HomeMy WebLinkAbout0053 CROSBY CIRCLE - Health 53 G ros �r
Centerville P =4
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ODIFUJULL NO. 1521/3 0RA
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° Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out '
forms on the 314bl3L
computer, use 1. Inspector:
only the tab key
to move your Carmen E Shay
cursor-do not Name of Inspector
use the return
key. Shay Environmental Services, Inc.
Company Name
rae 185 Ashumet Road
Company Address
Mashpee MA 02649
erwn City/Town State Zip Code ,
508-539-7966 3080
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 ingpection!!�T;he inslpection
was performed based on my training and experience in the proper function and mpintena. of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to SectiorE15.340,of
Title 5 (310 CMR 15.000). The system: :� .
=t CD
® Passes ❑ Conditionally Passes ❑ F : a., gs
Fq
❑ Needs Further Evaluation by the Local Approving Authority
CAR
4/3/09 a SH
Inspector's Signature Date
�,,ns trar��•
The system inspector shall submit a copy of this inspection report to the A�pp;cw 1 ority (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.
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/ always complete all of Section D
A) System Passes:
® 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:
Overflow leach pit has No Liquid. 3' Stainline noted, primary ccesspool level equal with outlet invert.
3' effective depth available in overflow pit.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank.is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-e
a, p 53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 5b feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is Centerville MA 02601 4/3/09
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*` This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria 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 1/2 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.
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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-
10,000g pd.
❑ ® 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 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
M regional office of the Department.
53 Crosby Circle,Centerville-Front•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
I
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle- FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® ❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue.
approximation of distance is unacceptable) [310 CMR 15.302(5)]
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
I
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle- FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is
required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 440 GPD Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: Currently
Unoccupied
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 2005-28,000 Gal
g ( y g (gpd)): 2006 -25,000 gal
Sump pump? ❑ Yes ® No
Last date of occupancy: 4/07Date
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:
Last date of occupancy/use: Date
Other(describe):
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Board of Health
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):
Approximate age of all components, date installed (if known) and source of information:
1980's- per homeowner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer (locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leaks, plumbing properly vented
Septic Tank (locate on site plan):
Depth below grade: 1.5feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every 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.):
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.):
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):
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
No D-Box Present
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.):
No D-Box Present
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
53 CrosbyCircle Centerville-Front•03108 Title 5 Official Inspection Form' rf 0Subsurface Sewage Disposal System•Page 11 of 15
7
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
lSubsurface Sewage Disposal System Form - Not for Voluntary Assessments
a,e' 53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number:
2 -6'diam x 6' D
❑ 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.):
SAS fuctioning properly, 1' liquid in overflow. 5' effective depth available. Primary liquid level equal
with outlet invert. Both covers are 18" below grade
I
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
E
ASV 53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth —top of liquid to inlet invert 101,
Depth of solids layer 5.5'
Depth of scum layer None
Dimensions of cesspool 6' x 6'
Materials of construction Cement Block
Indication of groundwater inflow ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
No evidence of hydraulic failure. Cesspool acting as a septic tank with an overflow leach pit.
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.):
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
8 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner — -------- - --.._
Owner's Name
information is required for Centerville MA 02601 _ _4/3/09
_
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.
CROSBY CIRCLE
Overflow
0 Swim Ties:
C A- Cesspool—25.
fZ f3- Cesspool—22'
O
S Cesspool Acting s A
B A —Leach Pit-38
Y B— Leach Pit—26'
C
I
F�
C
L
L Exist House
.,. 10
53 Crosby Circle,Centerville-Front.03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
' Commonwealth of Massachusetts
WQ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
53 Crosby Circle - FRONT SYSTEM
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every 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: 15+ feet
feet-
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Inspector has performed engineering design and perc test on this street.
53 Crosby Circle,Centerville-Front•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Per USGS MAP PLATE 2:
` Illev. of'Ground =50 Feet
Elev. Of Groundwater=5 Feet
Elev. Of Bottom of Leach Pit 41 Feet
Therefore: 41 —5 =36 feet separation between Bottom of Leach Pit and Groundwater.
Groundwater Adjustment using Index Well MIW-29 : 1.6 feet
Adjusted Groundwater Separation =36' —6.6=29.44 feet between bottom of Overt'low and adi. groundwater
Grade= Elev. 50 feet
Overflow
Cesspool
Bottom of Overflow= Elev. 41 feet
Adj. Groundwater= 61ev. 6.6
9 _
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle — RRCC
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms ma
y not be altered In any
way.
Important:When filling out A. General Information forms on the S14,5431
computer, use 1. InSpeCtOr:
only the tab key
to move your Carmen E Shay
cursor-do not Name of Inspector
use the return
key. Shay Environmental Services, Inc.
Company Name
ab 185 Ashumet Road
Company Address
Mashpee MA 02649
remm City/Town State Zip Code
508-539-7966 3080
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
0
❑ Needs Further Evaluation by the Local Approving Authority
P 1-
4/3/09 l
Inspect ' ignature Date C
C:, t—
r
The system inspector shall submit a copy of this inspection report to the Approvin Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a s ared 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.
L-bi
53 Crosby Circle,Centervilee-Rear•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
— W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
\a 53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
leach pit has No liquid.,4' stain line noted. 2 foot effective depth available
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
r
' -\
Commonwealth of Massachusetts
-f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V` 53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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.
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
I
Commonwealth of Massachusetts
— W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
`*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria 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 '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy Is within 100 feet of a surface water supply or
tributary to a surface water supply.
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
— W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
\a /p 53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
\a /p 53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® ❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5))
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
— W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
\a 53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 440 GPD Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: None
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 4/07
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:
Last date of occupancy/use: Date
Other(describe):
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is
required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Board of Health
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):
Approximate age of all components, date installed (if known) and source of information:
1995-BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leaks, plumbing properly vented
Septic Tank (locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,000 gallon tank
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
5' x8' x5'
Sludge depth:
4' - no notable sludge
Distance from top of sludge to bottom of outlet tee or baffle 48
Scum thickness 0
11
Distance from top of scum to top of outlet tee or baffle 4
Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined? Measured
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every 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.):
inlet and outlet baffle/Tee in good condition - no evidence of exfiltration or infiltation
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.):
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):
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert D-Box Not Present
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 6'diam x 6' D
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS fuctioning properly, no liquid in leach pit. 2' effective depth available. Cover is 3.5' below grade.
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
layer
Depth of scum la
p Y
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
�= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e
53 Crosby Circle
Property Address
Robert Shack
Owner Owner's Name
information is required for Centerville MA 02601 4/3/09
every 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: 15+ feet
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Inspector has performed engineering design and perc test on this street.
53 Crosby Circle,Centervilee-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
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Commonwealth ofMassachusetts
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information is
required for Centerville MA 02801 4/3/09
every page. u»'/vwo State Zip Code Date of Inspectiori
SystemD.
(cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
k> a1]easttwo permanent reference landmarks orbenchmarks. Locate all wells within 100 feet.
Locate whore public water supply enters the building.
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Per USGS MAP PLATE 2:
Elev. of Ground =50 feet
'Elev. Of Groundwater= 5 Feet
Llev. Of bottom of Leach Pit 41 Feet
Therefore: 41 —5 = 36 feet separation between Bottom of Leach Pit and Groundwater.
Groundwater Adjustment using Index Well MIW-29 : 1.6 feet
Adjusted Groundwater Separation = 36' —6.6 =29.44 feet between bottom of Overflow rind ad'. �roundwafer
Grade = Elev. 50 feet
Overflow
Cesspool
Bottom of Overflow= Elev. 4 1 feet
Adj. Groundwater = Elev. 6.6
Sys
TOWN OF BARNSTABLE PIQOX-
LOCATION ?j cm-- i� caci E3 SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL j 813-COS
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY 1 M6 C`aQNkc A 5 'A B ` XS'
LEACHING FACILITY: (type) _X l¢ (size)
NO.OF BEDROOMS 13 LJ 5
OWNERr� 'Shack
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility gq + Feet
Private Water Supply Well and Leaching Facility(If any wells exist
.on site or within 200 feet of leaching facili ) Feet
Edge of Wetland and Leaching Facili ( y e I exist
within 300 feet of leaching facili Feet
FURNISHED BY
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
+ d DEPARTMENT OF ENVIRONMENTAL PROTECTION
�1M Sae
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION �7
Property Address: #53 Crosby Circle
Centerville,MA
Owner's Name: Robert Shack A �g
r'
Owner's Address: 208 Meadow Wood Road
Holden,MA 01520 E
Date of Inspection: 04/30/07 VO r
Name of Inspector: (please print) Mr.Carmen E. Shay ra
Company Name: Shay Environmental Services,Inc. y
Mailing Address: 185 Ashumet Road r
Mashpee,MA 02649 r
Telephone Number: (508)-548-0796
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on rJy,;:wry
training and experience in the proper function and maintenance of on site sewage disposal systems. I am ;,'
approved system inspector pursuant to Section 15.340 of Title 5 310 CMR 15.000 . The system:
n 'rQ�����s��,�`'
PP Y P P ( ) Y
XX Passes E.
onditionally Passes o SHAY v
e urther Evaluation by the Local Approving Authori` o
Fa s QTIF-\
`FS INSPE�
Inspector's Signature: Date: 04/30/07
The system inspector shall submit a copy of this inspeca report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
Cesspool Acting as a Septic Tank with an Overflow Leach Pit.
Liquid Level in Leach Pit meets the required inspection criteria for Title V. No Liquid
observed in pit. Stain line observed at 3'. 3 Effective Sidewall Available.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: #53 Crosby Circle
Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
XX I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #53 Crosby Circle
_ Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #53 Crosby Circle
Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X__ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: #53 Crosby Circle
Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
XX _ Pumping information was provided by the owner,occupant,or Board of Health
XX Were any of the system components pumped out in the previous two weeks?
XX Has the system received normal flows in the previous two week period`?
XX Have large volumes of water been introduced to the system recently or as part of this inspection?
XX Were as built plans of the system obtained and examined?(If they were not available note as N/A)
XX _ Was the facility or dwelling inspected for signs of sewage back up?
XX _ Was the site inspected for signs of break out?
XX _ Were all system components,excluding the SAS, located on site'?
XX _ 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?
XX _ 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
XX _ Existing information. For example,a plan at the Board of Health.
XX _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: #53 Crosby Circle
Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
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):
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): 2005—28,000 Gal. 2006—25,000 gal.
Sump pump(yes or no): No
Last date of occupancy: Currently Unoccupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unknown
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
XX Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Leach Pit installed in 1980's- per Homeowners&BOH Records
Were sewage odors detected when arriving at the site(yes or no): No
•Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #53 Crosby Circle
Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
BUILDING SEWER(locate on site plan)
Depth below grade: 20"
Materials of construction: cast iron XX 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: _(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:,
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
. •Page 8of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #53 Crosby Circle
Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
•Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #53 Crosby Circle
Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
1 leaching pits,number: 6' diam by 6' deep Overflow Leach Pit
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation. Probed stone around SAS
with a 6' probe with no evidence of hvdraulic failure noted. Inspection inside Cesspool revealed no standing
water. 3' stain line observed.
CESSPOOLS: 1—ACTING AS SEPTIC TANK (cesspool must be pumped as part of inspection)(locate on site
plan)
Number and configuration: 1_
Depth—top of liquid to inlet invert: No liquid—cesspool was dry from non occupancy.
Depth of solids layer: 5.5
Depth of scum layer: No scum
Dimensions of cesspool: 6' x 6'
Materials of construction: Cement Block
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Stain lin indicated liquid level equal with outlet tee invert and overflows into overflow Properly_
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.):
r .,, 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #53 Crosby Circle
Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
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.
CROSBY CIRCLE
Overflow
0 Swim Ties:
C A- Cesspool—25.'
R O B- Cesspool—22'
S Cesspool Actin s A
B A—Leach Pit-38
Y B—Leach Pit—26'
C
I
R
C
L
E Exist House
. ., . . r .„.,. 10
4
a Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #53 Crosby Circle
Centerville,MA
Owner: Robert Shack
Date of Inspection: 04/30/07
SITE EXAM
Slope
Surface water -'/4 to''/2 mile+/-
Check cellar -Yes
Shallow wells—None
Estimated depth to ground water 15+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
XX 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)
XX Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Inspector has performed perc tests in area.
Per USGS MAP PLATE 2:
Elev.of Ground=50 Feet
Elev.Of Groundwater=5 Feet
Elev.Of Bottom of Leach Pit 41 Feet
Therefore: 41 —5 =36 feet separation between Bottom of Leach Pit and Groundwater.
Groundwater Adjustment using Index Well MIW-29 : 1.6 feet
Adjusted Groundwater Separation=36'—6.6=29.44 feet between bottom of Overflow and ad*.groundwater
Grade=Elev. 50 feet
Overflow
Cesspool
Bottom of Overflow=Elev.41 feet
Adj. Groundwater=Elev. 6.6
�l
TOWN OF BARNSTABLE
IL nIYCI4--.ilON _ 3 cbsb� �e.e�.E SEWAGE # 8 -S4la
ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. �' P, N\o1CG2c11�c- 4
SEPTIC TANK CAPACITY C S7a�\ A •r� �S���
LEACHING FACILITY: (type) o �p `���F (size) X w�
NO. OF BEDROOMS
BUILDER OR OWNER ��
PERMITDATE: 9-PCT COMPLIANCE DATE:
Separation Distance Between the: a 9+
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist �,11
on site or within 200 fe of leaching facility) W I iA Feet
Edge of Wetland and chi4g Facility(If elands exist (� Feet
witx"in 300 feet of 1 aching facility)
Furnished by r2lctr�.
�---
T
i ...
P � `r 9
(D `�
_•/
��-{
O'
- �J V1
V
� o
a
��� qsv�
A
A
DATE :10/21 /02
PROPERTY ADDRESS : 5_3 C_ro_sby__C_i_r_c_le________
Centerville,Mass.
------------------------ e
02632
RECEIVED
On the above date, I inspected the septic system at the above address.
This system consists of the following: OCT 3 12002
1 . 1 -1000 gallon septic tank.
F BAnNSTABLE
2. 1 -1 000 gallon leaching pit. T�WHEALTH DEPT.
3. 1 -6 'X6 ' Block cesspool & 1 -1000 gallon precast leaching pit as an
ovf tom
96sed on my inspection, I certify the following conditions:
4. This is a split sytem.
5. .Th6:-:tank & pit are in proper working order at the present time.
The leaching pit is presently dry.
6 . Rea system is in proper working order at the present time.
Pumped main cesspool .The overflow leaching pit is presently dry.
7. Pumped maIN CESSPOOL at time of inspection.The cesspool is structurally
sound and shows no evidence of water intrusion.
�. The complete system is in proper
working order at the present time.SIGNATUR :
Name : J . P . Macomber Jr .
COrlipany : JoserDh p__ Macomber & Son , Inc .
Address : BQx _E�-----__----_-
__ _ba-_Q-2_632-0066
Phon = 775- 3338
_y.----------------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville. MA 02632 0066
775.3338 775.6412
\ COMNIO',WE.ALTH OF NLkSSACHUSETTS
EXECUTIVE OF ICE OF ENVIRONMENTAL AFFAIRS
DEP:sx'.'I'ME�IT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL. INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:53 Crosby Circle
Centerville,_Mass.
Owner's Name: Bob Shack
Owner's Address: 208 Meadow W
n
Date of Inspection: 10/21 /02
Name of inspector: (please print) Joseph P. Macomber Jr.
Compan' Name: J .P . Macomber & Sons Inc
Mailing Address: Box 66
CPntPrvillP Ma 02632
Telephone Number: 508-775-3338 _
CERTIFICATION STATEMENT
I cenif that I have persona!Iv Inspected '_hc se`..age disposal system at this address and that the information reported
below is true. accurate and complete as oq the time of the inspection. The inspection was performed based on my
;Taming and experience in ;he proper �unct,on and maintenance of on site sewage disposal systems. I am a DEP
appro,,ed system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000), The system:
t~ " Ccndmonall Passes
_ :Weeds Further Evaluation by the Local Approving Authoriry
_ Is
Inspector's Signature&' W =- �� Date;
The system inspector shall of this inspection report to the Approving Authority(Board of Health or
DEP) within 30 days of coripleting C-^is nspecuon: 1f the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the systrtn owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to in,- 5�stem owner and copies sent to the buyer, if applicable, and the approving
auihoriry.
Notes and Comments
'This repon only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address l:o�+7e system will perform in the future under the same or different L
conditions of use.
Title 5 Inspection Form 6!! 5/2000 page I
*4:,i
Page 2 of 1 1
,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 53 Crosby Circle
Centerville,Mass .
Owner:Bob Shack
Date of Inspection: 10/21 /0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. =stemPasses:
NO I have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The two systemg are in proper working order at
the present time.
B. System Conditionally Passes:
NO 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.
No_ rhe septic tartl issd 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. v
ND explain:
NON .Observation of sewage backup or break out or high static water level in the 'stribution bo due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
PTO The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I I
. r
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:53 Crosby Circle
rPntarvill A Mc1.SG
Owner: Bob Shack
Date of Inspection: 1 0/21 /02
C. Further Evaluation is Required by the Board of Health:
No 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:
Ng Cesspool or privy is within 50 feet of a surface water
D�Q Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
?. 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:
NO-- The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or rributary to a surface water supply.
NO— The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
NCr The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
NO The system has a septic tan} 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 Visual
•'This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are Triggered. A copy of the analysis must be attached to this form.
3. Other:
This home has a split syste. 1 -1000 gallon septic tank
and 1 -1000 gallon precast leaching pit (Right side)
1 -6 'X6 ' block cesspool and a 1000 gallon precast leaching pit
as an overflow. ( Rear)
3
Paee a of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:53 Crosby Circle
CentPrvilIP.,Mass
Owner:Bob Shack
Date of Inspection: 1 0/21 /02
D. System Failure Criteria applicable to all systems:
You must indicate eyes" or "no" to each of the following for all inspections;
Yes No
_ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_: Discharee or ponding of effluent to the surface of the ground or surface waters due to an overloaded or j
clogged SAS or cesspool
4._ .f�G��Staiic liquid level in the disrribuuon box above outlet inven due to an overloaded or clogged SAS or
,,,Cesspool
_ iquid depth in cesspool is less than 6" below inven or available volume is less than '/, day now
Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e
of timespumped
gg p p (s). Number
,<
ny ponion of the SAS, cesspool or privy is below high ground water elevation.
An) ponion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
y ponion of a cesspool or privy is within a Zone I of a public well.
ponion of a cesspool or privy- is within 50 feet of a private water supply well.
!4 And ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supplN, well with no acceptable water quality analysis. (ibis system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Yes No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be.necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no. JJ
/�lhe system is within 400 feet of a surface drinking water supply
4 the system is within 200 feet of a tributary to a surface drinking water supply
4e system is located in a nirrogen sensitive area (Interim Wellhead Protection Area— 1WPA)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
"ves" 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 3 10 CMR
15 304 The system owner should contact the appropriate regional office of the Department.
4
Page S of
OFFIUs OINPE ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM SPECION FORM
PART B
CHECKLIST
Property Address: 53 Crosby C'i r-cJ 0
CantPrvi 1 1 c nn
Owner: Bob Rharlc_—
Date of IDspeetioD:
Check tf the following have been done. You must indicate —,Ts.' or..no,, as to each of the following:
Yes 'so
Zpurnp,ng information was provided by the owner, occupant, or Board of Health
—ZV'ere and of the system components pumped out in the previous two weeks ".
Has the system received normal (lows in the previous two week period '.
r
j/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
f/ 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
eft^e baffles or tees. material of construction, dimensions, depth of liquid, depth of sludge and depth of scum
Was the facility owner (and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System (SAS) on the site has been determined based on
Yes 0
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 53 Crosby Circle
Centerville,Mass .
Owner:Bob Shack
Date of Inspection: 10 /21 /0 2
FLOW CONDITIONS
RESIDENTIAL
0 Q Number of bedrooms(design): ' Number of bedrooms(actual):
i!- DESIGN flow based on 310 CMRR 15.203 (for example: 110 gpd x # of bedrooms): OV6
Number of current residents:
Does residence have a garbage grinder(yes or no):/—�s
Is laundry on a separate sewage system yes or no):,!.�-L (if yes separate inspection required)
Laundry system inspected yes or no):
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage (gpd)): 2000-71 , 000 gal lons=1 94. 52 GPD
Sump pump(yes or no):itlG 2001 —83, 000 gallons=227. 40 GPD
Last date of occupancy: .s71ri4
COMM ERCIAL[INDUSTRIA L
Type of establishment: �19
Design flow(based on 310 CMR 15.203): gpd
Basis of design Flow(seats/persons/sgft,etc.): ti
Grease trap present(yes or no):
Industrial waste holding tank present (yes or no): 4y
Non-sanitary waste discharged to the Title 5 system (yes or no):AO
Water meter readings, if available: 'e,o
Last date of occupancy/use: zb)
OTHER(describe): 2!�4
. GENERAL INFORMATION
Pumping Records _� r
Source of information:
Was system pumped as pan of the inspection (yes or no):
If yes, volume pumped: 0 gallons -- How was quantity pumped determined? xri9
Reason for pumping:
TYPE OF SYSTEM
dLO Septic tank, distribution box, soil absorption system
Single cesspool
�Overflowseel�/G7�l���r
OPrivy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
,VP Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
,11epTight tank iUQ Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Cesspool is 35-40 years old and the leaching pit is 10-15
years lod. �l
Were sewage odors detected when arriving at the site (yes or no):
6
r
Page 7ofII
44'
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 53 Crosby Circle
C•Pri ryille,Mass.
Owner: Roh Shank
Date of Inspection: 1-9 /�Tga
#1 4" Orangeberg pipe
BUILDING SEWER(locate on site plan) through out.
#2 Orangeberg has been
Depth below grade: 24" replaced with
Materials of consmructiorXX cast iron3{M40 PVCXX other(explain): NA Sch. 40 4" PVC pipe
Distance from private water supply well or suction liner 1 .j. and fittings.
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight No evidence of leakage The systems
are vented through the house vents.
SEPTIC TANK_(locate on site plan) 1 000 gallons
Depth below grade: 18
Material of consrmctionXX concreiNA metal NO fiberglasNO polyethylene
NO other(explain) NA
If tank is metal list age: NC) Is age confirmed by a Certificate of Compliance (yes or no)Uo_(attach a copy of
certificate)
Dimensions: 8 ' 6" long 4 ' 1 0" Wide 5 ' 7" High
Sludge depth3"
Distance from top of sludge to bottom of outlet tee or baffle:3
Scum thickness: 2 11
Distance from top of scum to top of outlet tee or baffle: A 11
Distance from bosom of scum to bottom of outlet tee or baffle: 1 0"
How;were dimensions determined:MPa c„rPrl
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Pump the septic tank annually arhage dispnGal is nrPsent Tnlet
and nutl et tees are in P1 are rrhn +--nnik i s ctr�ir•tiira 1 1 y cr%iinr1 d
shows no evidence of leakage.The liquid level at the outlet invert
fifty one inches.
GREASE TRAP: _(locate on site plan)
Depth below grade: None
Material of constructionNA concretNA metalNA fiberglass NA_polyethylenq[A_other
(explain):Grease trap is not present
Dimensions: NA
Scum thickness: NA
Distance from top of scum to top of outlet tee or baffleN
Distance from bonom of scum to bottom of outlet tee or baffle: 1ZA
Date of last pumping: NA
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present
7
Page 8 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ress:53 Crosby Circle
Centerville,Mass.
Owner:gQh Shack
Date of Inspection: 1 o/21 o 2
TIGHT or HOLDING TANK-"k'(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: ,ZIA
Material of construction: concrete AL4 metal 10 fiberglass olyethylene,_ other(explain):
Dimensions: _ l
Capacity: Xlt gallons
Design Flow: '4X gallons/day
Alarm present(yes or no):
Alarm level: A)/) Alarm in working order(yes or no):
Date of last pumping: A
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present
DISTRIBUTION BO tJe. (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Di*_s_t-ri hilt i nn hnx is nnt- nrP4Pnt
PUMP CHAMBER 2j- (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): _,&2fj
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Piim Lrhamhar i -q not nracAnt
z
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:53 Crosby Circle
Centerville,Mass.
Owner: Bob Shack
Date of inspection:121 /0 2
SOIL ABSORPTION SYSTEM (SAS): ovate on site elan, excavation not required)
1 -6 X8 block cesspool & 1000 gallon precast leaching pit 6 ' X10 '
These are in series.
If SAS not located explain why:
Located; See page 10
Type/f /
leaching pits, number:
_Vbleaching chambers, number:
leaching galleries, number: _Q
leaching trenches, number, length:
leaching fields, number, dimensions: (�
A�8 overflow cesspool, number: O
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.):
_Loamy sand to medium fine sand No signs of hydraulic failure or
ondin . Soils are dr .Ve etation is norma e overflow ITNUnlmu pit
is presently dry.The stain line is 6 up from the o om o e pit.
( 66" belo the invert pipe. )
CESSPOOL.': (cesspooL
g ust be Wn2e part of inspection)(locate on site plan)
Numbcr and configuration:.
Depth'top of liquid to Lnlet
Depth of solids layer:
Depth of scum laver: IX
�G�
Dimensions of cesspool: l
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
n cess ool shows no signs of hydraulic failure.Waste wa er
overt i e The cesspool is struct a ou
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.):
Priyy ;_a. nnt- present-
9
tt��of �3ia
86/Z/6 pastnaz
Fk�k �j Handles bath
1 �
Handles grey water
and a bath .
oo diddnt jlttM ollQnd lllyh� ltfo01) ,OOI l
�MIM fIIIM 11f001
.�!e t OVaI UIjgjlj lutUf Wlld OM1 ttfll tf O_t 1p�1 fPci��
(ltnoy o1u1 low ID � S
Page l I of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:53 Crosby Circle
Cen yi 1 1 Pf Mass _
Owner: Bnh Shark
Date of inspection: 1121 /c)2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water io 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: NA
yFS Observed site(abutting property/observation hole within 150 feet of SAS)
pro_Checked with local Board of Health-explain: NA
YES Checked with local excavators, installers- (attach documentation)
y SAccessed USGS database-explain: http; //town barnstable,ma. us .
You must describe how you established the high ground water elevation:
Used: Gahrety & Miller Model. ! 2/16/94 Ground water elevations above sea level.
Used: USGS; Observation well data. June 1992
Used; USGS; Technical bulletin 92-000-1 Plate #2 January 1992 Annual ranges
of around water elevations
ruuna
Leaching �l
Pit C� ,,-eet
�✓yd �
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet.
ll
1'UNN OF Barnstable
Il()ARU OF HEALTH
0 SUIISURFACR SF;KA(;E D1SR)SAL SYSTF,M IN9I'F.CTION FORM - PART D - CERTIFICATION
•••-•••�T•••..'.t-�.1,:��.T.T..�`n•�T'i�iT.TTii]-rrT.l-1'.T`-•.'1^1�T'�tYlTTlr"T1'TCAYT Si-i.'fiR'!i"T+1RLT4
•. fn^ntnrrnraev*T�rr-.•.—.rrr• --�. .-.
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS53 Crosby Circle Centerville,Mass.
ASSESSORS MAP , DLOCK AND PARCEL
OWNER ' s NAME Bob shack '
PA1?7' D - CERTIFICATICS I
NAME OF INSPECTOR Joseph P. Macomber Jr
COMPANY NAME Joseph P. Macomber &' ion Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street Town or City Stat• ZIP
COMPANY TELEPHONE ( 508 ) 775-3338 FAX ( 508 ) 790-1.578
CERTIFICATION STATEMCNT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of - inspection , The inspection was performed and any
reco,ninendations i,egarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
Systeln PASSED `
The inspection tfhich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED$
The inspection which I htive conducted has found that the system fails to
, protect the public health and the environment in accordance with Title
5 , :1.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
IInspector Signatur Date
copy of this ert.ification must be provided to the OWNER, the BUYER
One
where applicable ) and the HOARD OF HEAL'1'11 ,
• If the inspection FAILED , thZ: owner or "operator shall upgrado ' the eyetem
within one year or the date of the inspection , unless allowed or required
otherwise as provided in 3.10 ChiR 16 . 305 ,
partd - doc
SEWAGE INSPECTIONS _
LOCATION 53 Crosby Circle DATE 10/21 ,/0?.
VILLAGE Centerville,Mass. ASSESSOR'S MAP & LOT
-INS)?ECTOR Joseph P.Maw mber Jr.
SEPTIC TANK CAPACITY None 1 -6 'X8 ' block cesspool
LEACHING FACILITY: (type)1 -1 000 gallon LP (sizc) 1 500 gls.
NO. OF BEDROOMS 3
BUILDER OR OWNER Bob Shack
OWNER MAILING ADDRESS
208 Meadow Wood Drive-
Holden Mass.
01 520
i
'S'3 Crasb L"•�rc�C lGh-t'crv�'�lSz
p
vl
1
DATE:8/16/99--_—
PROPERTY ADDRESS: 53_.Crosby_Circle ____
Centeryille ,Mass .
------------------------
02632
� 0-0
S
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . This is a split system.
2 . 1-1000 gallon septic tank.
3 . 1-1000 gallon precast leaching ..pit .
4 . 1-1-6 ' x8 ' block c ss Poo wi h a 10o g 11.on it as n overflow,
Based on my inspection, certify t�e lollowir�g condi ons:
5 . This is a title five . septic system. ( 78 Codes ) 1
6 . The septic system has one broken pipe . Thisi een agreed to
to be repaired . ( Replaced )
Z . Other than this slight problem. The septic system is in working order
at the present time .
SIGNATURE: f J.
Name:_,�, _ Macomber Jr-___—__ 8 g f
Company: Jose2h_P. Macomber_& Son , Inc .
Address: Box 66
G 2 -
Centerville , Ma ._02632-0066 to r0ftor 3 19g�
Phone: 508_775=3338 A f
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds '
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
•
COMMONWEALTH OF MASS"ACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.6500
7R LTD Y CC
Secret
ARGEO PAUL CELLUCCI DAVIT) B. STRL
Governor commis-sicSUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CERTIFICATION
ProqeMAd&*s.s: 53 Crosby Circle Namw of owrser Robert Shack
Centerville ,Mass . 02632 Addio"ofowner: 208 Meadow W400d Pr; ve
oat. oflrupe<o«,: 8716/99 O1den ,Mass . 01520
Name of Irupector:(Plea.:.Prim) Joseph P.Macomber J r .
I am a DEP oved system inspector p"rwarrt to Section 15.340 of Tide 5 (310 CMR 15.000)
company N..T.: J.P.Macomber,. & Son Inc .
Ma&1sgAddraas: $oX 66 Centerville-,Mass _ 02632
Tale0wn,e Numb,": 5��-77 5—3-23 8
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:
Passes
Conditionally Passes
_ Needs Further Evaluation By the Loc I Approving Authority
_ Fails
4tspector's Signature: !!� Data:oft
^� /
The System inspector shall submit a copy of this lnspntion report to the Approving Authority (Board of Health or DEP)wrthin thirty (30) days o
completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greeter, the Inspector and the system own.
'shall submit the report to the appropriate regional office of the Department oKnvironmental Protection. The original should be sent to trss
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
V
l
revised 9/2/98 PagrIof11
t� f noted on 0.ecyeled Paps,
SUBSURFACE SEWAGE DISPOSAL SYSTEM QJ°skcTiON FORM
PART A
CERTIFICATION (corrtirwed)
Property Address: 53 Crosby Circle Centerville ,Mass .
Owner: Robert Shack
Date of kupectkm:8/1 6/9 9
WSPECTiON SUMMARY: Check A, B, C, or A
A. SYSTEM PASSES:
1 have not found any Information which indicates that any of the failure conditions described in 310 CMR 1fi.303 exist. Any failure
criteria not evalusted are Indicated below. .
coMMENTs: Line from the Gent; r tank tn_the 1 eaching pit has
to replace this line.
B. SYSTW CONDMONALLY PASSES:
.NV 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.
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,unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance (attached)Indicating that the tank was installed within twenty(20) years prior to the date of the Inspection; or
the septic tank, whether or not metal, Is 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 complying septic tank as
approved by the Board of Health.
--ten
/�/ 9 Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. :?he system will pass Inspection if(with approval of the Board of
Health).
broken pipes) are replaced
obstruction Is removed
distribution box is levelled or replaced
The system required pumphig-name thawfourtimes wyeardue to broken or obstructed pipe(s). The vystem wiii-par--
inspection If(with approval of the Board of Health): -
broken pipes) are'replaced
obstruction is removed
revised 9/2/98 page zorii '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 53 Crosby Circle Ceri'terville ,Mass .
Owner: Robert Shack
Data of Inspection: 8/16/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
AConditions 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING W A MANNER WMCH..WILL.PRQTECT THE PUBLIC HEALTIL AND SAFETY AND THE EN[1 MONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
A The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
C} SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC+1➢ON FORM
PART A
CERTIFICATION(continued)
Property Address: 53 Crosby Circle Centerville ,Mass .
Owner: Robert Shack
Data of Inspection: 8/16/9 9
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described 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.
Yes No i
"oraYsterr+component dusgo an overloaded orclagged S01S or ceaspoot.
Backup of-eewage intofecility y—
_ I' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
,VcW Static liquid level in� n 4tion b�%bbove 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).
Number of times pumped 0L.
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 I 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
Zr-coiiform bacteria, volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
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:
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:
Yes No
the system is within 400 feet of a surface drinking water supply
the system-is-witWn 200 feet of-&-ogmtery4oa4urfa0"4nkiP91WatW-#u19101Y
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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further Information.
revised 9/2/98 Page 4of11
f
1
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPL;CTION FORM
PART B
CHECKLIST
P,rpeortyAddr.:53 Crosby Circle Centerville ,Mass .
Owner: Robert Shack
Date of Inspect— 8/1 6/9 9
Check if the following have been done:You must indicate either"Yes" or "No" as to each of the following:
Yes No/+
Pumping information was provided by the owner, occupant, or Board of Health.
Z •None of the system�compowents kwwJwan pusnped4esuaRJeast twoawee"aadthe'system hasbeeowceivingrarArrsal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,somluding the Soil Absorption System,"have been located on the site.
_ 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.
The size and location of the Soil Absorption System orrthe site has been determined based on:
Je/ _ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(15.302(3)(b))
The facility owner.(and.ocrilpauts.if different from o)Amer),weraprn,idad.wtth r_sMA*oann rho;aapar r^alatanaar of
SubSurface Disposal Systems.
i
1
I
revised 9/2/98 Page 5of11
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPELTION FORM
PART C
SYSTEM INFORMATION
proowtyAddiress:53 Crosby Circle Centerville ,Mass .
owner: Robert Shack
Date of inspection: 8/16/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow:1,W g.p.d./bedro m.
Number of bedrooms d ig ) Number of bedrooms(actual):
Total DESIGN flowNY
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) es or no:_; If yes, separate.inspection.required
Laundry system Inspected ye or no)
Seasonal use(yes or no):_ �f
Water meter readings,if available(last two year's usage(gpd): /�'p�/*��
Sump Pump(yes or no):-A-0 )y " A50—A/ � 44
Last date of occupancy:�UA
COMMERCIAL/INDUSTRIAL:
Type of establishment: rfl/19 _
Design flow: stad ( Based on 16.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present:(yes or no).A&
Non-sanitary waste discharged to the Title 5 system: (yes or nokf/y _
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RE O DS and source at on, VOL
System pumped as part of spe tion:(yes or no)
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/&etrRwtimr-box/soil absorption system
_ Single cesspool
Overflow-sesepeol wf/a
Privy
Shared system(yes or no) (if yes, attach previous inspection records,If any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank / 4Copy of DEP Approval
Other
ROXIMATE E of all components, date i taH d4iff k�wn)•and uree 44nformation: G ,
Sewage odors detected when arriving at the site: (yes or no4?
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEZilON FORM
PART C
SYSTEM INFORMATION(continued)
Pr Address:53 Crosby Circle Centerville Mass
�y ,
Ownw: Robert Shack
Date of Inspection: 8/16/9 9
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of one ction: c t iron 0 PVC_other(ex lai
ok . r
Distance fro (private ater supply well or suction line
Diameter
Comments:(condition of Joints,venting,evidence of laakage,-etc.)
Joints apppnr tight Nn evidep6e eg leakage
S C TANK:
(locate on site plan)
Depth below grade:
Material of construction:Zncrete,!// metal/AFiberglass y4 Polyethylene ►other(explain)
If tank Is(petal,list age ls.age.confirmed by Certificate of Compliant (Yes/No)
,r •ld"d 6-17.r
Dimensions: ���
Sludge depth: Zrxga
Distance from top o sludge to bottom of outlet tee orbaffie:ff"Q ' _
Scum thickness:
le
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bo of outle tee r baffle.Za
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structureHntegrity,
evidence of leakage, etc.) Pump t a n k P v P r y —I jr p n r g T n l p t P. n„r 1 P t t P P
are in place . The tank is structurally sound - No Pv; rlpnrp of
l eakngP
GREASE TRAP:
(locate on site plan)
Depth below grader
Material of construction: gconcrete)16metaV 4/±FiberglassPolyethylene4W other(explain)
Dimensions:
Scum thickness: Aly
Distance from top of scum to top of outlet tee or baffle: &&
Distance from bottom of sc}rm to bottom of outlet tee or baffle:
Date of last pumping:
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.)
Grpasp trql2 ig not :rpgpnt
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT+ON FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 53 Crosby Circle Centerville ,Mass .
Owner: Robert Shack
Date of In"I" 6—:8/16/9 9
TIGHT OR HOLDING TANK-Ab&(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction:A!concreteAL4metaf4&yiberglas44 Polyethylena46qother(explain)
Dimensions: (�'
Capacity: /r gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:YesA[� Now
Date of previous pumping: AJA
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
iQ t or holdinjQ tanks are not present .
DISTRIBUTION BOX: (/
(locate on site plan)
Depth of liquid level above outlet Invert: AO
Comments:
(note•if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - —
Distribution box is not present .
PUMP CHAMBER:',cle,
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)-if
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
ump. chamber is not present .
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTE"SPECTiON FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 53 Crosby Circle Centerville ,Mass .
Owrw: Robert Shack
Dau of Irspection:8/16/9 9
SOIL ABSORPTION SYSTEM(SAS)_-_
(locate on site plan,If possible; excavation not required,location may be approximated by non intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields, number, dime slops:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to fine sand No signsof hy4r-akilie €ai •tre -
CESSPOOLS: ��))
(locate on site plan) /�Q9 Ai
f
Number and configuration:
Depth-top of liquid to Inlet Invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materlals of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of Inspection)
eSSDool dry , Did not have to pump. No ow d-e^ge ez ;�ai er
intrusion.
Comments:
(note condition of soil, signs of hydraulic failure, ovel of ponding,-condition of.vegetation, etc.)
Same as ahnvp,
PRIVY:Ai41i0_
(locate on site plan)
Materjals of construe ' n: �� Dimensions:
Depth of solids:Io
Comments:
(note condition of soil, signs of hydraulic failure;level of ponding, condition of vegetation;etc.)
Privy is not present
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSSEAI INSPECTION FORM
PART C f
SYSTEM WFOR1dATION le"f W0d)
PropemAd&*": 53 Crospy Circle Centerville ,Mass .
Own-me: Robert Shack.
D.L.of{nap.ctl«:8/16/9 9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locsta all wells wlthln 100' (Locate where public water supply comas Into house)
;t �> hcAgd-v s5
•ggsq s pus
J@gBm XGJ2 saTpusg
1 �
OZ
ggsq saTpusg
revised 9/2/98 Plitt 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Addreas: 53 Crosby Circle Centerville ,Mass .
owner: Robert Shack
Date of Impaction:8/1 6/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
f
Estimated Depth to Groundwater/'Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
—Z(5served.Site(Abutting propert observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
__jj�/Checked pumping records
hocked local excavators, Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map.
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page 11of11
Y
f
•r...nn.,-n.T�."TT� mrmr•ntrw�n rnrr+..n�.•�+�n�r++�nnn nrA1u nrna•n.at�+ .rs.-r.Tt-.ar....-'..�,..-..,`
'1'UHN OF Barnstable BOARD OF HEALTH
� .1^•Tf1_T•'._;; —T, �^�•1SUItFACF SEWAGE DISPOSAL SYSTEM IN�9i'�F,CTION FORM - PART Dn�CTEft'fmIFICATIUNR� - 1
-TYPL OR PRINT CLEARLY- 1
PROPERTY INSPECTED
STREET ADDRESS _ 53 Crosby Circle Centerville ,Mass . '
ASSESSORS MAP , BLOCK AND PARCEL
OWNER' s NAME Robert Shack
PARV D - CERTIFICATION
NAME OF INSPECTOR _ Joseph P.Macomber Jr . ..
COMPANY NAME J. P.Macomber & Son' Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City St at. LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 J 790 _ 1578
R
A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate ) and
complete as of the time. of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
witli my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Chec one ;
Systeui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or- the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have cone cted has found that the system fails to
Protect the j-)ublic health and the environment in accordance with Title
51 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature , Date `�C7
One copy of this certification must be provided to the OWNER, the BUYER
,A 1�e,,
( where applicable ) and the 130ARD OF }iEALTiI:
* If the inspection FAILED , the owner or• 'o` orator shall u p pgrade ' tho ayetem
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 Cmn 15 . 305-.
partd .doc
No. 7-6 Fee$ 5 n�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for ni5pogar *pgtem Construction 3permit
Application for a Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. Crosby Circle Owner's Name,Address and Tel.No. Nick Pusateri
Centerville,Mass. 02632 47 Crosby Circle
Assessor's Map/Parcel Centerville,Mass. 02632
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc.,,_ J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XX No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 x 1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 500 gallon tank. Type of S.A.S.
Description of Soil
Loamy sand to medium fine sand.
Nature of Repairs or Alterations(Answer when applicable) Omitting f i r s t cesspool.
cesspool is caving in. Installing new 1500 gallon tank and
and one distribution box to the existing leaching pit.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu by this B ar o alth.
Signed Date 21 /1 /9 7
Application Approved by - a Date
Application Disapproved or the following reasons
Permit No. - Date Issued
No. ? 7—GS6 Fee 5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1•�
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE.,MASSACHUSETTS
0(pprication for Mtgaal &pztem Construction Permit _
Application for a Permit to Construct( )Repair(X)§Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Crosby Circle Owner's Name,Address and Tel.No. Nick Pusateri
Centerville,Mass. 02632 47 Crosby Circle
Assessor's Map/Parcel Cent a rv€i ri a,Mass. 02632
Installer's Name,A dress,and Tel.No. 508-775-3338 6&signer's'Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macom9er & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 yf 1 10 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 50,0 gallon tan*. Type of S.A.S.
Description of Soil
Loamy sand to medium fine sand.
Nature o4eolp airs or Alterations(Answer when applicable) Omitting first Be s s poo l l
cesspois caving in. Installing new 1500 gallon tank and
and o istrlbttion box to the ex ins leaching pit.
Date last ''spected:
a,Agreement:,
The�Qersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of,C®mpliance has been issued by At his arNof lth.
Signed Date 21 /1 /9 7
Application Approved by �. Date
Application Disapproved or the.following;reasons
Permit No. a, Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired �X )Upgraded( )
Abandoned( )by J.P.Macomber & Son Inc.
at 47 Crosby Circle Centerville,Mass. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. `/7-&9_6 dated / Z - 2- 9 7
Installer J.P.MACOMBER & Son Inc. Designer J.P.Macomber & Son Inc.
The issuance of this permit shall not be construed as a guarantee that the systeVll function as designed.
Date_ ~" �"1 - ll Inspector 1 a
� No. � � ------------- -----Fee $ 50
THE COMMONWEALTH OF MASSACHUSETTS
` PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
wigooi pgtexT Construction Permit
:'ermiss hereby *ranted to Construct,( ) epair( �')Upgrade( )Abandon(( ))
Systemlocrr'atedat 4 '1 Crosby Circ.l a Centerville,Mass. 02632
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:Construction must be completed within three years of the date of thiQsermit.
Date: 17 Approved by �ic.,._��� ,/�, +, f� �►
i
ti
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, Joseph P.Macomber ,Tr_ , hereby certify that the application for disposal works
construction permit signed by me dated 12/1 /9 7 , concerning the
property located at 47 Crosby Circle eenterv; 1 le, Ma meets all of the
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
/'There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
9/ There are no variances requested or needed.
V If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will 114.4 be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 0
r
B)Observed Groundwater Table Elevation(according to Health Division well map) A?
SIGNED : DATE: 1 2/1 /9 7
LIC D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 71
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
q29
O 0e)
r
)s exvPA,;f 9�
TOWN OF BARNSTABLEs G
LOCATION 417 C C be SEWAGE#
VILLAGE C PNreR yll/P-�- ASSESSOR'S MAP &LOT
II+1, A LER'S NAME&PHONE N0 c v M ek
SEPT P TANK CAPACITY )O N Le ;
LEACHING FACILITY: (type) /d/ (size) D O 0
I '
j NO'QF BrEDROOMs
B:[DER OR OWNER
PERivIITDATE: —COMPLIANCE DATE: 1
Separation Distance Between the:
Mauaii ►Adjusted Groundwater Table and Bottom of Leaching Facility •Feet
Private Water Supply Well and Leaching Facility (If any wells exist
Feet
s.Pnsi.Ce or within 200 feet of leaching facility) _
Ed$ 00 Wetland and Leaching Facility(If any wetlands exist
:y'ithin 300 feet of leaching facility) Feet
Futnisshed by
j
............
-
TOWN OF BARNSTABLE
LOCATION $ C,ra\q_ SEWAGE# BA
VILLAGE l)e.c- ' �r�p ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE/NO.
SEPTIC TANK CAPACITY �' s P GL i n - CAS U:i-(Mk
LEACHING FACILITY:(type) (OX( ?t+ (size) xG �: }
NO.OF BEDROOMS 3
OWNER -Jk7�obec k iEhGck
PERMIT DATE: 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 facil' ) !`� Feet
Edge of Wetland and Leaching F it y a ds exist
within 300 feet of leaching cility) Feet
FURNISHED BY
o as 38 C;�6
i
cvtabb CC-
L _.C *q.1T S 'E PE E'!1 T N_0.
"LA
IgSTA "'S gAt3E b ADDRESS
BUILDER OR HER
DATE PERMIT ISSUED ,
DAT E C 0 M P L I A N C E ISSUED
(770
\r
/ i iL3' \gib
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........Jaw.'n.........OF....
Appliraffou for Dispaiial Works Toustrurtion ramit
Application is hereby made for a Permit to Construct or Repair (/,-�`hn Individual Sewage Disposal
System at: I
rcl........................... ....... .....................................................................................
on-Address or Lot.No.
..................................................
. .....................................................
r Address
..................................................................................................
$4 Installer ddress
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter--------------.. Depth................
Disposal Trench—No...................... Width.................... Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No-------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. f t.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----------------_------
4� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------- ---- -- I..................................................................................................
0 Description of Soil.................�51 Y .................................................................................................
W
........................................................................................................................................................................................................
................ ------ .............................................................................................. ----------------------------------- ................................
U Nature of Repairs or Alterations—Answer when applicable-_--------- 040--- J.:.............................................
.....................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of rHIPIE 5 of the State Sanitary Code—The undersigned further agre not to place the system in
'r'lgne' Iur",er ag e no,
operation until a Certificate of Complia c�ehas bee 'issued by the boardof health.
"1 0
igne .. 4...... . .. ........ . .. .... ....... .... SQ
..........
Date
Application Approved By...". ..... ......... .... ...............................................................
...................................
Date
or e following
Application Disapproved f/ reasons:.................................................................................................................
........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
No.1 2.-S-f14 Fus.
y
THE COMMONWEALTH OF MASSACHUSETTS
..�. BOARD OF HEALTH f
s
r t
Appliration for Dwpasal Workii (fnnuitrurtion unfit
Application is hereby made for a Permit to Construct ( ) or Repair (44-nn Individual Sewage Disposal
System at
I re t �A a
a Lo' ......................... ....... .. .. -- ---••---•------•---••---•--------------.............
tion Address d or Lot No.
�f t .r 8 k r.� A./,� r
............. .1 r._.. �......°C✓'�j^a................................................... .......:.... ..."._lr� f±�f.��.::.;.... .----............................----........---....
,f Y 19 '✓'�w e f F i Address
....... •----Y--• __••___... .....................................................................
Installer Address
dType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.................._.........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures -----------•------------•--------- - ----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
a' Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter-_-_____.--_.._- Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------------------ Diameter.................... Depth below inlet.....................Total leaching area...................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..........................
---------------------- ......................................................................................................................
O Description of Soil___________________ ......
x fr
U -•--------••••--•••----•--•--•-•--•..................•-------------•--•--••-------•------------•-••-••••-•••-----•--•-•---••----••-•-F,-•••-••---------------•-•-------••••••-••-----------•--•••-..----
W
-------------------------------------------------------------- -- ---------------------------------------------------------------------------------•----------------------------------------------
txj 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 TITLi, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
lo
operation until a Certificate of Compliance Jaas bee;>ssued by the board of health.
ignedr s
Date
Application Approved B ._ _., ! xlf ..............
Date'
Application Disapproved f r e following reasons-------------------------------------•-------------------------•-----------------..__....._...---•-•-••-••_...._
------••------------------------------------------------------------------•------.•...--•--••-------•------•-••-•--•--•--------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....tea...Es ✓.: ........OF.... ... r :: .:.. ..........................
Trrtifiratr of Tuntphaurr .
THIS-IS TO CERTIFY, That the Individual.Sewage Disposal System constructed ( ) or Repaired (i
1 � �}�' s t - : � )
bY----------
3 rInstaller ( i
' f ✓ t
..........
._. ._ !. �f�r F y k_ /r �f f r. ,"s _..-........................................................ �f� .......
:has been installed in accordance with the provisions of TITLE 5 of he State Sanitary Co . as escribed in the
S Z ` 2
application for Disposal Works Construction Permit No...7i_._..__`_..__ ______________ dated____._.. ...............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SAT4S FACT9RY.
�1 s l�1%-'
DATE....:--••--••---------------- ------•---- Inspector.. ....•.. .f r..... ........................................................
THE COMMONWEALTH OF MASSACHUSETTS
- BQARD OF HEALTH
......... .....OF.....t, ?Yf� "a, �:........................
1
No............
Dispolla1 nrk$ Tonotrnrtion wmit �
Permission is hereby granted...... . '.!
to Construct ( ).,or Repair.( ..) n Individual Sewage Disposal Systems
at No.__. ^' A-'•.''"„t P $ ._.. r{t{:_{` ` `�`tk t` !'� f}- ..... ...
+�.�` �- 7- - ---Street •- ..Dated
...._ .'.....................
as shown on the a ica on for Dispos@,Works Construction Perm •------=----�.. Dated.:_ `
............ ......... . ............ --------------•-------....................................Board of Health
DATE------. . .....••---------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS