HomeMy WebLinkAbout0680 CRAIGVILLE BEACH ROAD - Health 180 Craigville Beach Road
Centerville
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Commonwealth of Massachusetts o2 a at'O
�n ,p Title 5 Official Inspection Form
li; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville ✓ MA 02632 3/23/21
page. Citylrown 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.
A. Inspector Information 51 fr 15a-q
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
3/23/21
Inspec s Signat Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
��2(Ofo
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
F. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4� 680 Craigville Beach Rd.
Property Address
Green
Owner Owners Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 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:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owners Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�. ,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner s Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
li; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
r ,
Commonwealth of Massachusetts
�. ,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner s Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for aH inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
1
Commonwealth of Massachusetts
�. (o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L 680 Craigville Beach Rd.
Property Address
Green
Owner Owners Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
3 bedroom permit and plan on file at BOH
Number of current residents:
2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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 155 GPD
9 ( Y 9 (gP ))�
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�e
680 Craigville Beach Rd.
Property Address
Green
Owner Owners Name
information is
required for every Centerville MA 02632 3/23/21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Pumped March 8th per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
2014 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
2' I
Depth below grade: 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 18"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound, inlet cover to grade
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle '12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle
>2"
Distance from bottom of scum to bottom of outlet tee or baffle
>2"
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.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�. ,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
••� 680 Craig ville Beach Rd.
Property Address
Green
Owner Owners Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-20 D-box is in the driveway, it appears to be structurally sound, 2'6" below grade, cover to 12",
carryover in box
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
i
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
�. ,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
680 Crai9 ville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
H-20 chambers per BOH record, they are in the driveway, chambers were video inspected and are
damp at this time, no indication of past hydraulic failure, bottom of chambers is approximately 5'
below grade
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
�n ,IP Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
/
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 115 of 18
Commonwealth of Massachusetts
�. ,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: >10'
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: 2014 NGW 120"Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
4' seperation per 2014 compliance
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database-explain:
TOPO mapping shows the site at 26'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
680 Craigville Beach Rd.
Property Address
Green
Owner Owner's Name
information is
required for every Centerville MA 02632 3/23/21
page. CityrFown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Tate 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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n se a,c ays�rri) i11 Ltu�uri1fl11ae with,St Cr J T,uc a1.E..e uZs,tiong. F1au fevi[�0�.cyr
F t fnllnw'.
DANIEL A.
QJALA
(Lnstail�I'3 ':i€!ildtlll�) t~1VIL
pp a/BTP
/oNAL
(I1Rtri 'S S tire) (A six i�ier's 5 cep lje7d)
•' �cc�z �7Ari `'�r �� �►7tC�i rm���a.a� T�[r�,irQ�a�: '
_ 'ti i' t = I m,k 1J36L�Q � ` CbW. ' " „dt
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for Disposal 6pstrm Construrtion permit
Application for a Permit to Construct(t./Repair( ) Upgrade( ) Abandon( ) nomplete System ❑Individual Components
Location Address or Lot No. (9Pdbt 0 Owner's Name,Address,and Tel.No.
4*1
Assessor's Map/Parcel e1 _& L2V Gf�7vl '707. -- ,6 O6--507-,�
Installer's Name,Address,and Tel.No. 771_ Designer's Name,Address,and Tel.No.
ww om co 0 'may �'�`�`dc,
Type of Building:
Dwelling No.of Bedrooms Lot Size �e S� sq.ft. Garbage Grinder( )
Other Type of Building �(�°-�� No.of Persons 7i Showers(`j ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 O gpd Design flow provided '3 3o gpd
Plan Date �-Z�1- 14 Number of sheets ( Revision Date
Title
Size of Septic Tank rj(J� kL, Type of S.A.S. ✓l/ 2 D(�
Description of Soil 5AN-0 (0%jT /¢
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 p ce the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
t Date j
Application Approved Date
Application Disapproved by Date
for the following reasons
Permit No. B Date Issued
K
No. 6;01`7 /3 �2 '/ ..r Fee
THE COMMONWEAL-T ,OF..MASSACHUSETTS Entered in computer:. Yes
PUBLIC HEALTH DIVISION -TOWN bF BARNSTABLE, MASSACHUSETTS ;
r
Zippfitation for ]Disposal Opstem Construction Permit
Application for a Permit to Construct(LI/Repair( ) Upgrade( ) "Abandon( ) n�clmplete System ❑Individual Components'
Location Address or Lot No. (9 V1 } Owner's Name,Address,and Tel.No. .
Assessor's Map/Parcel 7-s(a (To ��� CAO- 7U2 - '6 Db-50�7�
Installer's Name,Address,and Tel.No. _ 77 I_ Designer's Name,Address,aarrld Tel.No.
1 luN G�'t Ic EA(► 1-J0i
T 7 CO J I +�U W gyARAw x
Type of Building: st
Dwelling No.of Bedrooms 'Lot Size �,�� sq.ft. Garbage Grinder( )
Other Type of Building RC 5 No.of Persons `� Showers(?j ) Cafeteria
Other Fixtures
Design Flow.(min.required) 130 gpd Design flow provided 330 � � = W_ gpd;t
Plan Date + Z-q- Number of sheets Revision Date
Title
Size of Septic Tank 1500 67ftlw, Type of S.A.S. LC—A( fZA" 2
Description of Soil 5mm 1 o ,T
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 ce the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
�Sign ' Date
! /
Application Approved y Date
Application Disapproved by Date
for the following reasons r
r
Permit No. D O Date Issued
. .t
-----------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(✓jam Repaired( ) Upgraded( )
Abandoned( )by J G/�-t 0 W' '1 CA ►11 � C577 X-1 G'�
at A Cgf�%VII W �E�•tA QT� , Wr I Ukbeen constructed in accordance
OF
with the provisions of Title 5 and the for Disposal System Construction Permit Na X11-1 dated
Installer Designer )
#bedrooms ` Approved de sign flow '� / gpd
The issuance of this permit shill not e)construed as a guarantee that the system w' 1 1 tion as�desiygned. Q G
Date / Inspector
C
No.OLU L! / 1 Fee 1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Disposal Opstrm Construction Permit
Permission is hereby granted to Construct( I-< Repair( ) Upgrade( ) Abandon( )
System located at GTh (RAJ4\/I I'L__c 43�k 0)
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction m stt be c mpleted within three years of the date of this pe it.
Date
��J Approved by
3/17/2021 ShowAsbuilt(1700x2200)
TOWN OF BARNSTABLE
LOCATION 6 /�} / t2�4t�t,tLLL` j(f{4—@PAGE# c�0�4�13b
VILLAGEr,aZ-y LA ASSESSOR'S MAP&PARCEL —L 1 1�P�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY r 5� A•CL. fV-/D
LEACHING FACILITY:(t)pe) (size.) c is 4—N-V3-AL..S_.-
NO.OF BEDROOMS 3 , S—ao
OWNER tLk�1F1
PERMIT DATE: S S 14 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility —8 5 Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) ►{ 4 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) _Feet
FURNISHED BY
-d--x h R7
1
https://itsgIdb.town.barnstable.ma.us:8431/Home/ShowAsbuiIt?mp=226120&sq=1 1/1
Town of Barnstable P#
Departinent of Regulatory.Services
Public Health Division Date
200 Main Street,Hyannis MA 02601
' �T4D NV4t .
Date Scheduled Time Fee Pd. 6 �Q
Soil Suitability .Assessment,for jBy:
Nieais s
Performed By: A,4-4! AX(i �G Witnessed
.LOCATION& GENERAAL J"WF01MATION
Location Address (O v �r all v% /�e lea / p� Owner's Nam, ,
t OOI/v2^.. ✓1 6 f (.�- 'T Address
Assessor's Map/Parcel: /�u/ Engineer's Name ( d vjv_
NEW CONSTRUCTION ( REPAIR Telephone# CIS 0 3`d �
Land Use: 20 A, .Vkf�( e.e�7 Slopes 96 40"r1u �
P ( ) Surface Stones
Distance's from: Open Water Body _f< possible Wet Area ft Drinking Water Well _A/+ft
Drainage Way ft Property l,Ine <71 C7 r ft Other
ft
(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands In proximity to holes)
o
Na
4—
Parent material(geologic) Co Depth to Bedrock - 77300./
Depth to Groundwater. Standing Water in Hole: �U�/4. weepingfrotnPItFga¢ 4610/lJ�.
Estimated Seasonal High Groundwater 0'1/�/ -
DETERMINArflON FOR SEASONAL HIGH WATER TABLE
Method Used: ,�
Depth Observed standing in obs.hole: In, Depth to soli mottles: In.
Depth to weeping from side of obs,hole: /� In. Groundwater Adjustment
Index Well# Reading Date: Index Well 1pY,l Adj,factor—Adj.Groundwater Leval—
PERCOLATION T +'tST We ag T n n /
Observation '
Hole# Tlmv at 9"
�• 11
Depth of Pere U Time at 6"
Start Pre-soak Time @ l r V U Tima(9"-0) �—
End Pre-soak Y i v 6
Rate Min./Inch +G 2 UY1
Site Guttabii:ty F.ssessra Ft; site Passes; ✓ Silp Failed: Additional Testing Needed(YIN) �t�
Original: Public Health Division Observation Hole Data To Be Completed on Back----
i
***If percolation test is to be conducted witb.in 100' of wetland,you must first notify the..
Barnstable Conservation Division at least one(I)week prior to beginning.
Q:\S EPTICWI1RCFORM.D O C
r.w
DEEP•OBSERVATION HOLE LOG Hole#
Depth from Soil horizon Soil Texture .Shcl Color Soil• Other
Surface(in.) (USDA) (Munsell) Mottling (Structure, Stones;Boulders.
' o i to �y,96'Gravcll
11: y12 '/z
ZY
2Y-1Zo L /l'!L tj 2, y'/y
I)EEP OBSERVATION,HOLE LOG ,, Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%G ve
ay-/Zv
N6 U-4
](SEEP OBSERVATION ROLE LOG Hole
De pth from Soil Horizon Soil Te
xture
Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure Stoncs,Boulders.
Co i to c G c
DEEP OBSERVATION HOLE LOG Bole#
Depth from Soil Horizon Soil Texture Soil Color Soll Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones''.Boulders,
Cositn 6
' z
I+lood Insurance Rate Map:
Above 500 year flood boundary No— Yes
Within 500 year boundary No Yes
Within 10 .0 year flood boundary No_ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas obstrved throughout the
area proposed for the soil absorption system? ems
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Bnvironm ntal Protection and that the above analysis was performed by me consistent with .
the required training,expertise and experience described in�10 CUR 15.017.
Signatur�f� Dato ZZ Zv0
�7
Q:\SEPT1aPERCP0RM.D0C
TOWN OF BARNSTABLE OP
LOCATION G�'� Ct2s�t G,VI CYZ.G� EYG W-WAGE# 61*- �3(�
VILLAGE hE7 r`Z2vt LL(g-ASSESSOR'S MAP&PARCEL - J jnn
INSTALLER'S NAME&PHONE NO. SOT•` -71=t 3t"
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) X_LL
NO.OF BEDROOMS
OWNER
PERMIT DATE: S `4 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility —4- S Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) 4 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) /_— Feet
FURNISHED BY
F—T , .
000
I I oil
,� /h j-7 G
i
PROFILE
SYSTEM PROF ILE MARKEDSYSTE
WITHC MAGNETIC TTAPEAOR BE
PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. NOTES
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE
2" PEASTONE OR GEOTEXTILE 1. DATUM IS APPROX. NGVD C1fi•a�� O
TOP FOUND. EL. 29.3' FILTER FABRIC OVER STONE
2. MUNICIPAL WATER IS EXISTING
2% SLOPE REQUIRED OVER SYSTEM
MINIMUM .75 OF COVER OVER PRECAST �
3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
PRECAST H-10 BLOCKS OR
RISERS (TYP.) PRECAST RISERS 4. DESIGN LOADING FOR ALL PROPOSED PRECAST
2'0 4"0SCH40 PVC MORTAR ALL 'H-10 UNITS TO BE AASHO H-10
t, PIPES LEVEL 1ST 2' 4' COMPONENTS
• ENDS (TYP.) 4'
*24.96' 10" 1500 GAL H-10 14" SIDES , 24.8' 5. PIPE JOINTS TO BE MADE WATERTIGHT. 9
poa�ao�op o; o Crai dle Beoch Rd.
°°°°°°°T-I
.. o°°°°°°°'
24.56' TEE SEPTIC TANK TEE 24.31 ' o mmm ���� mFnmm � °o °a� 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE
°o°°oo � o � o � 0000 000 � 0000000 0 0 0 0° ° ° .° o•0 6 MIN SUMP' o o ° �a�a�aoaa� aoaMa000aoo °°°°°°°° WITH 310 CMR 15.000 (TITLE 5.)MME
0 0 ° ° ° a O ° o ° ° °°O°O°O°°°°°� 12" MIN. INT. DIM. °°°°°° ooMaMaoaoM a E!lMMMoMoo ,°°°°°°°°GAS BAFFLE:: �_oC,o�o 0 0. c�i ° ° ° °°°°°°°° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND o s °
24.07' 23.9' o0000000 21 .8' NOT TO BE USED FOR LOT LINE STAKING OR ANY
4' LIQ. LEVEL (ACME OR EQUAL) :':
OTHER PURPOSE.
JOO O O OO.O.00.O OOO O O O•O.O O O O O�'t I ]]�� (gyp
°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°° H-20 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. " NajZtZLCAP.t
o°o°0000onon°1Og0000000°000P'o'0O�o„o�o�00000. 3�4"-1-1�2 DOUBLE WASHED STONE4' MIN.
(2) UNITS REQUIRED 8• PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. (�
ALL AROUND PRECAST STRUCTURES 9. COMPONENTS NOT TO BE BACKFILLED OR iJound
6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS To OUTSIDE of STONE: 25.0' X -12:83' CONCEALED WITHOUT INSPECTION BY BOARD OF
COMPACTION. (15.221 [21) 5.0' HEALTH AND PERMISSION OBTAINED FROM BOARD
( 4 % SLOPE) ( 1 % SLOPE) ( 1 % SLOPE) ' OF HEALTH.
10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP
LEACHI
NG
, CALLING DIGSAFE 1-888-344-7233 AND
FOUNDATION- 10 SEPTIC TANK 24 D BOX 12 1s.8 BOTTOM TH 1 & 2 VERIFYING THE LOCATION OF ALL UNDERGROUND & NOT TO SCALE
FACILITY NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL WORK.
ASSESSORS MAP 226 PARCEL 120
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 11. ANY UNSUITABLE MATERIAL ENCOUNTERED
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM SHALL BE REMOVED 5' BENEATH AND AROUND THE
PROPOSED LEACHING FACILITY.
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
r^ ' D AND REMOVED OR PUMPED AND FILLED WITH CLEAN
LEGt Iy SAND.
99- EXISTING CONTOUR
X 99.1 EXIST. SPOT ELEV.
99 PROPOSED CONTOUR SYSTEM DESIGN.
09-9-1 PROPOSED SPOT EL. GARBAGE DISPOSER IS NOT ALLOWED
TH1
TEST HOLE 28.34 DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD
2� SLOPE of GROUND 26.97 USE A 330 GPD DESIGN FLOW
75.00'
-�'� 2n74498
UTILITY POLE 2 SEPTIC TANK: 330 GPD ( )
= 660
2 834 \
j
w .0 e. ._,::_ -.- _.. _ >__ 1;5c A 1500 _GAL. xr IiL 'if�IVFf
FIRE H.DRANT I \ `\ ' 7,500 Sq. Ft b
NOTE NOT ALL SrABOLS MAY APPEAR IN DRAWING X 28-62--
G G r__,. LEACHING:
26.56
X z 2g SIDES: 2 25 + 12.83 2 74 - 112 GPD
'28.35 C ( ) ( ) -
TEST HOLE LOGS 2; 028.55
X 17 6�� BOTTOM 25 x 12.83 (.74) = 237 GPD
TOTAL: 472 S.F. 349 GPD
ENGINEER: ARNE H. OJALA, PE, SE � 36 25.86 _
DONNA MIORANDI, IRS V, 28,31 / USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
WITNESS: w \ WITH 4 STONE ALL AROUND
DATE: 10/22/13CD
< 2 MIN/INCH 0 1 , 2 0.30
PERC. RATE _ , IL-_ o X 28.50 110
ry CLASS I SOILS P# 14159 o
#torsi81 _ W NOTE: SEPTIC TANK
28 25.04 IS NOT SUITABLE
ELEV. ELEV. X 27.89 \ X 27.8 i� FOR VEHICLE
X .64 / LOADING
26.8' 0„ `�% 26.8' 27 X 27 _O O 24.72
PROPOSED WATER _M A.
X 27.59 \ LINE MIN. 10' FROM APPROVED DATE BOARD OF HEALTH
A A 11.2' X 12 ALL SEPTIC
1
LS LS COMPONENTS
27.21 27.81 X 27 7 \ 100 a 1tE�'S 25.5 \ g EXIST. SHED TO BE
1 OYR 4/2 1 OYR 4/2 / r 2 .52 REMOVED TITLESITE PLAN
» » � 5
X .8
8 8 � 57 \ ?�7.1 � R 5
> TH:11 _ .1 OF
5 78 . _
B B 670 �' 4.09
/ X
LS LS 2 \ (D -
9 25700' ` X?5.18 680 CRAIGVILLE BEACH ROAD
2.5Y 5/4 2.5Y 5/4 4.8
24„ 24.8, 24» 24.8 25 j = 24.40 \ CENTERVILLE
23.66 \
BENUH MARK - TAG BOLT #1704 PREPARED FOR
ON HYDRANT. ELEVATION = 27.2 PROP. DRIVE.
C \ \ M/M RICHARD GREEN
CRAIGVILLE BEACH EACH ROAD
/ NOVEMBER 27, 2013
MCS MCS
wc.REV. ar-
APRIL 29 2014 she.
J
2.5Y 7/4 2.5Y 7/4 45.95 23.67 Fes,
: F?sN° \ �N of yAss� off 508-362-4541
DAR1'.CLA. ti�s�, Sro�' DAi'aIEL rk: fax 508-362-9880
s OJt �1 o downcope.com
o ;o A.
°I U, down cope engineering, inC.
120" 16.8' 120" 16.8' � No. �6�02 l� rao. e °D ���'°
o� ciST �� ��Fss�a`aP " C/V/l engineers
NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 land surveyors
939 Main Street ( Rte 6A)
0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675
> 3- 198
I