HomeMy WebLinkAbout0019 DUNCAN LANE - Health DUNCAN LANE, ENTERVILLE ` I
UPC 12534
0.2.15 L0R
NAiTINO8.YN
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TOWN OF BARNSTABLE , Ij
LOCATIONS ����, SEWAGE#
VILLAGEae-,-�
ASSESSOR'S MAP&PARCEL f
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INSTALLER'S NAME&PHONE N � � ��
SEPTIC TANK CAPACITY e2 11,6it� j
LEACHING FACILITY:(typea��`(,j �� (size)
NO.OF BEDROOMS,
OWNER o ,e,.
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 leaching facility) Feet
FURNISHED BY
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P
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yetis
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for bisposal �pst M Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) ❑Complete System � ndividual Components
Location Address or Lot No. 9 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel LI UI-Cf II
Installer's Name Address,and Tel.Ao. De ' er's Name Addres an
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building ,ft n4(w No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.requi ed) gpd Design flow provided gpd
Plan Date � Number of sheets Re ision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature f Repairs or Alterations(Answer when applicabl ) hquitD
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place th ystem i eration until a Certificate of
Compliance has been issued by this ar alt
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �(�) (^) Date Issued
T °
----------------------------------
iw
r
# No. 3 s Fee ! LIP .
�4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION T .W Yes
N,0,, BARNSTABLE, MASSACHUSETTS x
ftplitation for Zisposal * stem Construction Permit
4
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) [,Complete System � ndividual Components,..,"
Location Address or Lot No. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel �_1 9� U.
Installer'sName Address andTel.Igo. Desi ertheanWI-1 er
-,,, 1!;?
Type'of Building:
r_^ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building fit (/� w, No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.requi eedd) 1 ' gpd Design[flow provided gpd
F Plan Date �,✓�' c,�� Number of sheets { Re ision Date
Title n-p. i
Size of Septic Tank ! Type`of S.A.S.
Description of Soil G
Nature of Repairs or Alterations(Answer when applicabl ) EJ h 1Lk:1
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in '.
accordance with the provisions of Title 5 of the Environmental Code and not to place th �ystem i o eration until a Certificate of
Compliance has been issued by this 'odd o .ealth `
Signed _ Date 16 /7 _
Application Approved by � Date
.Application Disapproved by Date ,
foc the following reasons `
Permit No. � � Date Issued r (�T
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
adz, THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) w Upgraded(�,✓)
Abandoned( )by
at J a)p3c qL has been constructed in accordance
with the provisions of Title
'51 and the for Disposal System Construction Permit No. —
a ;v dated
-Installer C�Sra . Designer—
#bedrooms Approved design flow gpd
The issuance of this permi sshall of be construed as a guarantee that the system ill func i sio, ed.
Date Inspector
No: ?- --�4 , a Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS _
Misposal bpstetn Construction V,ermit
Permission is hereby granted to Construct Repair) Repair( )j Upgrade Abandon
System located at � t,,Ak,- h y
w.^�e 1.
and as described in the above Application for Disposal System Construction Permit,.The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of thi's permit. '
Date to /zr�D Approved by G / , S
Town of Barnstable
IME,, Regulatory Services
Thomas F. Geiler, Director
BAMSfABLE, Public Health Division
9`bpr1 ' a`°� Thomas McKean Director
Fc��
200 Main Street, Hyannis,MA 02601
Office: 508- 62- 44 Fax 508-790-6304
Date: �o , Sewage Permit# Assessor's Map/Parcel 11
Installer &Designer Certification Form
Designer: ���� �'/� •(J Installer:
Address: �� '"�c� Addressr(i,V, �
On was issued a permit to install a
date (installer)
septic system at 41, based on a design drawn by
�� ' V7 (addre s)
I0• �"��^jk +Qb dated I zo .
(designer)
I
ertify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were mfound satisfactory.
I certify that. the. septic system referenced above was installed with major changes (i.e.
greater than 10', lateral relocation of the SAS or any vertical relocation of any component
of the ptic system).but in accordance with State & Local u '-Lions. Plan revision or
ce .if d as-built by:designer to follow. Stripout (if rp acted and the soils
gZo,und satisfactory. P��H OF M4 �
tr v
DAVID s9`y ;.
D B.
MASON n i�>
( st 1 e 's re) Z
L3 9 No.1066 c�
SST P �rr
TW`
esi er s Signature)
PLEASE RETURN TO BARNSTABLE PUBL.- �� ��fE
OF COMPLIANCE WILL NOT BE ISSUED UN i ii, isu i ri i tu6 r URiVI AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice fonnsldesignercertitication fonn.doc
f
Town of Barnstable
" Inspectional Services Department
• BARNSTABLE.
MASS, Public Health Division
Fc + 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4987 7923
August 11, 2020
SHWOM, JACQUELINE
19 DUNCAN LANE
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 19 Duncan Lane, Centerville, MA was inspected on
07/27/2020 by Daniel Hawkins, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Static liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool.
You are ordered to repair or replace the septic system within one (1)year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF T BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\]9 Duncan Lane Centerville.doc
Town of Barnstable
3 BARN31'ABLE,
A b 9. ,�� Inspectional Services Department
tfD MA'i a
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
O 1 YEAR DEADLINE CRITERIA
tatic liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool
❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation
❑ A portion of the cesspool is located within a Zone 1 to a public well
❑ A portion of the cesspool is located within 50 feet of a private water supply well
with no acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane :•
u
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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 '5 # ILI-1 p
on the computer, Daniel Hawkins
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
us Company Address
Sandwich Ma 02563
City/Town State Zip Code
rmea (508)477-0653 S114324
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. ❑Q Fails
Dan Hawkins Digitally signed by Dan Hawkins
'Date:zozo.m.zs�z:ons�-oa•oo. 7-27-2020
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
e, p.
cam, Commonwealth of Massachusetts
r= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c,
19 Duncan Lane
V
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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:
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
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 19 Duncan Lane
V
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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 188
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
±= li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............ 19 Duncan Lane -
Property Address
Jacqueline Shwom
Owner Owner's Name
information is
required for every Centerville Ma 02632 7-27-2020
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
❑ ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Q 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
i
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
J. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane
V
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Q Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 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.]
❑ 0 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
El El ' the system is located in a nitrogen sensitive area(Interim Wellhead Protection
1
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 -
Commonwealth of Massachusetts
m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane n
V
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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 CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no" for each of the following for all inspections:
Yes No
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ 0 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)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
❑ ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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:
El ❑ 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
El El 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane
Property Address
Jacqueline Shwom
Owner Owner's Name
information is required for every Centerville Ma 02632 7-27-2020
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
330/GPD
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
Number of current residents:
4
Does residence have a garbage grinder? ❑ Yes 0 No
Does residence have a water treatment unit? ❑ Yes rml No
If yes, discharges to:
Is laundry on a separate_sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes 0 No
Seasonal use? ❑ Yes 0 No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
2019- 155,000gallons 2018- 161,000gallons
Sump pump? ❑ Yes IMM No
current
Last date of occupancy: Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. � 19 Duncan Lane
emu,
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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 3 years ago
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
9
How was quantity pumped determined?
Reason for pumping:
t5insp.d6c•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane
V
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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:
Newest SAS added to existing system in 1999 per COC
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No "
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron X 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
�T Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane
V�
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
11011 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
v Dimensions: 1000gallons
611
Sludge depth:
3011
Distance from top of sludge to bottom of outlet tee or baffle
311
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
1511
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane
u
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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
t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
(' a Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
19 Duncan Lane
V�
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
required for every torvill e
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 R
9. Distribution Box(if present must be opened) (locate on site plan):
Over outlet
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 is full over outlet invert due to failed SAS.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 T ty
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. 19 Duncan Lane
V�
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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 workingorder: *
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:
(1 ) 6'x6' pit
El leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
4 Hi Cap infiltrators
El leaching fields number, dimensions:
❑ overflow cesspool number:
x
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
J-
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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 hydraulic failure at the time of inspection. Both leach pit and infiltrators
were full over inlet inverts.
r I
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
'ti.
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane
u
Property Address
Jacqueline Shwom
Owner Owner's Name
information is required for every Centerville Ma 02632 7-27-2020
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 F6My
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
19 Duncan Lane
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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
1 JJ,
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istXa sttax dtie� .ftnlne3 BuntSe?'3'pCr.Rap_,+Cpddii5 agTa.'�.a7tin¢:d.
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:rxp U;*�)aa azumsra uarnzmados
�,� � •3LHQ "a.7t•Str7"IdbYQ,i`�- _���.. =3:.dt"s::x-T!�'ti3d _
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t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
19 Duncan Lane
Property Address
Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
FEW! Check Slope
0 Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: NoGW@10'feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
If checked, date of design plan reviewed: Permit dated 9-13-1999Date
❑ 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:
A permit on file at the local Board of Health was used to determine high groundwater.
4 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
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
— �1. Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments
19 Duncan Lane F
Property Address
r_ Jacqueline Shwom
Owner Owner's Name
information is Centerville Ma 02632 7-27-2020
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:
Q 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 6ppropriate -
4 (Failure Criteria)and 6,(Checklist)completed
❑� D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached'
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
, 4
r .L
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
wry
h'ro. Fee 63_
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
s
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Digool *pmem Congtruction Permit
Application for a Permit to tract( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.L VUjU C 4 V L„aq Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's L4ame,Address wand Tel.No. Designer's Name,Address and Tel.No.
Type of Building: "� /
Dwelling No.of Bedrooms Lot Size ° J b sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank C)O v Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
U
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of it e Env nmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued thi Bid,o I3�a
SignedDate
Application Approved by r Date
Application Disapproved for the following reasons `
Permit No. <' Date Issued
R h
Fee
N THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
3ppiication for �Bigpogar *p5teni Construction Permit
Application for a Permit to truct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
\ Location Address or Lot.No.L ,,V ,� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel i/ � 'J � G ��t11 f �G
IV7-dl?
Installer's ame,Address and Tel.No. Designer's Name,Address and Tel.No.
A
Type of Building:
Dwelling No.of Bedrooms Lot Size t sq.ft. Garbage Grinder( )
p ,y Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
q Design Flow -3 3 U gallons per day. Calculated daily flow gallons.
Plan Date Number%of sheets Revision Date
Y' Title �y
Size of Septic Tank r o O v Type of S.A.S.
Description of Soil
a
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: !
Agreement:
The undersigned agrees to ensure the construction and maintenance of the'afore described on-site sewage disposal system
in accord,ance with the provisions of itle of the Envir.Qg.nmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued thi Bo d of 9A
Signed Date `
Application Approved by _14 Date
Application Disapproved for the following reasons 17
Aaq
Permit No. �' Date Issued
00-
--/ -------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
\ � BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
.,� THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( ,f(j Upgraded( )
Aba doned( )by M -
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ated
Installer Designer w<
The issuance f hi(s a shall not be construed as a guarantee that the 4 "ern-will funp� r� s s' + d �
Date I Inspector
f
----------------------------------Fee
----- --------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mfigpogaf *p!gtem Conotructton Permit
Permission is hereby granted to Construct( )Repair( ij Upgrade( )Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this < t.
Date: Approved by
_y
TOWN OF BARINSTA.BLE
sM F A6~ ss;rssOI;s 1Ai' f _,� _.
SEP"TIC' TANK CA?
(.t j pe)
MIS�%"AZTIDATE: S0I'APLLk.NCZ DATE:
Se_a:�do n D•si..wice Between the:
I
Maxim mi Adpu ted Groundwater'i 0,nie and Bottom of Leaching Faci i.f F ect
P:yvate'»`etee Supply S,Jeil xid Lading Facility (If any Weis exist
on site or within 200 feet of leaching facihtyy) _;�eet
Edge of eland and Leaching Faciii.y(If any wetlands e,,ist -- --
wiciiin 3W feet of leaching facility)`_
Furrushed by _
i
��) 'nc b
116199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PEIUMIT (WITHOUT DESIGNED PLANS)
I, hereby certify that the application for disposal works
construction permit signed by me dated / 3 ` - = concerning the
property located at /6 22 11 meets all of the
following criteria:
• The 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 I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
ma.imum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimotor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(1.1) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) d
B) G.W. Elevation the NI.AX High G.W. Adjustment . = 2-6
D 1FFEREN EN A and B
SIGNED : DATE. r 3
(Sketch proposed plan of system on back].
q:health folds:cat
.. too0
3zfccb Sc l�
TOWN OF BARNSTABLE
SEWAGE
ASSESSOR'S MAP&L0
SEY= TANK CA
LE,kCh-24G SAC .,
DUPLD OP,0bVaE '-5' /A
PEMN1 DA : j 3" COMI LUN DATE:
Separaion Distance Between the-
Maximum Adjusted Groundiwater`k zble and Bottom of Leaching Facility Feet
Private b+°ater Supply Well and beaching Facility (If any wells exist
on site or within 200 feet of leaching facility" Feet
Edge of Wedand and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Fee
Furnished by
- ,
3 -
i . .
v
lc a ro It
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
OF.. . ........................ .. .....................................
............ . ... ..............
Appliration for Disposal Works Tonstrudion jiumd
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at: `
�'C�rr�nr/cam-
......1 q..._.. •c rc �S1kf ----- -- -- ......................-............................_......_.:--
� Loc ti ddress or Lo N�
1�� ..._--------------------•--------•--...... �y � ...�u:..... .. �l s:
w Owner l�...A..d..re
.� :...... e....�....... ..................... ...............N.......---
.................. .............
a t' Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther$Type of Building ...........0................ No. of persons........._..........._...... Showers ( ) Cafeteria ( )
04 Other fixtures ......................................................................................................................................................
d tto
Design Flow.............::...................gallons per person per day. Total daily flow...................�J.Q................gallons.
Septic Tank—Liquid capacity............gallons Length..........o.o.o. Width................ Diameter................ Depth..........
DisposaltTrench—No..................... Width.....r........ Total Length.................... Total leaching area........��.-......--.sq. ft.
3 Seepage tPit No.......... ....... Diameter....J�.�.S.... Depth below inlet........�1......... Total leaching area....`;1��2....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..............................................0........................... Date........-.......0.0.........••..........
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water....-...................
f= Test Pit No. 2................minutes per inch Depth of Test Pit............-.0..... Depth to ground water........................
�+ .......................................••--•--•---........... ..........................
.............------------
..........................
ODescription of Soil.................................-..............................................................................................................•-••----•..............
W 00 .......................................
.. .. ......... .. ......0...Z..............'roxL��...........0................. ........... ....
Nature of Repairs or Alterations Answer when applicable.., d.... s?... �$73! ...r✓ Gl�
---- .x(a.�,t�A.ft...... --0r0...:�Z.. --.--- . •.................. ......-.............-.....................................--------•--
Agreement:
The undersigned agrees to install the afor de ribed Individual a age Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary C de—The under further agrees not to place the system in
operation until a Certificate of Compliance has issued b the b h. 2
Si .. ........ ........ •..........0............................ > �z .0......
Date
Application Approved BY ............ ..............................._ ....._..3..- �.-. .4f......
Date
Application Disapproved for the f olloun g se ons:.............•---• ....................................-.....................................0...........---
-•........................................•............. .....^........_.0.0........._....................................-......................................................._
Date
Permit No.............M.:Jay......._.._...... Issued_..---------•-. _..._....
-••--•--.......... .........
Daft
.\.\.n•Cva:r'nr -elf\'.N _.r. .,. ..eR. "'_• . .� "'T r - . . .. ti . . , � •. •Yn' Mwr - .. n v .V .. ..,n
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��! i '.� . ................................
is
Lt/ ' ..................O F A.
Applirtttion for Disposal Works Ton.strurtion Frrinit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at: ,�
. �1 __. �' L�/o"aar�5g.........................-...... .....................................................�y . .G&......................
c � �.....or
a a - l5• nil �C/ / 141&VI C14 Ad res�
......................................... .._.:....................•.........................•.. ••••••-•--............•--......•--•....._..................................................._.....
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
01 Other fixtures .......................••---•-••
WW Design Flow.............. ._.gallons per person per day. Total daily flow.............---.-.:--...__.................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. Width............... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.......... ....... Diameter....1!2.:.�..... Depth below inlet................. Total leaching area.. r�� ..sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................... ... Date........................................
,.a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....--..................
a •••••••••••••--•----••-•---.........•••••-••-•••.................••......................-••---..............--•---........................................_.
ODescription of Soil.................................................... ........ . ...........•--......------•-••--•--....-•----.......-•-•---•--•----........••••....................
•. ••••••••-----•----•.................•--:......-••-•••--•----•--•---.._..•••••--•--...._.....•••--••••......-•----•------•-••-......----••••-•••••--....-••-........................................
U Nature of Repairs'or Alterations—Answer when applicable..: V....1 M.... (Mar- Swm_ 7:�k.••c, Nr J_
_ .................•--•••........................... .
I a X•��? W+T:7t.....-..._i'7 �R.lC1' ''')
Agreement:
The undersigned agrees to install the aforedescribed IndividualfS age Disposal System in accordance with
m
the provisions of TITLE 5 of the State Sanitary�Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeri,issued by the board of,health./ }
Signed '� �, >7. -;`�' ..........................'` _..._
....
� � ` Date
A licarion Approved B / .......................................... - �s
v ! /° Date
Application Disapproved for the f ollotving reasons:..............................•---.........--•---•---......-•----•-•-••-•----.........-- -•--•---•-•----
............................••----......----•----•-•--•-•----........-••--..._........_._........_...........•----•-•---•-•••--.....••..._........._..._....•-••••-••-•----••-•-•-............---._
Date
Permit No............a..:_ 3 W........-__._.._ Issued................ ..............................
Da _
ce
THE COMMONWEALTH OF MASSACHU SETTS
BOARD OF HEALTH
OF.... Cf.. L
.. .......................................... ....................................................
Trr#if irtttr of Tomplittnre
THIS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (A )
by....--- ../ti`.C.: .............•-----••••---•---•----------•-•-----•-------..................--....._.--•--
/ Installer /
at_....19....l�(lc t CA I� Le( / +✓r'' T ' 1-t/i� 17T�/d�C�l
...... ..................--.----••-•--••-----.......^ ......•••.......----•----------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......g_�...... ...... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............••-••••-••...:t!--.. ....` ..1�. .... Inspector....... = ................................................
THE COMMONWEALTH OF MASSACHUSETTS
-7*5VA ( BOARD OF HEALTH
5/�J�... .... ,�.................................. FEE........................
`�S- 13 �/ ..OF........................:.((
do.A.
Disposal orks``T� onotrurtion V.ermft
Permission is hereby granted.....��_._... _. ....�-�?...1/l' C_
.•-•-••••--•---•--•--••------....•-•..............................................•••....._
to Construct ( ) or Repair (/,) an Individual Sewage Disposal System,
at No....�q.....0—il.-1 C4-t] t°ZI . Cf- X./ toil f ? 5WUj u
................................................... •-•----•---•••.....`
I -•••-•street
as shown on the application for Disposal Works Construction Permit No.A.,I3_2L. Dated..........................................
DATE_ Board of Health
........--•--••••••-••...-••••................•---............................
FORM 1255 HOBBS 6 WARREN. INC.. PUBLISHERS
LOCATIO , �G c-, SEWAGE PERMIT NO.
. . VILLAGE o• w`
INSTALLER'S NAME&ADDRESS
4,gi.�� s coor" r�l
19' bu Aco-y-", �-or
BUILDER.OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
oil 4r(
I. 3�._:� _� � -
.�
i I�
F
y�.
v
� ����
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No......................... Flz$.... ... .
THE COMMONWEALTH OF MASSACHUSETTS 4
F, BOARD RF HE . T
t> O.F.
rApphrttlion -for Ii-4 psal Workii Tontitrurtion Vrrmit
Application is hereby made.for a Permit to,Construct ("'S or Repair ( ) an Individual Sewage Disposal
system
--- `
1 Locati d ess TV-
r or t
F
O er -' Address
0 �
Installer Address
d Type of Build' Size Lot............................Sq. feet
U Dwellin —No. of Bedrooms_______________________`�_-___ ____________Expansion Attic Garbage Grinder ( )
aOther—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fi es ..-- .........
Design Flow - -- -
W g f gallons per person per day. Total daily flow____________ ________________________ ______gallons.
WSeptic Tank—Liquid capacity __,------gallons Len th__________ ____ Width_ •_V._._ Diameter_____.--._....:_ Depth______-____--...Dis osal Trench, o_ ____________________ Wit Upth
Ia J, Total leachin area---______.__._______s ft.
P � � - l� ��ce - g< q-
_____ Diameter____________��____ belo let_ To < lea it ar sc it.
Seepage Pit No rl .; ,e c -. V- 1-
Z Other Distribution box ( ) Dosing tank ( )
~" Percolation Test_Results Performed by_-------------
..__._.....__...__________,____ Date--'--`---_,_,-____-_----------------
Test Pit No. 1................minutes per inch Depth ofPit....._._ _.._.___ Depth to ground water_.....-_-___..____-Test Pit No 2 __. _minutes per inch Depth ofst Pit
oi ._ Depth to ground water------------------------
-wel ------------ i- . .
----•----
Descriptionof Sl------ ------- .. •-•••______________•---•------•-• -____._. ..-----•---•-•-------•------------•---•_----•--•-••---•---------------
V - -------------------------------------------------------------------------------------------------------------------------------•---•-•-•1•---------•----•-•-•-__._.._._-_.._..-•----•------
UW ------------------------------------=- -----------------------------------=------ -----------------------_....•-..•---•--•-•---------
Nature of Repairs or Alterations—Answer when applicable.______________":::_____-_____._._:......_..F____..._....._.__.-___.-__,___-_______-_,_,____----
- ........... .
-----•-•--•-------------- --------- = ----------- -------- --•----••--•------------------------------•-•-•---•__,___-•--------------------------•--••-•--__---
Agreement: _
The undersigned agrees to install the aforedescribed Individual, Sewage Disposal System in accordance with
the provisions of Article XI of the State.Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has;been issued LbDithe board of hteth,
n ••• ...........C]A ............... ----
ate
Application Approved BY•i
----•------------------------------------------------------ .....................-.............. ........................... -------------
Date
.AApplication Disapproved for the following reasons________________________________________________________________________________________________________________
i
Date
PermitNo.......................................................... PeIssued........................................................
Date
,w THE COMMONWEALTH O MASSSAACHUSETTS
B 7
OARD -L H
..........................................QF.... ................................................................................
Tntifiratr of f11nrmpiittnre
THIS k
TO C hat the Individu Sewa Dispo al S Wnstructed ( ) or Repaired ( ) f
by___� • I St ...................................
t
ib"/ 07 rat a
------------------ ---------�-----. -----.-_----.----------------- -------:---- ............................................................
has been,installed in accordance with the provisions of Articl k'' a State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF. THIS CERTIFICATE SHALL NOT,BE,,,CONSTRUED AS A GUARANI` E THAT THE
SYSTEM XILL FUNCTION SATISFACTORY. A`
f �
.G..P�_ ..................... Inspector....
DAT1 % =
THE COMMON WE OF MASSACHUSETTS
BOARD A
OF......................................:............................................
No.......................... FEE.........................
�i� -tt1� ark;i.�-L - ,�trurtinat r
Perini io hhereby gr<'' df= "� t W
=- = =� - ----•-•••------•--•-- •---•••-•-•-••••••-
to Conl�t 1�"Pal3�}lalis t
atNo....... --•••_____________.........9. -________--=--•-•-•••-•-••--•-•--..._-•--......___••.---
tr t
as shown on the application for Disposal Works Constructio ...................................
-.,...
�a: s Board-of He -
= DATE...................-------
.FORM 1255 HOBBS & WARf EN. INC., PUBLISHERS r
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD F h-4E LT -
...--- --.OF........ ... .
Aplifiration -for M! uiitt1 Workii Towitrurtton Vrruift
Application is hereby made for a Permit to Construct ( V<r Repair ( ) an Individual Sewage Disposal
System at:
�� "cam .finedP�vt h�•-•••--- ........................................-�1--"............................................
Location Address Lot No
�NA ------------ -----� --- ,eex ------1A-7�;.......124
---------gy-11
ner Address
Installer Address .� F O 0
Q Type of Building Size Lot_.!........................Sq. feet
U Dwelling -Expansion Attic (✓f Garbage Grinder ( )
�No. of Bedrooms---------------•---------------------------
a4 Other—Type of Building -------------- ----------- No. of persons.-._____-___________--__--__ Showers ( ) — Cafeteria ( )
Q' Other fixtures -----_................................................
W Design Flow.............y __.________ -gallons per person per day. Total daily flow..........Z_6'Y--- .............gallons.
WSeptic Tank.-Liquid capacity{ _-gallons Length................ Width_.___ ._... ._._ Diameter---------------- Depth--------_.-----
x Disposal Trench=No_ ____________________ Width___________----�} al L ng � Total leaching area.-------------.-----sq. ft.
Seepage Pit•No._._. Diameter/_ D Total leachinn area_...
/------------ f ...._. ..._ e0e nlet_... --------------sq. ft.
z Other Distribution box ( ) Dosilig tank ( ) O�" "' 1� i `7�
aPercolation Test Results Performed bY-------------------- ...................................................... Date__--------------------------------------
,� Test Pit No. 1..........._....minutes per inch Depth of Test Pit.................... Depth to ground water.._---__--_--_._-._.----
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-_.---_-.-_.-___----.
Ot r -----------------r----._._.r--
Description of Soil ............ ----------------------•....-•.--•------'--=-----••--
x
tJ --------------------------------------------------------------------------- ••••--••-•----'--------------------------------------------------------------------------------------------------------
.tF
_____________________________ __ _ _____ ___ __________________ _-------------------------------------------------------.-----------------------------------------------------
U Nature of Repairs or Alteraatibns—Answer when applicable.-----------------------------------------.....................................................
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a.Certificate of Compliance has been iss ed by,the board f health.
5
Signed- ---•---------------•• ------•----- -� ---�1�
Date
Date
Approved BY .G- --
Application
"
Disapproved for the following reasons:................................................................................................................
............................... --------------------•-------•-----------------------------•--•------•----•----••--------------------------------------------_-----••--------•-•--•--------------•-------
Permit No......................................................... j�
----------------------•-------...---.. Issued.--- --------
Date
LOCATION : Xot V/ 5EW&C-4E PERMIT IJO.
WST&LLER5 1. &ME 6 ADDRESS
15UILDER 5 tJ I MF— ADDRESS,
DNTE PERIA T .ISSUED —
D b.TE COMPLI &KiCE ISSUED : �S
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i� The instaila°l;'irl shall C:l/il�}ly)Kill)the State Environmental(:r1de Title�,'ar)d Town of-�'''"fL�
- - _ - Broard of 1-iealth Reguiations,
rum D ,' WiG� Gv '. '� �f'� ��r 2) Tihe septic system as proposed on this plan shall not be installed until a fir eased town installer
receives approval:ind an installation permit from the applicabFe town.
--- _ �• t :1 PriOt to installation,the installer shall verify the locaticn of utilities,se,,ucr inverts, sewer lines
and existing septic components prier to installation.
r 4) All gravity sewer piping is to be G inch schedule 40 PVC at 1/8"per foot. The first 2 feet out of
- - - -------- -'� the distribution box shall be hzvel. All;zotping connections to be glued.
�^` 'r l v' �� '-f 5 This septic design play, is not to be utri=zed for property fine determinatrc r or for any other
Lb I purpose other thz n the proposed septic system installation.
t i
- , _ V �-I Ali Title V comporents are to meet Title V specifications.
Parking shall be prohibited inter s itle V components unless, r_^mpow nts are H2O loaded-
-57
LO(ATI ON E � � g} The existing leaching or cesspaois sbail be pumper! and filled with material per Title V
,p, ! abandonment procedures Leaching and cesspool(s)and contaminated soils within the
proposed SAS shall be removed and replaced with clean sand pe+Title V specifications.
9? Septic components are« be ip' frorn a water service line. Sewer 11hies crossing a water line sll"�i
i
be sleeved with an appropr:ately sized schedule 40 PVC with ends grouted. The water service
_ liar or the septic line cart;e sleeved'err!h the sleeve lading.-4 distance 1�:' on boo-Eides 4
t:1'ossing the� line-
Co h ��;� /! � � � ! ,�, -AMj €f a garbage grinder exists in cS>e structure, it is to be removed it the septic: system is not
-- - I o5, b ` -- ' designed to accommodate a gartiagP gender.
1--- _i Thin installer is responsible`or tare—if excavation around aii ,,aiknes or,the property and
protecting the structural En,egrtty of all structures during tale rls'allatior, process of the septic
4--- ,
/ 1.2; This Alan only represents tllct a septic system can be instaS471.1 on fire property meeting Title V
l /
requirements.
?a; The property owner shah review cfesfg;,criteria to approve t}•t total number of bedrooms and
Te � design flow.lnstailatlai of the septic system as proposed and receipt o1 payment for the de.sigr,
3 � stta;l be deemed approval>;•€the design criteria by the property owner or egent of.
Tile validity of this pian st ali expire with the expiration of the town installation permit issued fc i
this plan or the validity of this rrlar, shall expire on the expiration of the Certificate of Compliance
issued for the ostallai -,al%o;rn_ f•.c ,c,<r-d sysrerr. rn :h;s plat).
`' �1,��_ I� �_ � I )lam- �! �,� �''�` ✓, 1�, Ct��'V�,r , _ ��� �1� �_ ��� (,��'��,
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