HomeMy WebLinkAbout0103 DONEGAL CIRCLE - Health 103 Donegal Circle
Centerville F
A = 169 031
I
i
�J ay
UPC 10259 �
No. H163OR
HASTINGS. UN
r .
1�9- a3 (
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form Not for VoluntaryAssessme
nts
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for 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. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information �l�tt is 3°I�o
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
- 374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
1ac�u (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey Dae:2021.05.17Y10:16:30 oaoo 5-13-2021
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
......................................
w� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
S,g � 103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:.
❑� I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.., ..,,j' 103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El a Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ a Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is required for every Centerville Ma 02632 5-13-2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ O Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 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:
❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ E 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd. '
❑ El The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
-(F Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section GA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 Were any of the system components pumped out in the previous two weeks?
0 ❑ Has the system received normal flows in the previous two week period?
❑ a Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ 0 Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
E ❑ Were all system components, excluding the SAS, located on site?
0 ❑ 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?
1:1 El 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:
El ❑ Existing information. For example, a plan at the Board of Health.
❑ El Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
I
Commonwealth of Massachusetts
_= - 1 Title 5 Official Inspection Form
- :� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i 103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 Number of bedrooms(design): Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD
Description:
Number of current residents:
2
Does residence have a garbage grinder? ❑ Yes [j] No
Does residence have a water treatment unit? ❑ Yes of No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ® Yes R] No
information in this report.)
Laundry system inspected? ❑ Yes F!] No
Seasonal use? ❑ Yes CE No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
2020- 72,000gallons 2019- 63,000gallons
Sump pump? ❑ Yes ❑■ No
Last date of occupancy: currentDate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
�w ---, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ® Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Owner- last pumped 4 years ago
,
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
IAA - = .... 1� Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
j` 103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El 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:
COC 5/9/2002
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5, Building Sewer(locate on site plan):
2'6"
Depth below grade: feet
Material of construction:
❑cast iron ❑■ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town water'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
P 9 P Y 9
I
......................................
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
V611
Depth below grade: feet
Material of construction:
❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed b a Certificate of Compliance? attach a co of certificate Y N g p ❑ es ❑ o
Y ( copy )
1
Dimensions: 000gallons
10If
Sludge depth:
2 611
Distance from top of sludge to bottom of outlet tee or baffle
311
Scum thickness
511
Distance from top of scum to top of outlet tee or baffle
1411
Distance from bottom of scum to bottom of outlet tee or baffle
measured
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.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
1{M —;o Title 5 Official Inspection Form
III I/ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t 103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: NAfeet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
15insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
In= = Title 5 Official Inspection Form
- - b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
o„
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.):
The d-box was in working order at the time of inspection.
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
'Aw Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ® Yes ® No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
(2)500 gallon chambers
0 leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
wn r Title 5 Official Inspection Form
..1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Leaching chambers were
dry when viewed.
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
OF, Title 5 Official Inspection Form
-- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............. 103 Donegal Circle
u —
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
3 '
"Z'C7WW OF BARNS'T'A.BL.E
LOCATION
17IZ LA(38 Y�r E+/.rf� ASSESSOR'S ;t4tAt'cr$
_. 1`NSTAP;r t�ke•5".NAME'8c PF30NE NO.: .��5.., 5�''.2o'—'�J�'4'�t''
SEPTIC'TANK CAPA.GITY.,.. O
LE A c.>Eru�rc F.>,Crx rr�r: ttyrw11' , p4614z Y52,
vo.c�g.BsnxooMs_:_ ..3
BUXLDER OR OWPr'SR rr
PPBRMST[SATE: _ '^S "L7 ten. CIJTvSPLIA2VCE DATE; 3
Separation Distance Bctwecn:the,
Mi u irnu n.Adjusted Ground water Table tothe Bottom of.Leach I r g'Ftacilaky der£
Private Water Supply Well and Leaching Facii7ity (if any wcils exist:
.on site or within 100 feet of leaching faciti y). ::FeGt
.E_dgc of Wcttand-aud-LeFtchiog tr$cility(Lf any:watlands:!tAist-
witlain 300£coL f 2eaclvin�facili -• IE^cct
i
1 +fi-
i
1
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
. . y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ji Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Check Slope
❑■ Surface water
■❑ Check cellar
0 Shallow wells
Estimated depth to high ground water: NoGW@10'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 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)
0 Accessed USGS database-explain:
Topo maps and charts
You must describe how you established the high ground water elevation:
Topo maps and charts were used to determine high groundwater. Ground water is
greater than 10' in area of SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
w� = Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Michael Ferreira
Owner Owner's Name
information is Centerville Ma 02632 5-13-2021
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
F■ A. Inspector Information: Complete all fields in this section.
■0 B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
■❑ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
0 D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.00c•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
103 Donegal Circlei
Property Address h
Mary 6hiochios9
Owner Owner's Name ...
information is :
required for every Centerville I/ MA 02632 6-19-17 Q
page. City/Town State Zip Code Date of Inspectio'rn
�k
-j
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
# / /cam"- �ppuNiup��
on the computer, of 0 �������tN OF 414������i,
use only the tab ��`� `SS
1. Inspector: ,� qc
key to move your '2;' y
cursor-do not �; rn
use the return James D.Sears fig,• JAMES Gm
key. Name of Inspector i v� SEARS
Capewide Enterprises '*' CCompany Name
;
� 153 Commercial Street I S
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certifythat I have personally inspected the sewage disposal system at this address and that the
P Y p 9 p Y
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-22-17
nspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Dispo al System•Pa e 1 of 17
Q VY
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
M
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. City/town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal. Tank D Box and two Chambers.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
H W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N . ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection'if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
Il ❑ 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
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS
❑ ® Liquid depth in is less than 6" below invert or available volume is less
than '/day flow ,I;£/4 C#1 V C
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r
Commonwealth of Massachusetts
w - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a.surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the.system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or, Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and two chambers.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2015-16,000Gal
g ( y g (gp ))' 2016-17,000Gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
H W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2002 Permit #2002 - 199.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: 14"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
2"
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 103 Donegal Circle
• M
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt -Tape
Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and covers at 14" below grade. In and outlet baffles. No sign of
leakage or over loading.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
F W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°,M s 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x 16" -34" Below grade. Box is clean and solid w/two lines out. No sign of over loading
or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
w - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two 500 Gal dry well chambers. Chambers at 38" below grade. Clean w/no sign of over
loading.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is Centerville MA 02632 6-19-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
R EAR 13 _ -bzck
3
t �
0 0
93
13-9
ayy.= aG
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
H W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c�M 103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells 10,
N�
Estimated depth toFigh ground water:
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:
Auger T.H. 10' no G.K. Bottom of chambers at 5'-8" below grade. Bottom of chambers at 4'-4"
above T.H. Depth.
I
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
103 Donegal Circle
Property Address
Mary Chiochios
Owner Owner's Name
information is required for every Centerville MA 02632 6-19-17
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, 6, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I
�1
525/01
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
hereby certify that the engineered plan signed by me
dated _ d2 concerning the property located at
./03 bo rJ 6r A L J meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS)and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or may conduct
preliminary tests at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the
Frimptor method when applicable)
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation +adjustment for high G.W. S = .0
e.
DIFFERENCE BETWEEN A and B
SIGNED DATE:
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
q:health folder:percexmp
W 1:
.ice► ,,
aw
��:\-;�`.:�.�./, �� /�;��•,j�Jf `�I�'I;� � '�,�f�ia;'�,►��(iU:---'IfjL��K�y��
�iAA L
�,
AF-
� .
lip
40go
,mac' <;?t;, ' !� ' ' ''s'- 1,�.,, \!
' , �►;, . IV
EWE
c, fit' �. r; /!► �++ �1
Q
03
Y M
N �
(lJ
lD
Ln
CD
0
N�
Q
E �
No. t ® FEE ✓ /
Board of Health, -i A ,3 MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - D Complete SystemIndividual Components
Location L �, Owner's Name '0+0-OW MAC
Map/Parcel# M4 1 9 PUCF3 AddressAlgae, egla
G
Lot# Telephone# Zo
Installer's Name Designer's Name
ti
Address AddressDN 3Z
Telephone# Telephone# i
Type of Building Lot Size / sq.ft.
Dwelling-No.of Bedrooms Garbage grinder/VA
rinder A
Other-Type of Building No.of persons Showers ( ),Cafeteria/( )
Other Fixtures -�
Design Flow (min.req70L
. ed) _0 gpd Calculated design flow 330 Design flow provided3X 4 �gpd
Plan: Date S Number of sheets Revision Date
Title S & S t'i
Description of Soil(s) a " i�-- d'l5 y�
Soil Evaluator Form No. Name of Soil Evaluator KA Date of Evaluation U Isc, 0-1
i
DESCRIPTION OF REPAIRS OR ALTERATIONS AN N's�( v�7 $�1 `�i � ��/ /"5=t f w-U-
NE kEPtAc,6D ey A A)9W 8-AOx aAO 2 - �- &A z DRXIAJKuS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to p ace the systepn operation until a Certificate of Compliance has been issued by the Board of Health.
SignedGI/ Date
Inspection
f FEE V\aV
�. k'' Board of Health, 1�/�/ A 1 , NIA.
APPLICATION FOP, DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑Complete System Individual Components
Location W3a) A L. _ Lg Owner's Name YO-+,_,10 L
Map/Parcel# MkP bPWF3 1 Address 0� G i '
Lot# Telephone# S 0 —
Installer's Name Designer's Name
Address Address �ny 3Z - i `r'
Telephone# r� Telephone#
Type of Building 6V/��/����1 p`z V Lot Size sq.ft.
Dwelling-No.of Bedrooms J 1. Garbage grinder
Other-Type of Building No.of persons Showers
Other Fixtures /�
Design Flow ( in.recdui ed) �_ 0 gpd Calculated design flow 3 3 Design flow provided gpd
Plan. Date o-Z Number of sheets 'r Revision Date
Title pp,�N� l�,1
6 Description of Soil(s) R0X ?,?"" Or— A'
Soil Evaluator Form No. Name of Soil Evaluator s 6= Date of Evaluation �T
DESCRIPTION OF REPAIRS ORALTERATIONS`4.`" A�vXn"S'� �jhY.-�• C� ]^�� ? iL
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ames to not to ace the syste operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
a
Inspection t^ Ile 1�
No. FEE
Board of Health, 6A�/15TT�!�1� MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System
The undersigned hereby rtifv that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by: ��Q �Q bo'c(of
at, 163 D oN ey b r(- 'tr^"
has been installe.4in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector: Date: U
The issuance of this permit shall not be construed as a guarantee that the system will function as designed
No. FE ---
C®MMONWEA LT �t" MASSACHUSETTS
Board of Health, OW, af MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permi Sion is ereby ranted tQ; Construct( ) Re ir( Upgrade ) Aband n( ) an individual sewage disposal system
at '� as described in the application for
Disposal System Construction Permit No. dated W9164—
t
Provided: Construction shall be completed wiyhirythree years of the date of t1nr0, 10
al conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date l/� Board of Health 4as
"'�.. TOWN OF BARNSTABLE F7C
LOCATION /0'S d6X 5q#1 ( /!-. SEWAGE # Ada
VILLAGE cl-an tG_d V//Ji` ASSESSOR'S MAP & LOT/lop 3/
INSTALLER'S NAME&PHONE NO. '03- 5'°.20 —9738
SEPTIC TANK CAPACITY M00
LEACHING FACILITY: (type) ^So0 (0 IZ 8
NO.OF BEDROOMS 3
- BUILDER OR OWNER
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 facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
- within 300 feet of leachin facili Feet
Furnished by "
i� ��j
I
�v I
�o, 0 i �.
��.lt•. � �3 _ _ _ _
i,: y
17'
•
�. 1
ti_.+-
TOWN OF BARNSTABLE FC
LOCATION-D Drg,,P,7,,-g,O#I iiii,
SEWAGE # D�2
VII-CAGE_ L�,�,�T,ry /i�f� ASSESSOR'S MAP & LOT (o
INSTALLER'S NAME&PHONE NO. OS-
SEPTIC TANK CAPACITY DO.
LEACHING FACILITY: (type) ,SOO 6
NO. OF BEDROOMS_
BUILDER OR OWNER dUa.4j�
PERMTTDATE: '—�g,O�, COMPLIANCE DATE:
Separation Distance Between the:
jMaximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and LeachingFacility ty (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist. Feet
within 300 feet of leachin facili
Furnished by- � Feet
.Gt
V
� A*-
1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF.-�IRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor A Commissioner
SUBSURFACE SEW GE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 163 i)ojuEGA(_ 6WC-6 Name of Owner MS MA 3✓�+�5
31 161 9? Address of Owner:
Date of Inspection:
Name of Inspector:!Please Print) �t
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: .I A Rc.8 E2't S
Mailing Address: 5'.[?. •3 0* Z 1 1;3 A a Lj o t r vr1 r}SS o A S 3 G —3 f/.2
Taephone Number: (2 a l l a a 6 - .;o q
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 Local Approving Authority
_ Fails
Inspector's Signature: w Date: !O
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (301 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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS PO AV Fti`'S AR f /� pc�a c F �g.vD o AFRA�9tlG /�S
dF 'vSPEC
-�
11 1919
i
revised 9/2/98 Page IofIt
A
i� Prinied on Recycled Paper
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
INSPECTION SUMMARY: Check C B, C, or A
A. SYSTEM PASSES:
have not found any information which indicates that any of the failure conditions described in 310 CMR 1 S.303 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.
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.
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. The system will pass inspection if(with approval of the Board of
Health)•
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipets)are replaced
obstruction is removed
RAN
revised 9/2/98 Page 2of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contimied)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
/✓/�_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
Cesspool or privy is within 50 feet of 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.
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 Page3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either"Yes" or "No" to each of the following:
N/A 1 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
Backup of sewage into facility or system component due to an overloaded or clogged SAS or Cesspool.
Discharge or ondin of effluent to the surface of the round or surface waters due to an overloaded r clogged A r
g p g g de o c gg SAS o
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 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
coliform 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 within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area--IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall 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 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either"Yes" or"No" 41310 each of the following:
�Yes No
,_ Pumping information was provided by the owner, occupant,or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
IVLA 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,excluding 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 on the site has been determined based on:
_ 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)
115.302(3)(b)]
The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page sof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 2.3 g.p.d./bedroom.
Number of bedrooms(design): Number of bedrooms(actual):-
Total DESIGN flowQ �ypp
Number of current residents: I
Garbage grinder(yes or no):—dip
Laundry(separate system) ( es or no):": If yes, separate inspection required
Laundry system inspected a or no)
Seasonal use(yes or no). t
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or no):_Q
Last date of occupancy: P;21:St^.-;'-
COMMERCIAL/INDUSTRIAL•
Type of establishment:
Design flow: gpd ( Based on 15.203)
YqA-Basis of design flow
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:
OTHER:(Describe)
'.ast date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
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)
1/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other /006 4rRL 0A/ AlK-- /Qpo G7kL4aN Z-F*C*
APPROXIMATE AGE of all components,date installed(if known)and source of information: /9 Ta 6 w.,v Es�-
Sewage odors detected when arriving at the site: (yes or no) NC7
revised 9/2/98 P2ge6of11
zj
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
N'JlWepth below grade:
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grader
Material of construction:_ oncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: J-- 8'r 6 r X N 5'7`•k W`V 110 f,
Sludge depth: -1 1 r 1•
Distance from top of sludge to bottom of outlet tee or baffle:_/r3
Scum thickness:_( 11_ i,
Distance from top of scum to top of outlet tee or baffle: it
Distance from bottom of scum to bottom of outlet tee or baffle:_L
4ow dimensions were determined: 1/r 5 yA L I NS PtC I"�O�cl
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.) -C M e PG NCA"T-1 to .t/ Goo D 6•V1 D r�NC;7
c�F ti;��►�GE
GREASE TRAP:
(locate on site plan)
l 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:
(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.)
revised 9/2/98 Page 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_
)VA
/ (locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, 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.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontinued)
Property Address:
Owner:
Date at Inspection: /
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: QE tAS'� fONCRc E
leaching pits,number:L
leaching chambers,number:_
leaching galleries,number:
leaching trenches,number,length-
leaching fields, number,dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of pondng, damp soil,condition of vegetation, etc.)
_ So, (- A-kuN UrC-Ei►4TWA/ IAl � .Va�rr4,L eewa/sioAl ✓o v)Drvre of
yW( 4Q C r4il-kft nQ ?0.v'DJA,1(r
CESSPOOLS•_
(locate on site plan)
Number and configuration:
/ lepth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
A./ (locate on site plan)
#Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of pondng, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
M
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
SYSTEM INFORMATION(contirt"
Property Address:
Owner:
Date of lnspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
RCA 2
N
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
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
Estimated Depth to Groundwate>lg-Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Ir
t tsT No�E OAc) A'0370l&-7,0j6 4%0RoVF'Z" (' Ili
revised 9/2/98 Page 11of11
ri
Please read this notice
Purpose: The information,in this report is based on visual inspection of the
listed property. This does not mean that.that every defect was discovered or
uncovered. This report does not offer nor imply a warranty to any defect to
the operation of this system. The process is to visually inspect, as much as
possible, the components of the septic system and to determine if this system
meets the criteria outlined by this report concerning Title Five regulations.
This information is based from the conditions noted at the time of the
inspection. There is no indication given as to the remaining useful years or if
the engineered design flow is at present use of this dwelling. The use of this
information is with the understanding that the above conditions are integral
to this report whether it is from the buyer or sellers position. A copy of this
report will be kept by me and is a available to all parties concerned.
If you require further information, please contact me directly at any time.
T�tvm�s s. -Ro$ERTs 1- 781 - jai; - Y309
(revised 04/25/271 Page 10 of 10
ASSE,SSDR'S MAP NO. �' PARCEL
LO CAT�I0 / EW E PE MIT NO.
VI l ACE
A D�i
I N S T A LLER'S NAME A ADDRESS
S UI DER' 0 OWNER
Z f ooMS, X .
DATE PERMIT ISSUED ,
PAT E C 0 M P L I A N C E ISSUED
'I
r ,
6 tlei
oo
r
\
V
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
FAILED INS LS 031
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 1r,: _J)wp-e c L Cdt r-c l-e.
cvrt'yvi o�G,3 RECEIVE®
Owner's Name:
Owner's Address: -
° DEC 1 1 2001
Date of Inspection: i l-14_p
TOWN OF BARNSTABLE
Name of Inspector:( ease print) R E I D C. E L L I S HEALTH DEPT.
Company Name: T L L I S g
Mailing Address: 23 ENTERPRISE ROAD, P.O. SOX 59 , YARMOUTH PORT, MA
Telephone Number: 5 011-3 6 7-6 2 3 7
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 my
training and experience in the proper function and maintenance of on site sewage disposal systems.I ant a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
eeds Further Evaluation by the Local Approving Authority
Inspector's Signature: L.`r! G � Date: Z6-'' d)
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments 49e�4e OQ iOA
****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/I5/2(jon nave I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: t o:3 Do n eG yp,.L. C-y f"
Cam, y7e r Js►1 .wt A oa b u,
Owner: i o 1� -}( &c 1}cam
Date of Inspection: k(-jq—b
Inspection Summary: Check A,B,C,D or E/ALWAYS co plete all of Section D
A. System Passes:
I have not found any information which indii v s that any of the failure criteria described in 310 CN R
15.303 or in 310 CMR 15.304 exist.Any failure crit ria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described' the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacem t 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* r the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration r tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank approved by the Board of Health.
'A metal septic tank will pass inspection if it is struc lly sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is avai ble.
ND explain:
Observation of sewage backup or break out or I igh 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 rem wed
distribution box W leveled or replaced
ND explain:
The system required pumping more than 4 time a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Heal ):
broken pipe(s)are i eplaced
obstruction is remo ved
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: i o 3 ! on L C%r. _T
Owner: Don0,1_ AC 17ok _
Date of Inspection: i i-i4- 61
C. Further Evaluation is Required by the Board of I
Conditions exist which require further evaluatior by the Board of Health in order to determine if the system
is failing to protect public health,safety or the enviro t.
1. System will pass unless Board of Health deter nines in accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner which v ill protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surf,ce water
_ Cesspool or privy is within 50 feet of a bok ering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(a.id Public Water Supplier,if any)determines that the
system is functioning in a manner that protects th public health,safety and environment:
_ The system has a septic tank and soil absory tion system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface wa r supply.
_ The system has a septic tank and SAS and a SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and t ie SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and t ie SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to de nnine distance
**This system passes if the well water analysis,I ierformed at a DEP certified laboratory,for colifoan
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nit ogen 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.
71
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:10-'A Doped kL G r.
('����"es'►.+i Ile,m� o�b`��
Owner::2QnA I r1 ll1l1IF�C_t" auq jR-1L
Date of Inspection: t 1-1 -
D. System Failure Criteria applicable to all systems:
Yoq must indicate"yes"or"no"to each of the following for all inspections:
yysY s No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
scharge 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
— _ �/ ce 1
// quid depth in cesspool is less than 6"below invert or available volume is less than%day flow
uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of es pumped
portion of the SAS,cesspool or privy is below high ground water elevation.
y onion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
w r supply.
_ — rtion of a cesspool or privy is within a Zone I of a public well.
y 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 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: v
To be considered a large system the system must se e 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 f lowing:
(The following criteria apply to large systems in additic n to the criteria above)
yes no
the system is within 400 feet of a surface g water supply
the system is within 200 feet of a tributary to surface drinking water supply
— _ the system is located in a nitrogen sensitive (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.le owner or operator of any large.system considered a
significant threat under Section E or failed under SectD shall upgrade the system in accordance with 310 CMR15.304.The system owner should contact the appropriregional office of the Department.
Page 5 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: AL i i- —_
CP-VIA
Owner:T)on 'h1 m DQL&10
Date of Inspection: I j-L y-b l
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes N
ping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
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,nrccluding the SAS,located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of th affles 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:
Ye no
L 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(3)(b)j
e;
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: .a. y e.ir
� .n �Ci �j 6 a
Owner: o o a , _rnh„D-4
Date of Inspection: i i-t tf-o i
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: _
Does residence have a garbage grinder(yes or no):/(/`D
Is laundry on a separate sewage system(ye�i�o-r-no)�if yes separate inspection required]
Laundry system inspected(yes or no):� � ` ��/� Z.0
Seasonal use:(yes or no)-,Ot
Water meter readings,if available(last 2 years usage(gpd)):- ��K'_�b
Sump pump(yes or no):,&/p
Last date of occupancy: +0 t
1
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
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 res or no):—
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION /' �'l/ d 4
Pumping Records
Source of information: p/n� � �
Was system pumped as of the inspection(yes or no):
If yes,volume pumped tons--How was quanti ' �t3.determined?
Reaso for pumping.�- jet i .� Cow-�1lI d
TY 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/Altemative 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 componen sled(if known)and source of informations
Were sewage odors detected when arriving at the site(yes or no):��
r
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: j o 3 Donau qL Cur
E��T-��V i tle,1,�►�i oaL�3�
Owner: 0iL��L
Date of Inspection: . 11- i 4_bi
BUILDING SEWER(locate on site plan)
a
Depth below grade: v2
Materials of construction: Vcast'von _40 PVC_other(explain):
Distance from private water supply well or suction line: ,26F'
Comments(on condition of joints,venting,evidence of leakage,etc.):
1/[-s tlAr'L. i�YS�Q�e-�'Q,o.J 7•D�rf 9 P�tS
SEPTIC TANK:*0cate on site plan)
y
Depth below grade: 13
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) f <
o90
Dimensions: � _
Sludge depth: h
Distance from top of sludge to bottom of outlet tee or baffle: Z
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: I
Distance from bottom of scum to botto of o et tee orjbe-:��215
How were dimensions determined: V
Comments(on pumping recommend ions,inlet and outlet tee or baffle edition, ctural integrity,liquid levels
as related to utlet' vert,a 'deuce of leakage,etc.):
.. was
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction: concrete metal—fibe rglass;_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 01 baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and on let tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of l l
OFFICIAL INSPECTION FORM r-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: -e L 0— r'
OwnerlZ4
Date of Inspection:
N
TIGHT or HOLDING TANK: (tank must be p at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal rglass___polyethylene other(explain):
Dimensions:
Capacity gallons
Design Flow: galloxWday
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:Aif present must be opened)Oocate 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 car yove y 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 ol pumps and appurtenances,etc.)
Page 4 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 D3 0 1}L e-tf
Owner. jrAA
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):f,
locate on site plan,excavation not required)
If SAS not located explain why:
pe
leaching pits,number
leaching chambers,number.
leaching galleries,number
leaching wenches,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.):
'cl Gc�� c� �ov� 13 Sr i.✓,�.✓�- �c� �G,�
b
CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 7nsite plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer.
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no).
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
/r, . I
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic fa ilure,level of ponding,condition of vegetation,etc.):
Page 10 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �� /
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM YV
PART C
SYSTEM INFORMATION(continued) A/
Property Address: 103 DonwkL C�,►r
/v
("i,►aville YAR OKIPT;L,
Owner: 'A �loca+al1 6—
Date of Inspection: i 1-11_0 l
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.
L
0A 1�
S.
t�
O
i
v v
o 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: 163 DQrvegRL C—if'
l n aLx3 -
Owner:�onWI�.YVI► i7c�ur.r�l
Date of Inspection: I(-I Ll�-m
SITE EXAM
Slope
Surface water
Check cellar a
Shallow wells H4—
Estimated depth to ground water .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:
Observed site(abutting property/observation hole within 150 feet of SAS)
Ch ked with local Board of Health-explain:
ecked with local excavators,installers-(attach documentati n)
Accessed USGS.database-explain: 1f "r I,._`j/'
You must describe how ou established the high ground water elevation:
L I
IV
CENTER VILLE
t
L UMBERT ONEGAL�CIR.
POND W
A.M. 170 q
LOCUS p
o J 1� EXIST.
_ `Spp, LEACHPIT
A.M. 169/30 lgg g �� :` = 7titi��Ioo & FILLED TO BE P U MPED ��
W/SAND g
TELEPHONE LINE GAS — O / \
,A TO BE RELOCATED/ LOCUS MAP
O _
PLAN REF 223/139
_ENCLOSED_ ___ �1 o EXIST. ZONING. RC
_-__-_ _ 1,000 CALg FLOOD ZONE'' "C"
T.O.F. TANK
/ -ELEV.=100.0��3 _
/ _(ASSUMED)_______- _ ,
// tip'------------------ - SEPTIC SYSTEM REPAIR PLAN
HOUSE_=_ LOCATED AT
L W _ _--_,fl03-___= p� 103 DONEGAL CIRCLE
.NrCB/DH �� - _- ��' ti� CENTER VILLE, MA.
PREPARED FOR:
w - -= DONALD & JOAN MacDOUGALL
A.M. 169 32 DECEMBER 17, 2001
p. ' �o� ;� / GRAPHIC SCALE
M OF O op'' WV �� 20 0 10 20 40 80
PAM
A. M. 169131 otio
v AREA=15,000 f S.F. ��
( IN FEET )
I inch = 20 ft.
�' po' PESCE ENGINEERING & A SSOCIA TES
o EDWARD L. . .
LAND SURVEYING BY � � � P 0 BOX J21 pESCE n`
N®32001 OS TER VIL L E MA. 02655
. YANKEE SURVEY CONSULTANTS '� � ,� �
UNIT 1, 40 INDUSTRY ROAD �'o,� c� PH. (508)428-37.30
P. 0. BOX 265
MARSTONS MILLS, MASS. 02648
TEL• 428-0055 FAX 420-5553
SHEET 1 OF 2 J# 52960 GM
TOP OF MUNDATION
EL =100.0(ASSUVED)
�— 10' MIN.
2"LA YER OF
4" SCHEDULE 40 'P. V.C. 1/8"-1/2"
EL= 98.6' MIN. P/?L^H I/B PER FT 314" TO 1-_-1/2" WASHED STONE
"SHED ST7NE
EL 100'
i i / / / / /
4" CAST IRON PIPE EL.= 98.46' INVER7 INVERT '
(OR EQUAL MINIMUM —96.3'
PITCH 1/4 PER FT EL.=96. 7' ��L EL.—___ CLEAN SAND FILL 9"
4 P SCH /R7R 2. MIN.
FLOW LINE 40 P� PIPE � 9713' Iftbameftm
# EXISTING
INVERT 110" 14"
o 0 0 0 Q O om ° O O Vo±
m o 0 0
INVERT INVERT INVERT 24" o O O O f-1 �o� O O m 4y
97.13' EL.= 9_6.5' EL._�4-3- ° °°°° mom °�°� EL.=94.3'
DISTRIBUTION 4.0 e.5' 2.o' 4.o —
BOX �T > 27.0'
EXISTING 1,000 GALLON TO BE WATER TESTED 2-500 GAL. DRY WELLS
SEPTIC TANK AND PLACED ON LEVEL, STABLE
BASE OF 6" OF COMPACTED CRUSHED STONE
TEST HOLE ELEV= 88.4'
BOTTOM OF S
PROFILE OF
SEWAGE DISPOSAL SYSTEM ESTIMATED SEASONAL HIGH GW
NOT TO SCALE ELEVATION= 74. 0'
OBSERVATION HOLE 1 ELEV.= 100.4 3WASHED S NE, 1/8" — I/2-WASHED STONE
EL= 100.4 ViEPTH HORIZ TEXTURE COLOR MOTT. OTHER
EL= 99.9 0-6"' A SANDY LOAM $
EL= 98.6 6"-22" B LOAMY SAND 0YR 518 / $°a�$$ O O $��$$
GENERAL NOTES EL= 88.4 z"-144 C MEDIUM SAND 25rr/4 ' 4' 4 8' 1 4•
12.8'
1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. NO GROUNDWATER ENCOUNTERED DRY WELL
TITLE 5 AND THE TOWN OF BARNSTABLE__ RULES AND DATE OF SOIL TEST 12108101 END VIEW
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE.
2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO WITNESSED BY: WAIVED
WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" SOIL TEST DONE BY EDWARD PESCE, RE
3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN DESIGN CALCULA TIONS.'
10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 3
)
4 ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL NUMBER of BEDROOMS . .
GARBAGE DISPOSALL . . NO
BE MORTERED IN PLACE. TOTAL ESTIMATED FLOW
5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH ( _110 _CAL/BR/DAY x _ s_ BR) 330 GAL/DAY
DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT 1S TO USE 1500 GAL SEPTIC TANK 1500 CAL
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
`sY 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR INSTALL- 2- 500 CAL DRY WELLS ( WITH 4' CRUSHED STONE)
IS TO CALL "DIG- SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS SOIL CLASSIFICATION . . . . . . . . I
PRIOR TO COMMENCING WORK ON SITE. DESIGN PERCOLATION RATE . . . . . < 5 MIN./IN.
7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS EFFLUENT LOADING RATE . . . . . . •74 CAL/DAY/S.F.
SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. TOTAL LEACHING CAPACITY 373.55 CAL/DA Y
8) PARCEL IS IN FLOOD ZONE___"C"___— SO77VM-L 7' t .8 X 2" X 7 SIALID.74J=117.B1 CAL/DAY
9) LOT IS SHOWN ON ASSESSORS MAP _ 169 AS PARCEL _ 31___. BOTTOM (27' X I2.BJ(.74)=255.74 CAL/DAY
10) NO WATER SUPPLY WELL EXISTS WITHIN 150' OF SAS
SHEET 2 OF 2 J. f 52960 GM