance on file at Health Dept.
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: n/a
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan): '
Depth below grade: 2.5 at inlet 3' at outlet
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: 9.6'X 5'X 5' 1500 gallond
Sludge depth: 2
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 70 Conners Road
Property Address -- —
Anthony Martin
Owner Owner's Name — —
information is
required for every Centerville MA 02632 June 1, 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 32
Scum thickness 1" at inlet 1/2" at outlet
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 14" _
How were dimensions determined? Tape measure and dip tube.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet PVC tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade.
Outlet cover is 24' Polyloc cover.
Grease Trap (locate on site plan):
Depth below grade: —
feet
Material of construction.-
concrete ❑ metal fiberglass ❑ polyethylene
El other(explain):
Dimensions:
Scum thickness
Distance from top of scum /bottom
t tee or baffle
Distance from bottom of scof outlet tee or baffle
Date of last pumping:
Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.— 70 Conners Road
Property Address -- -- -- —
Anthony Martin
Owner Owner's Name —
information is
required for every Centerville MA 02632 June 1, 2015
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: 7
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑— — /� other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: El Yes El No
Alarm level: Alarm in working order: El Yes ❑ No
Date of last pumpin .
/ Date
Comments (condition of alarm and float switches, etc.).-
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�. 70 Conners Road
Property Address - - --
Anthony Martin
Owner Owner's Name -
information is
required for every Centerville MA 02632 June 1, 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
11
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.):
One inlet, one outlet. D-box is 4' below grade. H-10. Very light solids carryover. No staining over
outlet invert. Riser brings cover 2" below grade.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No'
Comments (note condition of pump c amber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
w F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Conners Road
Property Address
Anthony Martin
Owner Owner's Name --
information is required for every Centerville MA 02632 June 1, 2015
_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number: -
® leaching galleries number: 4-4' X 4' w/
stone.
❑ 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.):
Camera used to locate and inspect SAS. Unit dry at time of inspection. No sign of past hydraulic
failure. SAS over 5' below grade. No vent found.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration -
Depth -top of liquid to inlet invert
Depth of solids layer -
Depth of scum layer
Dimensions of cesspool
i
j Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
r
Commonwealth of Massachusetts
AM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Conners Road
Property Address
Anthony Martin
Owner Owner's Name
information is required for every Centerville MA 02632 June 1, 2015
_
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions --- -
Depth of solids
Comments (note condition of soil, signs o hydraulic failure, level of ponding, condition of vegetation,
etc.):
/
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.•''r 70 Conners Road
Property Address
Anthony Martin
Owner Owner's Name
information is
required for every Centerville MA 02632 June 1, 2015
page. CltylTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t
i
3= ` w1
l. 3I
3c)
o
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
f
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,. 70 Conners Road _
Property Address --
Anthony Martin
Owner Owner's Name
information is
required for every Centerville MA 02632 June 1, 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: '5
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:
maps_massgis state.ma.us/oliver.php
You must describe how you established the high ground water elevation:
Slope to rear of property drops to pond. 10'+-from base of SAS to current pond level. Accessed local
ground water contours and topo mapping. No high ground water in area of system.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Conners Road
Property Address
A_nthony Martin
Owner Owner's Name
information is required for every Centerville MA 02632 June 1, 2015
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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b►�ut aw��-43� t � o41� I�Fv4%-Y1 : ab k4), V.Lul@.CLA,�f%f
PI MICATIOM SHAJA,DB COWLUM W4 T WM XICCERMN,D►1 CD AKDr>1 MM-M MPLC IG NOTt1►ICA'1'lM WILL NOT
BE AAf�W1L1.�Rb:161ph�D RY 77dE I�AXIMIW[OF 1.t1tu1R B N'IOR1d4plRG>�.11�V1l:LOMMdtd'1'.
MUM MM i lrowftror wdi mma oww's Wm win bo cmplca ft PolioMnB);
rtr�q t?afieer
Ad�aa
1 'd1¢11mvC ta♦a1Jli�wi+ie d►e coining t�QuM p{tllo Coratlennwepldl4if'Me61ar21saeYt;Load Ibltanbl�ProoWe:ioee mp1 Caslrol itag�IWfianl►1Qa
CMR 4ti0:176,i&oWMftq li Idw-r*;ftlon l and cMuqmmi4 I Ruftreaffily OW i army opal will be pCfttuttt{eg lbr(blM AAS 1OW44 09101"
(1 bare Ckdod ab dwe+0plyp
�irna�eamsaparl/m�e s.AbDlsblaoMltlio a�tlolandw.>ti aib�1 arms.aaatrera
i sadly►dae all the h Agnwlbn suslarend 1a Mb waft t:nffi mr im em so"7""f and f dk:c
one
Xcrwod JWW7
Rpr 27 11 02i20p Jahn Lyons 50B-778-2276 p. 1
J,1-a4-Y4.e011 IV.gt*vl 1*11L 4 ULLW%.ray MUM.
DepwtR mt of PAW Ht:M&p0pwwwnt of IAbOr
1V0T®WATM(W DF.>UMC.WORK:
t AD aw tlooa of thk ttto®l he cot a&W IN order to amply wkb
• the nevif ndim reedrehsimb of BLC.L.C.1111197.
4%C1r1R 22M am toS CMYt/640A at*wort molly amended
Cuntruaar perfirmlvg prvjeel�il�• ,[,,�(�,5_, >V>�me Q,S7[�QJ��.'Lsp.Dam
fiend Paint Inspecror� s' OJrf� Date o[xaapegtloa �Liceme#.,ejh t p.pole
Street AddreW/ �' S 1?0.ag . AOL Number
City
Praperoy Owner f _ AdtmLq "'�(,_I al 4& Q war
TNcphone Number
DioleadingMathod,�es/DvyS<rAping.� f i d� [}PleatGuM pLlquidIiiKnpsalanL
00M011tlon CnuatreA ❑1Lcprelcement
QCmwering A Otbor
ir,omlu l,sdieLYcd,plwltc calplaiu —
Cheek one: Dwelling�,q,uai.,54111y ,� 5ingtl f 1Y 01t
f
Start nowAR COfiplotlnu Detc_ f �= ��
Wken will work Ix dent*. wM L/ Pvf _fiML1 o usite) Wcokdnmta4 ;�/
If
Projscl$upatwiror Nopto_�� 4'. �Iot�� Lcmmo N Lkp.lritoq�lv�
Wancce'sCempersatlonFWkyNambcp err Z�fAB" 9kQ lA'2 ` Carri °�'ljYja e�isi'rt(�,
In sae of anaMWY�n4tcU,kl�3�, yb115 —Tell� )�,��
(contrRows nerwdletdative)
p�Ci.¢nrirNC CONxQ�,�R
Tile undereiened hereby stalea,wndar t1to pains end penalties of perjury.that IW41o!has reed and underptNA the CaMolonwcalill at
Mnlsachuserta Wend lot RceulatiotiN 04 CMR 22.00,and ilte Lam ral6eping Premden And Control ftnlMtung,IDS CMP 46ILM,slid
"jai,the infernwarlan eentaiaed in thlt ropllcatiatt Ia tt•ue and to t is IHt heft at hisnter knowledo and btditr.
Data14 0 i 1 SiEnFJ
Company Nea -ln C'fi•1PS L L
4�!/ rJ'L/iL fl�°Ie� 6-7-3
A'elaowne Nun*ar
OVER-4
Rpr 27 11 02: 21p John Lmons 508-778-2276 p. 1
JAM-19ra211_12:27 FROM:UMD LEAD PRGM 50899MI73 TO:15rAe7782 76 P.3.3
G OO i Ci 1� r -7o C' ,ow�E' S k G f'f�J viler at
�t �y oY15 � rage2 or z
[a ueoonlrute wilh Margchuacm Ge,rorot fawn C,It 1419714.%CM It=09 and I US C.4IM 4fi0.Pf14,nadee of the date and mat4d(r)nr
signore+i areoverine of patht.plastor or ocher accessible materiulr runtainior dunCerv„a ievcls orloid is to be pravlded and most bo received
by the rollowtne aepnnka,nt lenstj.([4)dory prior to On bogln■inp urduleildinc,
NOTOCATIONS MAY BE FAXED.
1. Department omabor,Lead pregrem.MvIslon arOteupationol SaRty
19$taaifurd Sircct,1"none.boatiffl,MA 4yt 1d FAX:M 7426-65
L Uireegor,Childh od LowJ puimming Prevemouo Prugrrra
nepawnlent of public lleahb.Donovan"WIth Building,]kandnlph Street,Gunton,MA 02021 I'AX 791-774.6700
� t' p�
J. Occupanb of dwunina toil N�,�f 0 ec�llc t:Ca n�kl��anY IJI i in .� p 1'l k1.1y1 i nq,Q l rc I �414 V 1, l�ct
�'at 35
4. All other occeponls army Maidenliol prOMIM4 Irony
4. 1.ncal guard orNeaublCoda LnforaRtentACenry - y ��'JC�{� (p
C Maitauchuaelta historical Commisslell (if p"labeq ore Ibled on the State Regiteref Hbtorlc
228 Morris:tey Blvd. Pieces,Ws no0catlon Muhl be mode olrnn reecho or 40
Mutaa,MA tt22112 Order to Correct Vtolatklu or atkoat 30 daya prior ce
FAX(617)727.SJ28 inlNndne prRvcncive d4ft9$inC)
NOT MCATlONS SI IAI L BE COMPLF.M TM T14EM F.NTMETV,DATED AND SICNED%INCOMPLETE NOTIP1t.11ONS WILL N(YT
BE ACCEPTED AND WILL BE A&TURNFD DY THE eEPA MduN r or LAWR&WORMFORCE MWELOPMENT.
PI207'Flay CIEYNRI.1(Irownerer nnlitxli owmi Agent wiA to perfurminb itsw.tis'k deleM t work.completo dte ioPowing);
Property O�cr Ageat(tt)
Atldrt
Tolopllone Nwnbei l __j•
I Muty lhpt 1 hove 0M.Ow with Ibo Iroinips Nquirtmaitc ortho Cafommwolth orMtttispclwsmi Lczd Poisoning Prgveatiwt and Cmitmi Regulations,101
( CMR 460.1'/S,for uwn�Jagcrit Ipu+.risK ItbarotneM:m4 Contalne�enl, 1 turthcrCcttNy that t�my agent wi tl be perfurm;ny,Uto Ibllo++�ing Iow•rtsk etxiai<ir,� '
(1 hale elrded all that apply)'
ppplying liquid encopulanr cappine baaoboitds removing doers.clibinct ilour*.Nhotlem i
apptyialk attar vinyl riding covering ourlaees �i r
t CMIry d►at ail dts lltti mwtkm cogU ticd in this ndiJNtitlon is Mw and altered to d rq�i t Ittiow1ow and bclicl:
Batt• ftned
JLcvwud Ill1UU7
r
aim Town:0.L.Barnstable P#.
j
Depart'
Ili of Regulatory Servlees
ttaaKARS.�ar�et� i Public Health Division -
�'eyp` 200 Main Snr.� Date..
E et H o ano tMx+ la
Y MA 026
�
Date Scheduled k
. .
Tune gl '
---- Fee Pd. t�
Soil Suitability Assessment or Se
Performed By: .f wage Disposal.
Witnessed BY: _
Location Address 7.0 IOCATION &GENERAL I FORMATIO C N
onners Rd, CenterV.1j.e:Owner•sName Anthony & Lenore
Address . 3 Martin
Assessor's Map/Parcel; 251%023 Channig .Cir..
Bngincer'sNa�brldge, ..MA 02138
NEW CONSTRUCTION BSC :Grob
//J� REPAIR TelephoneN 508-77$_. Rr Inc;
Land Use YC.�S.TQe'/l1Ty,�L. p 8919.
Slopes(96) /�%,�. �"j ,
Surface Stones b!t/Distances from: Open Water Body '
R .Possible Wei Area ���'
Drinking Water WellR
Drainage Way Propertji tine 30/
Other R
SKETCH:(Street name,dimensions or lot.exact localion'of test hole.&pero tests,locate wetland$
in proximity to holes)
..d '. a .
i
r I
i .. .�
Parent material �+- ..
(geologic) h�i. :;� Y
Depth to BedrockIq
Depth to Oroundwater. Standing Water in Hole: �" r
Weeping from pit
Estimated Seasonal High Oroundwater : IAA ,� :;,
DETERMINATION FOR SEA ONAL HIGH WATER TAIILE
Method Used: ?��4jCt �L�✓
Depth Observed standing in obs.hole:
Depth to weeping from side of obs.hole: Depth to soil moltlost In
Index Well N In. Groundwater Adjusemenl n,
Reading Date: Index Well ICVCI � A ,faclor
� ...�_.,_,r. Ad).draundwoter L.evel,,,,.,
PERCOLATION TEST... uattt�� 'rlu�.¢ //R/►?
Observation
Holc M
at 91, 4/
Depth of Pere U7
`. Timti at 6'•
Start Pre-soak Time @ V'OO p!po
--— Time(9"•6")
Bnd Pre-soak
Rate Minllnch GG Z
Site Suitability Assessment: Site Passed Site 0ailf d:
Addi i onal Testing Needed(YIN)
t
Original: Public Health Division
Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland you must first notify the
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:VEPTICU'ERCPORM.DOC ('
DEEP-OBSERVATION HOVE LOG Hole# .
Depth from Boil 1-lorizon Soil Texture Shcl Color Soil• Other
Surface(in.) (USDA) th (Munsell) Monlln 1 g (SWclure.Stones;Boulders.' .
• �•S�nit� D ��•u � o�� •
Of 3 i °1f.� /O`toms HMO.
DEEP OBSERVATION HO E LOG Hole# 2.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell). Mottling (Structure,Stones.Boulders,
Consistency,
it 4� 1
• �Z "�Sys .
1/4 /t>i .Tau .
DEEP OBSERVATION HO1LE LOG Hole# _
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) .' Mottling (Structure,Stones,Boulders.
Consistency,
Lid* v
l5 '� S�N f7 ib Q7
DEEP OBSERVATION HOLE LOG: Hole# 7�__
Depth from Soil Horizon Soil Texture Soil Color Boll Other
Surface(in.) (USDA). (Munsell) Mottling (Structure,Stones;Boulders.
onsistency.
bro GS 0 t/v �-4y a
Flood Insurance Rate Map:
•
Above 500 year flood boundaryNo Veli
. .. Within 500 year boundary Nos, Yes '
Within too year flood bounds No f
Y
boundary Yes
Depth of Naturally Occurring Pervious aerial'
Does at least four feet of naturally occurring pervlou material exist in all areas observed throughout the:
j area proposed for the soil absorption system? t;
1
If not,what is the depth of natural) occurrin ervidus material
I certify that on /I.O�. (dale)I have passed the soil evaluator examination approved b the
Depart
ment of Environmental Protection and that the above analysis was performed by me consistent with
f the required training.expertis nd experience described in 10 CMR 15.017.
Signature
Da
I
Q:4SePTICU'BRCt'ORM.DOC f"
TOWN OF BARNSTABLE
LOCATION ys'Nes"zf,T 5: SEWAGE#
VILLAGE L•-e— ASSESSOR'S MAP&PARCEL o� 6
ZZ �
afffgr�'S NAME&PHONE NO.��d
SEPTIC TANK CAPACITY k S®0
LEACHING FACILITY: 6fft�(size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility , 5 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�,���c►�.(�G$�
n
1 ❑ kF
t C-h
3 �
r
No........APPAMM FI;:s...$3 0 . 0 0......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cato TOWN OF BARNSTABLE
Appliratiou for Dig mittl Wnrkii Towitrurtiun ramit
ba3Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
Conners .Rd Centerville
�) Howard M. Spitbo :q es5 393 Temple St. 1 bN Have n Ct
W W.E. Robinson Septic Service P.O. Box 1089 Centerville MA
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms....-3
-------------------------------------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. l................minutes per inch Depth of Test Pit...........--..----. Depth to ground water..----.-..-..-..-..-.---
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.-.---.-..------_--- Depth to ground water........................
a -----------------------------------------------------------------------------------------•--•---............:--•-------•-----------------...............-----
0 Description of Soil..................sand..........................................................................................................................................
x
Z ----------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- j
V Nature of Repairs or Alterations—Answer when applicable......i.nsta11...a-.-1..,.50.0....g.a1---tank.....................
•---------------------------------------------------------------------------and 4 �allias-Lies.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has beepwisue y tl�e board of h th. n
Signed ....... ............................................................................... ...... ...... -----------
Dare
ApplicationApproved By ......... - --- ---------------------------------------------------------------------------- ----- - ----1-7--- Lj
Application Disapproved for the following reasons: .................................................... .... .. .... ......... ......... .......................
------.._------------------------------------------------------------------------------........-----------------------------------..............._...---..........--------------------.......- ----------------------------------------
�y Dale
Permit No. -----?,`-----(�.O�a........ Issued ..... ..... .... ......................--
Date
No................--....... Fick $".30.00......
THE COMMONWEALTH OF MASSACHUSETTS11'L�_H
5 V BOARD OF HEALTH
' TOWN OF BARNSTABLE
Appliratiou for BiuVuuttl lVark,5 Towitrnrtiun rrrmif
3Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
,i System at:
1 ' Conners Rd Centerville
- --•--........--••------•------•.............•---•-=--•-------------.........-------•-•...... ............-•--•••-•------•--•---•---•------•----------•-----•----------•••-•..........-•-•-••--
Howard M. Spi-t6;-ry`,6ess 393 Temple St. 10
4 NHaven Ct
......................-.......................................................................... •--•-------••------••-••-•--------•-•--.....-••-------••••-•-----•----•••......-----••--....-•-•--
Own r , Ad ress
W W.E. Robinson Septic Service P.C. Box 1089 Centerville MA
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 ( )
d 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 ( ) 11�1
►" Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_.-_-______.____----___.
P4 ._..-----•------------------•••-•-•••-•-•--•------------•---••••••--•••••-••••••-•----------•-------•-----••--•---••--......-----•-•-•• -----------••-----
DDescription of Soil-----•-------------aand....................................................................................... ............................ ......................
W .............. . .....................•--------..__.....-----------......----------------•----------------------....------•------•--•-•---------•-.._......._......-•---•-•----. . +t
e
U Nature of Repairs or Alterations—Answer when applicable.-----in.Sta.1.l...a--- .___Ij.a1. ......................
...........................................................................and...4...?e.liies
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee �'y00, ard of h- th.
Signed ...1iz-- 1 .............................................. �t
Date
Application Approved By .......C �..... ------- ........ ...................................... - -- . � ------------L;
Application Disapproved for the following reasons:
.... ............................... . ..... ................................................................--. ..... --------------------------------------
?` _--1 V Dare
Permit No. - Issued
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f TOWN OF BARNSTABLE
%L,je I � II �IIlti lt�SYtCE
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x )
by ......W.E. Robinson Septic .Service
--------------------------------- ------------------------------------------
at ------ Insrdlrr
15 Conners Rd Centerville
-------------------------------------------------------...------------------------------------......------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
CP
the application for Disposal Works Construction Permit No. ..... V-•...a'_13.6-------- dated ------___---------------------------- ----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
.... 7........ - - - - .. Inspector = ............. ------- ..-�
-------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.... ..1: 8� FEE. ..3 0.0 0
Rupusal Workii Tanu#rur#iun "nutit
W E. Robinson Septic Service ........................
Permission is hereby granted.-W.E. -----------------------------p-•--------__-_-__
to Construct ( or Repair (x ) an Individual Sewage Disposal System
atNo.........................Conners._�R--�-----•--C t1temvi iia_._MZ�- ------------------------••-----------------....------------------------....---.......
Street
as shown on the application for Disposal Works Construction Permit No. .:_�Y6 Dated-_- ?._.'.-�_.`.�t�
......................................r ' :Board of Health----------------------.............................
G
DATE.............. r... . V
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
4. a 7" 1 13 A b
C' TOWN OF BARNSTABLE
LOCATION a - A- s Ka SEWAGE # `l L
VILLAGE C ASSESSOR'S MAP & LOT,Z--.4"/-025
INSTALLER'S NAME 6z PHONE NO. 2a Fi 1 �•. S o �-- 1 2 " 72 {
SEPTIC TANK CAPACITY s 6 1
LEACHING FACILITY:(type) C j. .S (size) GZ+
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE.GRANTED: Yes No lj
",
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