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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:. 158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name /
information is required for every Centerville MA 02632 7-20-20
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.
A. Inspector Information
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508-495-0905. S 13971
Telephone Number License Number
B. Certification
I certify that:) am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty 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
7-20-20
s ect ignature 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
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
i,'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is Centerville MA 02632 7-20-20
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:
® 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:
System is in good wgorking order with no sign of failure.
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):
I
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I-i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•;_ y�'.
158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
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 El ❑ ND (Explain below):
❑ obstruction is removed ❑ Y El ❑ 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
�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
> c"
158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
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
❑ ® 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
s Commonwealth of Massachusetts
r� ,w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
1
sue` Commonwealth of Massachusetts
Title 5 official Inspection Form
.%t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Ln
J
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
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
❑ ® 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?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
rill 3 Title 5 Official Inspection Form
, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Ln
Property Address
Mansour,Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 20
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 2020Date
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
ri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
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: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
c Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
r�l Subsurface Sewage Disposal System Form Not for Voluntary Assessments
158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System: t?
® 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:
2000's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 24"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.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
> cr
v.,
158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 18"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
�w
IQ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Lin
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspecti on)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
ii
ri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Ln
Property Address
Mansour KairouZ
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
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):
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.):
Good condition.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachu r setts
Title 5 Official Inspection Form
! ;Pi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3-500's
❑ 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
Title 5 Official Inspection Form
iCM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,_�,
158 Elijah j h Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
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.):
Leach chambers in good condition and empty at inspection with stain line at 6"off bottom of chamber.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
161 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� :. 158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
a� Title 5 Official Inspection Form
ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Ln
J'
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
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
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r ,rr
``" 158 Elijah Childs Ln
T, '
Property Address
Mansour Kairouz
Owner Owner's Name
information is
required for every Centerville MA 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 124
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:
USGS and town maps show groundwater at greater than 12'.
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
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Elijah Childs Ln
Property Address
Mansour Kairouz
Owner Owner's Name
information is required for every Centerville MA 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. inspector information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
3
T Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'Ell g�, G�, s Lam1
Property Address /
e
h rl h � e �� ,
Owner Owner's Nam J All �o' �� ✓
information is Name yt/ �y
required for every ."�
page. City/Town State Zip Code Date of spectio rl
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab
key to move your 1. Inspector:
cursor-do not
use the return Name of Inspector
key.
Company Name V 49
Company Address L S /�/ G✓rl /�� DpZ
� City/Towrt/`A� OL)` %��— � no State L O�� Zip Code
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 R 15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspect '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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Q Gree��
Owner Owners Name,
information is , 14-4rvl /!e �/7 oalD 3 � 3 �ti
required for every
page. City/Town State Zip Code Date of In ection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System P ses:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'a C4-/✓s y
Property Address
Owner Owner's Name �,w /f/J / /
information is �r/ l/ �'�/,4 0.�b 3a C�
required for every
page. City[Town State Zip Code Date of] pact
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name /�
information is HT�Vz Ile 0,a d 3a
required for every
page. City/Town State Zip Code Date of In ection
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
llllllllllll������ clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Eh
I
Property Address
d lrleele
Owner Owner's NameC
information is
required for every
page. CityTTown State Zip Code Date of In pection
B. Certification (cont.)
Yes No
❑ me"*" 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary/Assessments
Property Address
Owner Owner's Name 6"rv,i
b /information is ` e ✓T VO IGs 7required for every
page. City/Town State Zip Code Date of Inspec on
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes N
Pumping information was provided by the owner, occupant, or Board of Health
P 9
❑ Were any of the system components pumped out in the previous two weeks?
❑ the system received normal flows in the previous two week period?
El 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
een 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: .3
o�
Number of bedrooms(design): — — Number of bedrooms (actual): —
be �30
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
g f a �i z
r
Property Address O lie-eW�
Owner Owner's Name
information is
required for every
page. City(rown State Zip Code Date of I pection
D. System Information
Description: / /Soo / /j0� SP /G / a µ G✓ —
I SA
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes �o
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonaluse? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes . No
C�✓ram
Last date of occupancy: 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner's Name _ v /� 14 / V
information is r �
required for every
page. City/Town State Zip Code Date o nspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?, ❑ Yes o
If yes,volume pumped: gaiions
How was quantity pumped determined?
Reason for pumping:
Type of Sy
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
N Title 5 Official Inspection Form
al Subsurface Sewage Disposal System FormJ-Not for Voluntary Assessments
Property Address
L
Owner Owner's Name r_,
information is pa drequired for every —5Gj� w�
page. City/Town State Zip Code Date of I pectin
D. System Information (cont.)
Approximate age of all components, date installed (I known)and source of information:
,2Oog oY--9'91-- Y0171-
Were sewage odors detected when arriving at the site? ElYes No
Building Sewer(locate on site plan):
Depth below grade: feet 3
Material of constructi;4'0
❑ cast iron PVC ❑ other(explain): — - - ----- - - -- -
/O / 71—
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan): w //
Depth below grade: feet pL]
Materi construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: tl
Sludge depth: I
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
I
r�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
/�sg A R � a /c/s
Property Address
Owner Owner's Name a
information is 141A
required for every
page. City/Town State Zip Code Date of AspectioA
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
0 1-
2
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.):
iI ,ORI Y1 �O7— �ee: /c ,
Gvr GNJS
OD G CO'0C41/70 I
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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for
Voluntary Assessments
Property Address
Owner Owner's Name/�
information is / ��rv`11,e
IN ,,� tarequired for every (.�l%(/N�'��GG _ _ _
page. City/Town State Zip Code Date of I pection
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 Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is � e //�j� Oa b 76�
required for every ��//���YY —
page. City/Town State Zip Code Date of specti n
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
-- 1410.__�o , V/
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'mill I Ct As
Property Address
�eeize-
Owner Owner's Name p Q
information is
required for every
City/Town State Zip Code Date of Ins Pi —
page.
D. System I ormation (cont.)
Type' ✓ �0'0
A-, (�576-r4
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:. ---- -
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
ONji d! /17 -e
/0 J15nj v,ee Ntj c4,atjr -74� 114re-
011
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.5116 TiUe 5 officiai Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
PC
Property Address
Owner Owner's Name
information is required for every
page. CitylTown State Zip Code Date of specti n
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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Volunta Assessments
Property Address
Owner Owner's Name
information is A/XC�pN`+G✓(�/
required for every --
page. City/Town State Zip Code Date of I pectio
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two wmanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where Ic water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
Soo
� Cs�/loh Nis �
03
00
ok
Sept/c /QtSprt
l CNcln�1/,f
00-sooz
A3 - Y7, 93- do. �
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Mr
Property Address
o
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date o Inspec on
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells �� f
Estimated depth to high 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 d cribe how you established the high ground water elevation:
Dig Ze,
at t✓i epi Cke, +o
1- 410 to C 4,C1.
--- --- /
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage/Disposal System Form Not for Voluntary Assessments
'Ell
Property Address
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date of I spec
E. Repo ompleteness Checklist
Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
�s 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
No. ( L �O ., r 1 Fee ®THE COMMONWEALTH OF MASSACHUSETTS Efitered in computer: V
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS
ZIppYication for -Migaaf bpotem Congtruction Permit
Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) C5 Complete System ❑Individual Components
Location Address or Lot No. wner's Name,Address and Tel.No.
1117,
Asses sgr' ar—ar5 Li,3 /+p� nlll/e p
Installer's Name,Address,and Tel.No. (/ri ! Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Z Lot Size / sq.ft. Garbage Grinder(_0
Other Type of Building iTo.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow J� gallons per day. Calculated daily flow y0 gallons.
Plan Date �/J� 6'y Number of sheets / Revision Date
Title (,T' 3 $ % Z5 r
Size of Septic Tank / % Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been i Z�do alth,, / /
Signed Date �6
Application Approved by Date O
ET
Application Disapproved for the following reasons
78 Permit No. — Date Issued
No. �=d�� z� �` _ W Fee Q
t>1
". E�Fiiered
.�•,�._ �` s" r THEZOMMONWEALTH OF MASSACHUSETTS in computer:
Yes t
v'" '1
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pplication for Biopogar *pgtem Cow6truction j3ermit
'Application for a Permit to Construct( )Repair(✓)Upgrade( s )Abandon( ) U+Complete System El Individual Components
Locatibn Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's May/ParcelVrv/, //e
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
le
�30r F e� 4plvle
--0'3
Type of Building:
Dwelling No.of Bedrooms Z- Lot Size sq.ft. Garbage Grinder(-41a
Other 'Type of Building o.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 7Jl� gallons per day. Calculated daily flow gallons.
Plan Date_ : 7/l/l y Number of sheets / Revision Date
Title eP la'9 _ 94jzlz
Size of Septic Tank / '/) Type of S.A.S. 0 en P/_S
i
Description of Soil /D�' 3�.r7 /
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been i sue s do ealth,,
Signed �� � - Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. �;Co L4 -- Date Issued t7 O L
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CER FY, that t On-site Sewage Disposal System Constructed( )Repaired(✓)Upgraded( )
Abandoned( )by _
at �i iY YI/ s�been constructed in accordance
with the provisions of Title' and the for Disposal System Construction Permit No. dated
Installer t,y..,W .o Designer
The issuance of this permit shall not be construe as a guarantee that the system will function as dfsiigned. 0 6
Date !� a. 1 ,_ ;I Inspector''.,�., ,✓► �� ! ..71"n A(' t
�� `'/ lam/iil -..- o `L.�G :{�u t t ��° 1
No. r —of I Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
;Di!5pogar *pztem Con0truction Permit
Permission is hereby granted to Construct( )Rep r(✓)Up ade( )Aban�on( )
System located at 1 g f// )� C �a% 1,op o,B-
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:Constru tion must be completed within three years of the date f this p T"t
Date: 7 6 y _ Approved by
9 I'
i
Town of Barnstable
�oFsr�E'o�ti Regulatory Services
Thomas F. Geiler,Director
♦ BAMSTABLE. • '
MASS.S. 1�� Public Health Division
�rEp �s Thomas McKean,Director
200 Main Street;Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: /
Designer: Installer: sel_AI 161 e D5ew, /zw
STEPHEN J.DOY-LE AND ASSOCIATES
Address: 42 CANTERBURY LANE Address: �.��D`�157`ry
EW FALMOUTH,MASSACHUSETTS 02636
508/540-2534
On �l `'( �Dr �// i'�Q�?6 was issued a permit to install a
6
(date) (installer) 141,
septic system at 1S-b'� ��Jam' 5 G741ae bused on a design drawn by
(address)
- s dated !
desi er)
I certify 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.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
0►P���OF MAs340", d�
GAS"EAFC 6J,
z �
(Installer's Signature) SZEPNE N
D��E
t
(Desi er's kgdature) (Affix Desi e ' Stamp Here)
PLEASE- RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
TOWN FHB ST E �'C.
n 41064
g
LOCATION j l' SEWAGE # 0
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VILLAGE C_ e-dl ./��/��!L� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. Ae011 Z � 42L , 77/'� 2-f
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) /'eeW/0 (size)
"NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 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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Pff
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2 -
i FAILED INSPECTION
l
COMMONWEALTH OF MASSACHUSETTS
Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
-1,4 sv 0
350 MAIN STREET
WEST YARMOUTH,MA
508-775-2800 q;p
2C,04
TITLE 5 iJt�nEP�[ �ARriS7AELE
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS -H DL"T-
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 171 PAR 243 I�
Property Address: 158 ELIJAH CHILDS I e*q L A N E MAP
CENTERVILLE,MA 02632
Owner's Name: POWERS,FRANCES PARCEL Z
Owner's Address: 158 ELIJAH CHILDS ROAD �0 ,
CENTERVILLE,MA 02632
Date of Inspection DECEMBER 18,2003
Name of Inspector:(please print) JAMES D. SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yannouth,MA 02673
Telephone Number: 508-775-2800
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 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
./ Fails
Inspector's Signature: Date: �� /J'o:3
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 tot he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE,MA 02632
Owner: POWERS,FRANCES
Date of Inspection: DECEMBER 18,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: N/A
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
r
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE,MA 02632
Owner: POWERS,FRANCES
Date of Inspection: DECEMBER 18,2003
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
i
Title 5 Inspection Form 6/15/2000 3
i
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE,MA 02632
Owner: POWERS,FRANCES
Date of Inspection: DECEMBER 18,2003
D. System Failure Criteria applicable to all systems: ✓
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in pit is less than 6"below invert or available volume is less than 'h day flow
_V 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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this fonn.)
YES (Yes/No)The system fails. I have detennined 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 detennine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE,MA 02632
Owner: POWERS,FRANCES
Date of Inspection: DECEMBER 18,2003
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 nonnal 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 infonnation on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Detennined 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)]
Title 5 Inspection Form 6/15/2000 5
I
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE,MA 02632
Owner: POWERS,FRANCES
Date of Inspection: DECEMBER 18,2003
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms: 220
Number of current residents: 1
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: DECEMBER 1,2003
Was system pumped as part of the inspection(yes or 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)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1982 PERMIT#81-756
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE,MA 02632
Owner: MOPEOPZZ/EPPZZA;PM2FP
Date of Inspection: DECEMBER 18,2003
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 16"
Materials of construction: Cast iron ,t/40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 20"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 0"
Distance from top of sludge to the bottom of outlet tee or baffle: 30"
Scum thickness: 0"
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: 18"
How were dimensions detennined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL.TANK AND COVERS 20"BELOW GRADE. INLET TEE,OUTLET
BAFFLE.NO SIGN OF LEAKAGE.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Scorn thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
i
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE, MA 02632
Owner: POWERS,FRANCES
Date of Inspection: DECEMBER 18,2003
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alanm and float switches,etc.):
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.,):
DISTRIBUTION BOX IS 2'6"BELOW GRADE. LOCATED ON SITE.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alanms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE,MA 02632
Owner: POWERS,FRANCES
Date of Inspection: DECEMBER 18,2003
SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
J leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT IS 58"BELOW GRADE.COVER AT 20"
WATER 20"BELOW COVER. STAIN LINE2"FROM COVER. LINE PIPED INTO RISOR.PIT IS NOT
LEACHING.
CESSPOOLS: N/A (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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of]I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE,MA 02632
Owner: POWERS,FRANCES
Date of Inspection: DECEMBER 18,2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
t
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►l fr' F l� R
u
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/u/ T
Title 5 Inspection Form 6/15/2000 10
Page I I of I
r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 158 ELIJAH CHILDS ROAD
CENTERVILLE,MA 02632
Owber: POWERS,FRANCES
Date of Inspection: DECEMBER 18,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
/V
Estimated depth trroundwater 15 feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
✓ Observation 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:
HAND DUG TEST HOLE 15'. TEST HOLE 4' BELOW BOTTOM OF PIT.NO WATER AT 15'.
If
7—
Title 5 Inspection Form 6/15/2000 11
r
Sty
ti A R,
f
-
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ;``
r DEPARTMENT OF ENVIRONMENTAL PROTECTION
h `
y� 4!
M � r
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ;
PART A
CERTIFICATION
• �lJl �p�o `r't
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632
Owner's Name: MRS. POWERS '
Owner's Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632t
Date of Inspection: 12/10/01
RECEIVED
Name of Inspector: (please print) { JOHN GRACI ;
Company Name: SEPTIC INSPECTIONS a
Mailing Address: PIA BOX 2119 TEATICKET,MA.02536 DEC 2 ONO
O �
Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN pF BARNSTABLE
HEALTH DEPT. ,
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 am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes s
_ Conditionally Pa es k :'
_ Needs Furth aluation by the Local Approving Authority ,
Fails H i
,
3 !
ti �X
F F
Inspector's Signature: Date: 12/10/01 44:T y
The system inspector shall submit fcoopy 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 d or greater,the
Y p g P Y Y g gp g
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 ; r
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW THEN EVERY YEAR TO PROLONG THE
SYSTEM'S USEFUL LIFE.
This report only describes conditions at the time of inspection and under the conditions of use at that time.This 5 x �
inspection does not address how,the system will perform in the future under the same or different conditions of use. rRN'
s � .
Page 2 of 11
�tT
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A : ..
CERTIFICATION (continued)
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632 n `
Owner: MRS.POWERS
Date of Inspection: 12/10/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D ,.
A. System Passes: , a
k.
X 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: .rG1 "..
SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW THEN EVERY YEAR TO PROLONG ,;, ;
THE SYSTEM'S USEFUL LIFE. t `
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.re air as approved b the Board of Health will ass. { = <<
P P P P- ,. PP Y P
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits t� f
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced ' ',.
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup break out or high static water level in the distribution box due to broken or obstructed axrt #K„
g P ,;. � g
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health): t
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced '
ND explain: n/a
n/a The system required pumping mo e than 4 times a year due to broken or obstructed pipe(s).The system will pass k*'
inspection if(with approval of the Board of Health): ate '
_broken pipe(s)are replaced
_obstruction is removed r
3
ND explain: n/a
�1 7
Page 3 of 11
f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ' '
CERTIFICATION(continued) , 'a
x
4.
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632
Owner: MRS. POWERS
Date of Inspection: 12/10/01 . ;I
C. Further Evaluation is Required by the Board of Health: n
_ 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 1
not functioning in a manner which will protect public health safety and the environment: f
_ 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 marshy ..
N
C� t�
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
� a
system is functioning in a manner that protects the public health,safety and environment: F�tr'
_ 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. ,rr
3 Rkty b.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. t
_ The system has a septii?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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and r�
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 m provided that no other failure criteria are triggered.A copy
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of the analysis must be attached to this form.
3. Other:
n/a ��
Syr,sib
�r�r°fir
is
Page 4 of 11 a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ~ ^
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , s
PART A ':r
CERTIFICATION(continued)
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632 .._�.
Owner: MRS. POWERS =<''
Date of Inspection: 12/10/01
�t
D. System Failure Criteria applicable to all systems:
M
You must indicate"yes"or"no"to each of the following for all-inspections: ;
Yes No
_ X Backupof sewage into facility or stem component due to overloaded or clogged SAS or cesspool
g ty Y P gg P
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 'S4 �
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool �sa
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 day flow }'
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X An portion of cess oolor privy is within 100 feet of a surface water supply or tributary to a surface water supply. '
Y P P' P �'Y PPY rY
X Any portion of a cesspool.-or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with %*,
no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP i
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free = tx
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or "4g
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 1011,
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. T
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following: I
(The following criteria apply to large s system in addition to the criteria above) t l
yes no34.
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitro en 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
r h77
"yes" in Section D above the large systems 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 re ional office of the Department.
g P
rat gh
;I
Page 5 of 11 , r,
tv
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ='
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632
Owner: MRS. POWERS 4" "
Date of Inspection: 12/10/01
+ t
F.
Check if the following have been done.'You must indicate"yes" or"no"as to each of the following:
Yes No +
r
X _ Pumping information was provided by the owner,occupant,or Board of Health
t .r
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period ? s
X Have large volumes of water been introduced to the system recently or as part of this inspection ? ;
,.:;.
.f� �1
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
x S
X _ Was the facility or dwelling inspected for signs of sewage back up? _; ?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site? c "
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance f
of subsurface sewage disposal systems? :
4 =z
The size and location of the Soil Absorption System(SAS)on the site has been determined based on: f`'
Yes no
X _ Existing information. For example,a plan at the Board of Health. l�}
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is F w
unacceptable) [310 CMR 15.302(3)(b)] t '
t �
s i ,
;1
' S
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION ' . ^
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632
Owner: MRS. POWERS
Date of Inspection: 12/10/01
�r
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):2 Number of bedrooms(actual): 2 '
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 '
Number of current residents: 1 -4
tx
Does residence have a garbage grinder(yes or no): NO < E.
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] t
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a a;
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a T
Design flow(based on 310 CMR;15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a e
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION :`
Pumping Records V1, ;
Source of information: n/a '`'
Was system pumped as part of the inspection(yes or no): NO s
If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a r
Reason for pumping: n/a A-
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system , .4,_.
_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) `
e x� �
_Tight tank Attach a copy of the DEP approval ;£ k
Other(describe): n/a �,j
Approximate age of all components,date installed(if known)and source of information:
20 YRS
Were sewage odors detected when arriving at the site(yes or no): NO q ;
r,
Page 7 of I l #
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) 4 d
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632
Owner: MRS.POWERS "{
Date of Inspection: 12/10/01
BUILDING SEWER(locate on site plan) .
1 2�
Depth below grade:30"
Materials of construction: cast iron X40 PVC_other(explain): n/a T
Distance from private water supply well or suction line: n/a K
1..,
Comments on condition of joints,venting,evidence of leakage,etc.): 4 `
TOWN WATER #y:
SEPTIC TANK: X(locate on site plan) k.
Depth below grade:24" .
Material of construction: Xconcrete_metal_fiberglass polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed b a Certificate of Compliance es or no : NO attach a co of certificate "+g g Y P (Y ) ( PY )
Dimensions: 1000G L 8' 6" H 5' 7" W 41,101111
Sludge depth: I" ,y
Distance from top of sludge to bottom of outlet tee or baffle:33" x
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING NOW AND THEN EVERY YEAR TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a s'
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a � -
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a ;,,w,
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a ': f
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
i
to outlet invert,evidence of leakage,etc.)":,
n/a `
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fk"
J 3
.t
Page 8 of I I �.
• F
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ; r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM h ;
PART C ^`-
SYSTEM INFORMATION(continued)
ryv _
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632 '
Owner: MRS.POWERS
Date of Inspection: 12/10/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a <- }
Material of construction:_concrete_metal_fiberglass—polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons ; :F
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A - § ;
Alarm level: N/A Alarm in working order(yes or no): NO H, _•
Date of last pumping: n/a ''
Comments(condition of alarm and float switches;etc.): r
n/a w
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) '
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 3
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into t
or out of box,etc.):
D-BOX IS STRUCTURALLY SOUND. ,
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO 4 .
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): .
n/a x
µ.
z
b'
ae ,
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632 t
Owner: MRS. POWERS
Date of Inspection: 12/10/01 .
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why: `"
n/a :r
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a "=
n/a overflow cesspool, number: n/a
n/a innovative/alternative system :.
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THERE IS 6" OF LEACHING
LEFT.BOTTOM IS AT 10'. �
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) x:
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a F;�
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
;i
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a f
Dimensions: n/a t
Depth of solids: n/a °.
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a ;:w;
A.
y 5x.
e
• Page 10 of 11 .
7. ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
�. SS
Y 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t �°
PART C
SYSTEM INFORMATION(continued) it "
3
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632
Owner: MRS.POWERS r
Date of Inspection: 12/10/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposai 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.
P PP Y
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 158 ELIJAH CHILDS LN CENTERVILLE,MA 02632
Owner: MRS.POWERS
Date of Inspection: 12/10/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells '•=
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation) ' I
YES Accessed USGS database=explain:,n/a
You must describe how you established the high ground water elevation:
GROUNDWATER DETERMINED BY AUGER-NO WATER AT 12'
� f
•f`a�i
1
A,€S
tttt fa.4',
f.
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No..dl=-.7.5G Fps..... ..........
THE COMMONWEALTH OF MA�ACHUSETTS
BPOAR® OF HEALTH
40U. -- -- ........OF......... ...... ..... ...................................
App iration for Bispvii al Works Tonstrur#iun thrutit
SyAApplication is hereby
made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy�/ at
Ste' - ,�
..........
. ...... ..................................... .............. ------------. •----------...............-••------------
....__... . .. •- -
ocation-Address r Lot N
........................ .......... __. ... ..---•-•--
Owner Address
Installer Address
U Type of Building Size Lot........ feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( �1/h"
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Otheq fixtures ...._..
W Design Flow......... ............ allons per person per day. Total daily flow.._._..._...-_._...........................gallons.
9 Septic Tank—Liquid*capacity/Allons Length................ Width................ Diameter................ Depth................
x Disposal Trench—:To . _......_.... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..... �................ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.-___---_---_-___------
(i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------•-----------------------•---.......................-----.._...---..........................................................
0 Description of Soil............................................................................................................. ....................................................
x
U •••--•---------•-••---••--•------------------------------•-------------------------•-..........-----------------------•---••-•-----•-•••-•-•---•---------------------------------------••-•----------•--
W •----------------•-•-----•-------------•---•----•••-•---•-•--------•--------------••----------••--------------•---------•----------------••-••-•---------------------•------------------•----•----....--
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL iTl11, 5 of the State Sanitary Code—The undersigned rther agrees not to place the system in
operation until a Certificate of Compliance has been issued by the o ealth. !�
Signed .......................... ... .
Application Approved By................. _ ---
D to
Application Disapproved for the following reasons---------------------------------------------------------------•----------------•-----------------------•-•-
-------------------------•----••--•-•--•-••-•------••----•--------•-------•----------••-------------....-'---------------------------•.••-------------•-------••-------•...-----•----•-••---------......_
Date
PermitNo........................•----•--••-------------------... Issued.......................................................
No...C91--75G _ _ -=. z Fi s............................_
-�
R THE COMMONWEALTH OF MAbh ACHUSETTS
BOARD OF HEALTH
..............................OF..........................................................................................
Appliration for Disposal Works Tnn,strnrtion jhrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-••............._........---........---.........------......---------------------............---• --.._..-•---...............-----•--...--•----- .........................................
Location-Address or Lot No.
..............•-----.._........................---.....-•-.................................._.... .................__...-----•-•-------.....-•-...................-••...............................
Owner Address
a ................. ...............••-----•------•------....................................••... •-----......-•••••-•-....---•---••---•----...----•---••---------•----.............................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Pa Other fixtures ------------------------------••-- -
W 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.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by............ ............................................................ Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--__•---.__._-__-..___--
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •-•-----------------------------------------------------------------------------
•------
•------------
-----
---..........
----------------------------------
••••-
0 Description of Soil........................................................................................................-..............................................................
W ---•-•---•-•-------•••---------•--••-•••-•-•----••-•--•--•------••••----•-•-••-•--•--------•---•--•--•--•---------------------------•••••---••----•••--•••••--•-••••-•---•-••-•---••---.._...---------•-
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT 4E 55 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ................................
Date
Application Approved By--•-----••-_... i_�1' -------• ----/L/? ?�-',�'
Application Disapproved for the following reasons---------------------------=----------------------------------------------------------•••--D-................
......................................................-..................................................................................................................................................
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-77
......... .C2-?..........OF....'- 'a� ,-/..u4......................................
Tntifirtttr of TomptiFanrr
b THIS IS TO TIFY, That the Individual Sewage Disposal System constructed r or Repaired ( )
y - - ----:-- .......... -=---------------------------------------- .............---•---------•--...-------•----.............-------------•----.
I4j to ler J
at -- -- ----- ��-.-- ..... -------- r /G------------------------------------------------------•--------
has been installed in accordance wrt�provisions of TIT F 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___& 5_!............ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................................�ZrA' ................ Inspector..... •ct4-A...................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............J..... :...........OF.......... .. >!� ...................................•
No._.c�' :.� 6_ FEE...'3.S.........
Disposal Works Tuntrnr#ilan ramit
Permissionis hereby granted-------: .......0,11.......a= ....----•------------------------------------------------------------------- '
to Construct ���or R�epPair ( ) an jdividual S wa e Disposal System /
at No..............-�1`�-.1�v--... ?�!_._.. / ... .:_....
O Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
.
DATE........................... L 2.1� ��---•-•------------•---
Xarld of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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LOCATION SEWAGE PERMIT NO.
lot 66 Elijah Chil 81 6
� ds Ln -7 5
VILLAGE
Centerville, Niel,.
,-)-NSTA LLER'S NAME & ADDRESS
Robert Our Co. .
Harwich, NIA.
BUILDER OR OWNER
Alan E. Small, Inc.
Box 136 Centerville, NIA.
D A T E P E R M I T I S S U E D 14/42/81
n•
DATE CO-MPLIANCE ISSUED
- � -
/_
/Vx
0 0
El 56.5E
1/8' to 1/2' Wasbed Stone ® 9' Mich
�,�, 7777TTfT17TIT, Finish Grade El 56!1-
Na -77777/777//
tch Existing 0 Di O:Die 0"Di V
� DISTRIBUTION BOX-
10' I
o00 000
so'Alin s "3fn INV 4pop 1VV EL INV EL d d a' _ eeo e m --e e El. 50.40' 34�E7-
. ::I INV EL s53.05' 52.40e e 4"
Beloit F7orr Line 53.55' 53.25' • • ' 2,3„ 8/4` — 1 1/2` 8'eshed stone d2INV EL3Liquid Level 48' . . 2, „ ,)
••......••.. 53.80' PRECAST REINFORCED CONCRETE DISTRIBUTION BOX 58 (-•—
Number of Trenches — 1
Install on a level base
Minimum wall thickness 2 PROPOSED (EACH TRENCH 5' Number of chambers 3
"
1500 GALLON SEPTIC TANK Minimum inside dimension = m 11 Adj. High Ground Water DEL. 30' - Mapped
Outlet inverts shall be equal to each other and a t 2 minimum q " PROPOSED LEACH TRENCH — END VIEW N.T.S.
1500 GALLON REINFORCED CONCRETE SEPTIC TANK below inlet invert., El. 45.4'
Minimum Construction Materials Per 310CHR 15.226(2) The distribution lines from the distribution box shall all have
Tees shall be constructed of Schedule 40 PVC and shall extend a equal inverts as determined by flooding the distribution box to
minimum of 6" above the flow line of the septic tank and be on the height of the distribution nine invert after all lines have
the centerline of the septic tank located directly under the been sealed in place.
clean—out manhole. Invert adjustments shall be made by filling with durable and LANE
The inlet pipe elevation shall be no less than 2" nor more than 3" nondeformable material permanently fastened to the line or
above the invert elevation of the outlet pipe. reconstructing the lines until all inverts are of equal elevation.
Septic tank shall be installed level and true to grade on a level,
stable base that has been mechanically compacted and on which
6" of crushed stone has been placed to ensure-stability and 9�' x 0 ,
to prevent t settling:
Septic tank shall have a minimum cover of 9
p
Three 20 manholes with readily removable impermeable covers 1 LDS.�LIJ�..�I � �I
of durable material shall be provided with access ports
being placed at the center and over the inlet and outlet tees 31, aye1ne_n_t_�--
The outlet tee shall be equipped with gas baffle. y 26 edge ___-__�_of 5{ --
p- CB FND.
•3--------- , g
660
Storm 5.001 % goo Iyq` d LOCUS
5� Drain g 17 �b
S8706 00"W L= ► c� ; Denotes
Spot Elev. C LJ,S' MAP
TB - El 56. 0' ; 8 b (TYP)
SL LOT 66 32.3
1 U1
,
4 f N c�hArHT� SCALE
» » � p• oy '16,IOlfsq.:"c. � � ► 57.0 ,�
LS' 10yr 6/6 ; ,� ��{ 57.0 ! G? 20 0 10 20 a0 80
c� vt Walk
38 o k _ 24.5
y 56.8
i tr�J f�
................. .....
MED i '"•,�..�-*-�""�'.. :::: ;:•::::::::: ,. ......... ... •• IN FEET )
„G,,, TO 1 inch = 20 ft_
1
COURSE i E7,STING DWE'�NG ASSESSORS DATA:
SAND 55.12' 171 — 243
2. Y .
:Baseir
6 4 ;; ::::•:::::- No :;; o
i REFERENCE PLAN
61'Basement sa. 5 . 192 - 129
Wooded ::: °
:::. _......
..................
::::.........
El. 45. D' 132 i Landscape I �, 0 56.9
lyiFEMA DATA: ZONE "C"
No Water Encountered /� o 0 55.8 ZONING DIST. RC
o ° ° OVERLAY DIST GP & GPOD
i
Q
56.0' , SAS pane
Soil Log i t : 0 30.8' Reserve i 15
Performed By S. Doyle i o 56 4' 32.6' ---- ----------'
Da te: April 19, 2004 o ,
Perc Rate: <2 Min/Inch i o 96 �,
I Maple Tree N87'06'00"E Se ma ge SyS t em Re c`?ZI"' P]an
deb 55.7' o p
CB FM t =i6.5' 181.27 CB FAT. Prepared For.-
i BY- Top CB
i Proposed SAS
Existing 1000 Gallon Tank Elev. 56.10'
Datum: NGVDd 158 li II c�12S Childs Lane
iF
�i osed 1500 Gallon Tank
GENERAL CONSTRUCTION NOTES 54.89 + Prop In
Remove Existing LP *�cu of ''Ass
1. All the workmanship and materials shall conform to D.E'P Title 5 �•��`` �!t1uAt� q� Cen t ervzlle, Ma,Ssa ch use t tS
and the Town of Barnstable rules and regulations for the subsurface
g UESERMAN H
disposal of sewage. ENO- 13971 y Scale: 1 = 20 Date.- April 20, 2004
2. At least one access port over tank tees shall be accessible ,S T i, Prepared By
within 6 of finish grade, with any remaining access ports brought srQH �HG� Stephen J. Doyle and Associates
to within 12 of finish grade. E. Falmouth MA 02536
g 42 Canterbury Lane, ,
3. All components of the sanitary system shall be capable of Design Da ta: ' Telephone. 5081540-2534
withstanding H-10 loading unless they are under or within 10 ft vi s i o _E3_z
o c k
of drives or parking: H-20 loading shall be used under or within Two Bedroom = ;2 °X 110 gpd = 220 gpd Required Flow ►X,AAA
10 ft of drives or parking unless noted. Plastic equals may be No 'arbage Disposal ►►��,�or�t�,ss���
used in lieu of all precast units Use: Chamber ! •each 301 x 10'W x 2' Eff/Depth � �Q��`STEAFocy�s�
4. The excavator/contractor shall verify the location of all sito , . , . �� ST�HEN .
[30 f 30 f 10 f 107 x 2.0 = 160 o J. ►
utilities prior to any excavation, and shall be responsible for . �n� ►
all matters relating to electric easements 30 x '0' = 300 #37559 ,!
460 x 0. 74 = 340 GPD Total Design Flow - �o
5. Sewer pipes shall be 4" Schedule 40 PVC laid at 0.02 slope. ,►►q�`a \y�`�
6. Any masonry units used to bring covers to grade shall be
mortared In place.
NO.7Finish grade shall ha ve a rrrinim um slope of 0.02 ft per. foot. DATE DESCRIPTION BY_
-