HomeMy WebLinkAbout0104 COTTONWOOD LANE - Health 104 Cottonwood Lane
Centerville
A= 252-149-163
No. 42101/3 ORA
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Commonwealth of Massachusetts a5a
N r Title 5 Official Inspection Form /
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Cottonwood Ln. Centerville, MA 02632
Property Address h4
Greg Hamm 120 Buttonwood Ln. '
Owner Owners Name UJ
information is
required for every West Barnstable MA 02668 6/18/2018 ::.,
page. City/Town State Zip Code Date of Inspection I--,'
X1
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
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin
use the return Name of Inspector
key.
Cape Cod Septic Services
ry Company Name
350 Main St
Company Address
W.Yarmouth MA 02673
City/Town State Zip Code
508-775-2825 S15016
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 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6/26/2018
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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
information is West Barnstable
required for every MA 02668 6/18/2018 `
page. City1rown 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:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System in working condition.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
e y 104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owners Name
required for
is every West Barnstable
required for eve MA 02668 6/18/2018
page. CityrFown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
x Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owners Name
information is every
West Barnstable
required for eve MA 02668 6/18/2018
page. Cityrrown 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 cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owners Name
information is required for every West Barnstable MA 02668 6/18/2018
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 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
information is every West Barnstable
required for eve MA 02668 6/18/2018
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 backup?
® ❑ 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): 110x3=
330gpd
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Cottonwood Ln. Centerville MA 02 632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
required for
is every
West Barnstable
required for eve MA 02668 6/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 6
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available usage last 2 ears 2016=241gpd
( Y g (gpd))' 2017=244gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•'� 104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owners Name
information is West Barnstable
required for every MA 02668 6/18/2018
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: No Records
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
u u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M "t 104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
required for
is every West Barnstable
required for eve MA 02668 6/18/2018
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:
2012 Per BOH records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10,
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Line checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan):
Depth below grade: 811feet
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: 1000Gal
Sludge depth: 8-10"
t5ins-3113 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
r 104 Cottonwood Ln. Centerville, MA 02632
0�.
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
information is West Barnstable
required for every MA 02668 6/18/2018
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
Scum thickness 6-8"
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? Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Coveres
8" below grade. Recommend service of tank.
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 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
u W Title 5 Official Ins ection . Form
p
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G'N ,•°'� 104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owners Name
required for
is every West Barnstable
required for eve MA 02668 6/18/2018
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 El 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
information is required for every West Barnstable MA 02668 6/18/2018
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
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-20 DB-3 with 1 line in and 2 lines out in good condition. Box is clean and level with minimal solids
carryover. Outlet lines equal with speed levelers in place. Cover 3' 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 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:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M
104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
information is West Barnstable
required for every MA 02668 6/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500Gal
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
2-500Gal chambers with stone in a 13'x25'x2'Trench. 8"of effluent in chambers during inspection
with no evident staining any higher. No sign of overloading or hydraulic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
❑ Yes ❑ No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
w w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
information is required for every West Barnstable MA 02668 6/18/2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
information is every
West Barnstable
required for eve MA 02668 6/18/2018
page. Cityrrown 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c 104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
information is required for every West Barnstable MA 02668 6/18/2018
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: 12
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: 2012
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:
Test hole data per plan on file at BOH. Max bottom of leaching is 5'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Cottonwood Ln. Centerville, MA 02632
Property Address
Greg Hamm 120 Buttonwood Ln.
Owner Owner's Name
required for
is every West Barnstable
required for eve MA 02668 6/18/2018
page. City/Town 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
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
----------a-- -.�... ..�.w„ Page 1 of
TOWN OF BARNSTABLE
LOCATION SEWAGE#=`�Z�'�'�
VILLAGE G 1-rT ASSESSOR'S MAP&PARCEL-Z� �99
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NO.OF BEDROOMS
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PERMIT DATE: /_.3-11R
COMPLIANCE DATE: s'—-a"'
Separation Distance Between the: it o.✓r le,
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) .� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY LTi/W
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http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=252149&seq=1 6/7/2018
�Cape-Cod Septic Services Inc.
Invoice
350 Route 28
W. Yarmouth MA 02673
Date Invoice#
6/18/2018 5262
Bill Address Service Address
GREG HAMM 104 COTTONWOOD LANE
120 BUTTONWOOD LANE CENTERVILLE,MA 02632
W BARNSTABLE MA 02668 617-448-6666
P.O. No. Terms
Due on receipt
Description Rate Amount
TITLE 5 SEPTIC INSPECTION 294.00 294.00
An interest charge of 1.5%per month(16%per annum)will be charged on all invoices over 30 days.If any invoice remains unpaid
for more than sixty(60)days and is referred to Legal Counsel for collection;then,in addition to the unpaid billing and accrued Total $294.00
service charges,the above signed further agrees to be responsible for all costs of collection,including all legal fees incurred by
Cape Cod Septic Services Inc.
Phone# Fax# Payments/Credits $0.00
508-775-2825 508-775-0424 Balance Due $294.00
No. J �C
Fee
THE COMMONWEALTH OF MASSACRUSETTS Entered in computer:
r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppfication for nigo!5al *p5tem Cow9tructiou 'Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System Windividual Components
Location Address or Lot No.-/1�7 GO G�/o�e� ^z Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
V//ate �l�'o�l/� 7.�✓t' o�o� �i'd�/tJ .L.' ��,J'v N ��
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building ref No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Zoom Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. �,
Signed Date
Application Approved by ,31 Date l
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
LL
Ni. ,, Fee
THE COMMONWEALTH OF MASSACM�J,ET -S Entered in computer:
PUBLIC HEALTH—d S'ION - TOWN OF BARNSTABLE,' MASSACHUSETTS Yes
9013Yication for � gpogar *pgtem Congtruction permit
j Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System Individual Components
Location Address or Lot No.--'4 C001�;'-6l/0 Cc6rT Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
of
3�1>
i
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( )
I,
Other Type of Building GF'e_ = No.of Persons Showers( ) Cafeteria
Other Fixtures
i. Design Flow(min. required) 3` gpd Design flow provided -�yP gpd
Plan .Date /..Z�3 0�/ Number of sheets J' Revision Date
Title
I
Size of Septic Tank cE`�CiJ'%//Y� /000 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed , Date
Application Approved by 1 1 Date f
Application Disapproved by: f Date
for the following reasons7 on
-
i
r
! Permit No. Date Issued
i
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
k
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (l/) Upgraded ( )
Abandoned( )by //1l LGC�pE�U/C iJ"c�G�f/ 1'EyOL!//G�
at ---'O y G !Gp oQ /�„ �'/✓T has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. � ""' 3 dated 3 Zd Z
Installer(J�1_0 ��Bo�y/� Designere5:WG/Q "6- jfJ�f fP n
#bedrooms 3 Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system will-fu-notion-a des; ned. '
Date Lf tt-' Inspector
L / Fee
THE COMMONWEALTH OF MASSACHUSETTS P
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
ligpogal *pgtem Con5truction Permit
Permission is hereby granted to Construct ( ) Repair (G'") Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Co ,structi in must be completed within three years of the date of this permi . ' l
Date . I Approved by ,-�—�
f
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TOWN OF BARNSTABLE
i' 'CATION So f` �7los✓�OO! LA'• SEWAGE
VILLAGE ASSESSOR'S MAP&PARCEL-2 fX /y9
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY.(type) T�``��y �'��° (size) >e-2
NO.OF BEDROOMS -�
OWNER
PERMIT DATE: ' 3- COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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Town of Barnstable
Regulatory Services
Thomas F. Geiler,.Director
Public Health Division
019.
A�� Thomas McKean.,Director.
a
200 Main Street, Hyannis,MA 0260I
Office: 508-862-4644 Fax: 508-790-6304
Date Sewage Perimit# ��� aa3 Assessor's Map/Parcel
Installer&Designer Certification Form
Designer: 2)q z) 0. lhf Installer:;1,)Yj
Address: �'9c57' cf�4K/PLt,'lG�__ - Address:
!11ktL45P riy
On, I 3 is t'�' as issued a permit to install a
( 'ate) (installer)
septic system at L7 '-�'�1+.+w ' based on a design drawn by
.1(address)
',�
"�r/'^�i dated a oo
l,
(designer)
V I certify that the septic system referenced above was installed substaiztially according to
the design, which may include manor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&.Local F- '-tions, Plan revision or
certified as-built by designer to follow. Stripout(if r-- cted and the sons
were found satisfactory. -��k OF M,q s
o� DAVIDB.
9�\c
(Installer's s—��e) - Z MASON
fUa.1066 o c,
,sT
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(Designer's Signature) n��
PLEASE RETURN TO BARNSTABLE PUBL.- �. ��tE
OF COMPLIANCE WILL NOT BE ISSUED UN i u, tsu i n A tub k'ORM AND AS-
BUMT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAofPice fonn"esipercerdfication formAm
VIE Town of Barnstable P# 100--�
Department of Regulatory Services
�EAWWAIR4 Public Health Division Date 1�P-J
A
.639. 200 Main Street,Hyannis MA 02601
RFD IMF a
Date Scheduled Time 10,
Fee Pd. (()0. 00
Soil
Suitability Ass��{�e{.ssss`m� nt for S _ isposal
Performed By: Y " `� �• - 1 r/`�+—� Witnessed By: -
LOCATION&GENERAL INFORMATION
Location Address wK6.� - Owner's Name/ �O' "",+ "
0 I Address � j�'• '
Assessor's MaD/Parcel: Engineer's Name jY•My ✓t;bw
NEW CONSTRUCTION REPAIR I Telephone# 606-3C. 401
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
� I
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Parent material(geologic) 0(TZ�) `„7 J Depth to Bedrock
Depth to Groundwater:Standing Water in Hole: A 4 , Weeping from Pit Face /,4'
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date Time
Observation
Hole# Time at 9"
1
Depth of Perc Time at 6"
Start Pre-soak Time r@ t Time(9"-6")
Z
End Pre-soak I
Rate MinAnch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
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:\SEPTIC\PERCFORM.DOC
f
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
11 Consistency,%Gravel)
Flo l��al0.
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
V / /
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
Within 500 year boundary No
Within 100 year flood boundary No 1_//Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervi us mat 'al exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of natural y occurring pervious material? ��
Certification
I certify that on �D (date)I have passed the soil evaluator examination approved by the
Department of Envir en 1 Protection and that the above analysis was performed by me consistent with
the requires fining,expertise d el F rig ce described in 310 CMR 15.017. /
Signl Date
Q:\SEPTIC\PERCFORM.DOC
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
M w
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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4 ti 11
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G„M Sy0"
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 104 COT
TONWOOD LANE CENTERVILLE MA 02632
Owner's Name: ROBERT KELLAND
Owner's Address: 35 COLONIAL AVE,WALTHAM MA 02453 Q+t"b
� Q�
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Date of Inspection: 4/10/02 4%1-
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS MAP
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
PARCEL : I
Telephone Number: 508-564-6813 FAX 508-564-7270 LOT
Y
CERTIFICATION STATEMENT
1 certify that I have personally inspected the.sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Pass s
_ Needs Further luation by the Local Approving Authority
Fails
Inspector's Signature: Yap Date: 4/10/02
The system inspector shall submit a opy 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."file original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG Ti-iL
SYSTEM'S USEFUL LIFE.
""This report only describes conditions at the time of inspection and under t',e conditions of use al that live. 'Phis
inspection does not address how the system will perform in the future under thc same or different conditions of use.
7
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Titlr C Incnrrtinn Frn-m .;il snnnO
' `0age 2 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 104 COTTONWOOD.LANE CENTERVILLE, MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 C M R 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined" please explain.
n/a The septic tank is metal and'bv'er 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a "
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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: n/a
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 104 COTTONWOOD LANE CENTERVILLE, MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02
s
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.
I. 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 4hich Will protect public health,safety and the environment:
T
_ Cesspool or privy is within 50 feet.o.f a surface water
_ Cesspool or privy is.within;50 feet of a bordering vegetated wetland or a salt marsh
a,
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 aseptic 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 deteniiine distance n/a
:,i
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compound's indicates ih�at.the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal toor less than 5 ppm, provided that no other failure criteria are triggered. A copy
of the analysis must be'attacfied to this form.
F^ I
3. Other:
n/a
Z
Wage 4 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 104 COTTONWOOD LANE CENTERVILLE, MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02.
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspection/orogged
Yes No
_ X Backupof sewage into facility or system component due to oveogged SAS or cesspool
X Discharge brponding of effluent to the surface of the ground orrs due to an overloaded or clogged
SAS or cesspool_ X Static liquid level in�h��distribution'box above outlet invert dueaded or clogged SAS or cesspool
X Liquid depth in cesspooll ess than 6"below invert or availablss than '/2 day flow
X Required pumping more than' times in the last year NOT due tobstructed pipe(s).Number of times
pumped
X Any portion of the SAS,cesspool or vy is below high gro d water elevation.
X Any portion of cesspool or privy is wit hi 00 feet ofa sup-ce water supply or tributary to a surface water supply.
X Any portion of a.cgsspool or privy is.within one 1 of public well.
_ X Any portion of a cesspool or privy is within 50 t of ivate water supply well.
X Any portion of a cesspool or.privy is less than 100 6t but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. IThis syste i p sses if the well water analysis,performed at a DEP
certified laboratory,for soliform bacteria aild vola ' e organic compounds indicates that the well is flee
from pollution from that facility and the esence ofa monia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other ailure criteria a e triggered. A copy of the analysis must be
attached to this form.l
f
(Yes/No)The system .1,have determined that one or more of the bove failure criteria exist as described in 310
CMR 15.303,therefore the system fails.The system owner should contact the Boa 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 10,0 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of'a tributary to a surface drinking water supply
s: -
_ X the system is 1,6cated in a nitrogen sensitive area(Interim Wellhead Protection Area—I W PA)or a mapped
Zone II 00 public watersupply well
i
If you have answered."yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section h above the 1�rge sysleiii hIS'f iled, The owner or operator of any lame system considered a significant threat
under Section E or failed.under Section D shall upgrade the system in accordance with 310 CMIZ 15.30,1. The system o wirer
should contact the appropriate regional office of the Department.
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Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 104 COTTONWOOD LANE CENTERVILLE,MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks
_ X Has the system received normal flows in the previous two week period `?
X Have large volumes of water been introduced to the system recently or as part of this inspection'?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up`?
e
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site'?
X _ 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 ?
X _ 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
X _ Existing information. For example, a plan at the Board of Health.
X _ Determined in the field(if any of th`e failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
t
Page 6 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 104 COTTONWOOD LANE CENTERVILLE,MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR,15.203 (for example: 1 10 gpd x#of bedrooms): 330
Number of current residents: n/a `V., `'•
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): YES
Water meter readings, if available(last 2 years usage(gpd)):.yLa. ZbD®. 2 I t D bU
Sump pump(yes or no): NO Last date of occupancy: n/a 20D1 _
��t D00
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a ;
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records .
Source of information: MACOMBER,9/18/01 BY OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--`How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
PKI Ill' ONVNI?R
Were sewage odors detected when arriving at the site(yes or no): NO
A
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 COTTONWOOD LANE CENTERVILLE, MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02
BUILDING SEWER(locate on site plan)',
Depth below grade: 18"
Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage, etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete metal fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is'age`coiifirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5'^7'`' W 4' 10`1
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 1"
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: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet.and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping reconirncrdations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage„etc.):
n/a
ski
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 COTTONWOOD LANE CENTERVILLE, MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02
TIGHT or HOLDING TANK:._;(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
n/a
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
n/a
e
Pry
h.
t
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: 104 COTTONWOOD LANE CENTERVILLE,MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' OCTAGON leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soii,'sigtis of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF
FAILURE. PIT WAS HALF FULL AT TIME OF INSPECTION AND STAIN LINES INDICATE THAT PIT HAS
NEVER BEEN MORE THAN HALF FULL. BOTTOM OF PIT IS AT 91.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
' Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 COTTONWOOD LANE CENTERVILLE, MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
I't
o � I
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IBC tit
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' Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 COTTONWOOD LANE CENTERVILLE, MA 02632
Owner: ROBERT KELLAND
Date of Inspection: 4/10/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12 +feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain:An/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
C���e
OW' N OF BARNSTABLE
LOCA C v WUI.CI- �4� SEWAGE #
VILLAGE L(.lJ ASSESSOR'S MAP & LOTJ,4 ,
INSTALLER'S NAME&PHONE NO. 60
//��
SEPTIC TANK CAPACITY �V
LEACHING FACII.ITY: (type) V +��( (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
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
I� a
D �
� g c
AS 36
A-C
64 �a�
V
Commor we ith of Mossochusetts .John Grad
Executive Office of ErMrorm ntai Affairs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Environmental Protection Teaticket, MA 02536
r (508) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ORT A H RC^f
CERTIFICATION
Property Address: 104 Cottonwood Lane Centerville Address of Owner: 1991
pF�,,�
Date of Inspection:3128197 (If different) y O p4,
Name of Inspector:John Graci Emma
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This Inspection is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs F rth Evaluation B the Local Approving Authority performing at the time of the Inspection. e l Inspection does
Y PP 9 tY not Imply any warranty or guarantee of the longevity of the
Fails septic system and any of its components useful life.
Inspector's Signature: / Date: 3130197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B.C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.)
_ The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 104 Cottonwood Lane Centerville
Owner: Emma
Date of Inspection:3129197
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four 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
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 the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 104 Cottonwood Lane Centerville
Owner: Emma
Date of Inspection:3128197
D]SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 t 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115195)
• 3
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST.
Property Address: 104 Cottonwood Lane Centerville
Owner: Emma
Date of Inspection:3128197
Check if the following have been done:
X Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
n/aAs built plans have been obtained and examined. Note if they are not available with N/A.
X The facility-or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 104 Cottonwood Lane Centerville
Owner: Emma
Date of Inspection:3129197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 1
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: nla
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: rVa
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nla
Last date of occupancy: n1a
OTHER: (Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last two years.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: o gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
13 years.
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 Cottonwood Lane Centerville
Owner: Emma
Date of Inspection:3128197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 8'
Material of construction:X concreate_metai_FRP_other(explain)
Dimensions: L8'ti'H5'7"W4'10'
Sludge depth:2'
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness:1'
Distance from top of scum to top of outlet tee or baffle:5"
Distance form bottom of scum to bottom of outlet tee or baffle: 17'
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle:n1a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
n1a
95(revised 11115/ )
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 Cottonwood Lane Centerville
Owner: Emma
Date of Inspection:3128197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: nla
Capacity: n1a gallons
Design flow: nla gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
n1a
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: Llquld level with bottom of pipe.
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
Distribution box is structurally sound -
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
n1a
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 Cottonwood Lane Centerville
Owner: Emma
Date of Inspection:3128197
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
n1a
Type:
leaching pits,number: 1,000 gallon leach pit Octagon
leaching chambers,number:n1a
leaching galleries, number: nfa
leaching trenches,number,length: n1a
leaching fields,number,dimensions:nla
overflow cesspool,number:n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
The overflow is structurally sound and functioning properly.It had'I'of water in it.
CESSPOOLS:
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: n1a
Depth of scum layer: n1a
Dimensions of cesspool: nla
Materials of construction: n1a
Indication of groundwater: nla
inflow(cesspool must be pumped as part of inspection)
n1a
Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Na
PRIVY:
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: nla
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Na
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 Cottonwood Lane Centerville
Owner: Emma
Date of Inspection:3128197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
NI 0
MG
p A
�J
M N
lac 3�
M `I9
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115/95)
9
i
1. 0CAT10N 04 SEWAGE PERMIT NO.
Ldt 163 Cottomwood Lane $3-544
VILLAGE
Centerville I
INSTALLER'S NAME i ADDRESS
Robert B. Our Co. Inc.
Great Western Rd. North Harwich, Mass.
B U I L D E R OR OWNER
McKeon Custom Homes
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
J��
�a
t
1
` t
3y, AA
0
M..0.._3�� Fmc....��...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...................OF............�
Appliration for Uhipos al Works Tonstrnrtinn Prrutit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at
.. ?.f 4 1....ce.` W.cr0 5L La Ce w"�e� v_....e M A o Z 6`�`_z-........---
-
Location-Address _ or Lot o.
1 f1 t 5 Mp►f`5. ---.... L---...... = ............
1J` ...._..... �: _
Owner Address
a 1Z2J.}�1.....� ._ ..........................
likstaller Address
U C'Type of Building \\. Size Lot............................Sq. feet
Dwelling—No. of Bedrooms. __l. �rrr_-'S...._..._...._Expansion Attic Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ----------••--• ......••...---- -
W Design Flow.......5. ..............................gallons per person per day. Total daily flow.......... 3®--------------
---------gallons.
WSeptic Tank—Liquid capacity.19AP...gallons Length..Ac.!-... Width..! 4'r.. Diameter................ Depth_5`:g"._.
x Disposal Trench—No..................... Width...............:.... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No........I----------- Diameter.....10......... Depth below inlet......�ft'......... Total leaching area.!i6 ......sq. ft.
Z Other Distribution box (✓) Dosing tank ( )
° l
Percolation Test Results.f Performed .............................. Date........4P .. _� ..........
aTest Pit No. l--------_/__....minutes per inch Depth of Test Pit....... Depth to ground water--_---- ..........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description ofS��oil
......- b�� �`- -..t.- 5 ���( � �.._.. � .I 0----. ��.................
-- . :.Y. ..._..
'�' " .'T_p e�.__. �._.w . ..............................................................................................
( \ . ....... .....
�W
............... ........................................................................................................................................................................................
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
`. ne ----------------- 7`2- F ... -- .
ApplicationApproved. By---•........ •• .•------•-••••-••---•-.....••••••••••-•......-•------•---........•••....... - ---�---
Date
Application Disapproved r th following reasons: ---------------------------------------------------------------------------•--•----------------------•---•--...
Da te
PermitNo......................................................... Issued-------------------------------------•---••--••-•-•••--
Date
Fmic-'........._____
-^ THE oomMomvvsxLr* OF MASsxo*ussrrs
U����� |��� ���� HEALTH
����"~" ^�� �,"
...................OF............� ���������� ��� Disposal ����- -orv-------- ---- ----n- ~- --'--~-~- ~~-- -~`~r~~-~~ r~~~~~~~
Aoolicuduo is hereby ooule for u Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at: �
' ...........................� � | Y�___ (,��- ���L!\t��____ _ ____.....��
Address m
��_____lu��__ ��l_�=zt _ ��_r_���� ___ _ ..................................
_..______________
Owner Address
--------------'-----'_-'�����--_-----'-'------'_-- --------.------'----'----------------_-------__--
��� Address
Type of Building \ Size Lot-------------Sq. feet
| I)w�l'ng—No. of 8�dr000�u.fc-^.�-.�l1��. ~--..Bxoaooion Attic Garbage Grinder ( )
� Other—Type of Building --_--................ No. ofpera000---------.--. Sbmvcru ( ) -- Cafeteria / )
Otherfixtures .---_------------.----___.-'-_-----_-.----...._______________________
` Deu6/o Flow........!55.5-_-_--____ �30___ �
Septic Tank—Liquid*cupucity.inf1Q-gallons I.eugt6'R!&n -. Width... Diameter................ I}cp8z.5.������
Disposal Trench--YJo. .................... Width.................... Total I.eogt6.---.---.-' Totalleaching area----_'---m� ft.- Seepage Pit 2�o----L--- D�oz�er--�<�'--- Depth below �let-.-�........... Totu leaching urca.. ft.
� Other Distribution box D �
~~ Percolation Test Ileaolta Performed by....\�\\.!'��.��-�(��='`t~................................ Date........................................ �
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water-------- ............... �
�r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Drydz to gToom1 water........................
---_-_-------__'_--'---'---_--____-'-------'_-----'------------'--'-'----
� 0 Description c6 Soil........................................................................................................................................................................
..................................................................................................................-`...................................................................................
----'-----.............................................................................................................................................................................
U Nature of Repairs or Alterations--Answer when .-.----._-.--_.-'-__._____.___.______�
.......................................................................................................................................................................................................
Agreement: �
The undersigned agrees to install the uforedescribed Individual Sewage Disposal System inaccordance with
the provisions ofZ[TIZ- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation oodl u Certificate of Compliance has been issued by th board of health
d --------.-- -
Da e
'`pv^ca""" '`pv`",=^ By --'=---'--'-----'------------------'- .....��"��'z�~�.^*-�r--' �
' o*"
Application Disapproved tm pn^oxming reasons:................... .............................................................................
...............
.........................................................................................................................................................................................................
Date
Permit
Date
/
THE COMMONWEALTH or MAseAonusErrs
BOARD OF HEALTH
-1{)�±��\------��F----.�^��1�'/���
T-5rdi«iratr of Toutplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( >4L) or Repaired
has been installed"m accordance with the provisions of TITT7 5 of T4e State Sanitary Code ed in the
Zoe
THE ISSUANCE OF .THIS CERTIFICATE SHALL NOT BE C/ONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUNC7TION SATISFACTORY.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
~~ �� �
--(��Ji6����-----'x�F--.K>�i�-..[�..��..LP*..��\. --------�
No FoE-.........------'
Disposal
to Construc or Repair an Individual Sewage Disposal Systerp
Street
. �
-
-M
�7.36T7
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25 '6.J1 DTLI
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LEGEND
EXISTING SPOT ELEVATION 0„0 tNOF '�+s\ CERTIFIED PLOT PLAN
EXISTING CONTOUR ---- 0 e�Pf
FINISHED SPOT ELEVATION ROBERT. /G3 L.C,#2oZ39
FINISHED CONTOUR 0 BRUCE,; '
ELDRED IN
APPROVED , BOARD OF HEALTH
suR��� BACH it fAl) oMASS*
DATE AGENT SCALEI �3d DATE, 7
LDREDGE ENGINEERING CQ wo CLIENT �'�'^
£(SISTER£ REGISTERED 83Q/ BUILDING IF SHOWN HAT
ONTHE
THIS R�P LAND
CIVIL LAND JOB N0.
DR. QE E CONFORMS TO THE ZONIN LAWS
EN(il EER RVE OF BARNSTABLE, M A SA� L � �
712 MAIN STREET CH. BYs 993=_
N Y A N N I S, MASS. SHEET-1— Z / �3
OF WE RE(3. LAND; SURVEYOR
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�ROAGf D/SPO.SAL 111VIT SO/L TE3�'
TaTAL E3TI/rt�TED. FLAN/ 3 3 o G.4t�LtI1 Y SOIL TEST / SOIL 7FST2 .
NUMBER CW LEACXtNG P/73_ �^ftEY. /o�.o -ELE✓, Q4TE OF 30I,C, TEST
SIDE LEACHJ.NG PER P/T fT. Gogh RFsutrs svirivzssEv dYj�AcvQi� J2e
$�TTOM/I A4CN1NG PAR P/T�S4• FT � SUL3Soru PER COL AT/Olv AATg */ , � ^1,111�IlNCH
//1NG AREA Z�3.. sip FT. �c�qY ¢ PIE,ICOLATION R.,,TF I�2 iN M/N.�/NCtJ
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QESFRVEGEAG'lvlN6ARE Z63 S?. FT.. E �?�Sr6N F2�c. 2.a dr �/ /�+
CDTTaN
OF �ASj'cG /6 3,.
/Z ROBERT �, p �11 BERTi G N
' BRUCE A. Cl�✓ �
o E R D I MORSE �, El-DRE'DGEENVGJNE�RING CD,JNG.
No-10951�O�Q �2 v,9/.0 7J Z MA l y S;r , //Y.q VA1JS, tiIAtJ.
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�sTE O o��sS10N � GROt1ND GY,4TCR fNCOcNTfR.- CL/ENT:�(cA� DRTE : !9
r3 G/COC!/VO -WATER? AT AFI-l N
.JOD NO. 83/3/_ SHEET Of
� ASSESSORS MAP : � NOTES:
_ - _�� _ TEST HOLE LOGS
PARCEL:
Title of
r SOIL EVALUATOR : \/IP 1 , ` ` The installation shall comply with V and Town o
FLOOD ZONE: ,-0' r 1) __.. _�t .-_.__
-- Health Regulations.
WITNESS : 11m-k ,
REFERENCE: - �Z�'Cf G DATE. , �`� �c 2) The installer shall verify the location of utilities, sewer inverts and septic
_ � "� "j L e-� PERCOLATION RATE: ..G 1 , I components prior to installation and setting base elevations.
C'� V ��' -- - -- --- - �''� _ 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first
_ `
two feet out of the d-box to the leaching shal l be level.
TH- ! TH-2
4) This plan is not to be utilized for property line determination nor any other
purpose other than the proposed system installation.
�\ 5) All septic components must meet Title V specifications.
/„��� 6) Parking shall not be constructed over H10 septic components.
' AV �l8 7) The property is bounded by property corners and property lines.
. , , A� �� �S 17'5 8) The property owner shall review design considerations to approve of total
LOCATION MAP
6` 5 design flow and number of bedrooms to be considered for design. Receipt
1 of payment for the plan and installation based on the plan shall be deemed
ITl 6 Y�A rD approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material
per Title V abandonment procedures. Those within the proposed SAS shall
be removed along with contaminated soil and replaced with clean sand per
wl• _ \�� �� ���� Title V specs.
K10 49Y4 wy,l 10)System components to be 10 feet from water line. Sewer lines crossing the
' water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
applicable. The proposed SAS is being installed below the water service
-i-F line. The line is to be sleeved as aforementioned and maintained in place.
o SEPTIC SYSTEM ' DESIGN
11) If a garbage grinder exists it is to be removed and is the responsibility of the
owner to ensure such.
FLOW ESTIMATE ! 12)The installer is to take caution in excavation around the gas line if such
j4Qw\_ exists.
BEDROOMS AT GAL/DAY/BEDROOM GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer
lines exiting the dwelling prior to the installation.
SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting
I W Title V requirements.
I GAL/DAY x 2 DAYS - � GAL
---- USE IWO GALLON SEPTIC TANK
alai _
I S01- L. ABSORPTION SYSTEM
-1C/
1�k OF
C "V By
SIDE AREA. -i 1 Z " t - �' 1ASON r
BOTTOM AREA: 0.ya66�a
S TIC SYSTEM ' SECTION
L-9► U
-- - �!
:7 Vrr JZ-
D-BOX
_ /6700 GAL
SEPTIC TAN �fo2 1. l�W .?`2 ' 3/ = l t'2-7'D� Li_. ..
M1 ,
SITE AND SEWAGE PLAN
LOCATION :
PREPARED FOR : :Ti I-�" C Fz*
M
;{ --,IK4 115
o ! .
0
f. SCALE: I'.'
DAV I D B . MASON11�5 DATE:�Z io ?Al
DBC ENVIRONMENTAL DESIGNS
EAST SANDWICH . MA
DATE HEALTH AGENT ( 508 ) 833- 2 177
f