HomeMy WebLinkAbout0435 ELLIOTT ROAD - Health 435 ELLIOTT RD.
CENTERYILLE
A = 227 110-
�rilUll� sREc�c�Evc
UPC 12534
N0. 2153LOR
HA37INGS, MN
-� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments f
435 Elliott Rd.
Property Address t
SKLAREW,PAUL R TR
Owner Owner's Name
information is Centerville MA 02632 6/7/20
required for every
page Cityrrown 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 completenes
s checklist at the end of the form.
Important:When A. Inspector Information j (14(it L.(
filling out forms 1
on the computer,
use only the tab Robert Paolini
key to move your Name of Inspector
cursor-do not Robert Paolini
use the return Company Name
key. '
67 Tanbark Rd.
Company Address
Marstons Mills MA 02648
City/Town State Zip Code
(508)280-9499 S14454
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title
5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true,"accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
6/7/20
Inspect r ign a Date
The system inspector shal 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
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 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:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved,by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c Commonwealth of Massachusetts
ro Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is Centerville MA 02632 6/7/20
required for every
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
I
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
El 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
v01 Commonwealth of Massachusetts
m Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
.
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:
** performed at a DEP certified laboratory,This system passes of the well water analyses, p 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
page. City(rown 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'h 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 C.4_
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
t54nsp.doc-cep.7126/2018 Title 5 Mcial inspection Form:Subsurface Sewage Disposal System-Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for 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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
c
I i
t5insp.doc•rev.7l26t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
nZ Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I
u
435 Elliott Rd. .
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: na
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: NA
Date
t5insp.doc•rev.7/2 612 01 8 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
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:
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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is
required for every Centerville MA 02632 6/7/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from.system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 3
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.):
Joints appear tight. No evidence of leakage.System vented through DBox.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 p Y ry
>r,
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 3
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 GI.
Sludge depth:
4»
Distance from top of sludge to bottom of outlet tee or baffle
46"
Scum thickness 2
Distance from top of scum to top of outlet tee or baffle
7»
Distance from bottom of scum to bottom of outlet tee or baffle 12
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.):
Pump every two years.lnlet and outlet tees in place.No signs of leakage.
� t
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
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 inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
f
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is
required for every Centerville MA 02632 6/7/20
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
No
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.):
Box is Ievel.Box has two outlet laterals with equal distribution.No signs of leakage.
t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Fig Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
435 Elliott Rd.
u
Property Address I
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
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:
i
Type:
® leaching pits. number:
2/6'x6' 2' stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
C
Commonwealth of Massachusetts
Title 5 Official Inspection Form
} Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
u 435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.No signs of hydraulic failure. Pit 1 water level 2' below invert.Pit 2 water level 50" blelow in%
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Ofricial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
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.):
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
�c Commonwealth of Massachusetts
Title 5 Official Inspection Form
- .I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
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
N
I
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is required for every Centerville MA 02632 6/7/20
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: 12
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:
As- Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used USGS observation well data.Used technical bulletin 92-0001
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
^cam Commonwealth of Massachusetts
Title 5 official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
435 Elliott Rd.
Property Address
SKLAREW,PAUL R TR
Owner Owner's Name
information is Centerville MA 02632 6/7/20
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® 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
..r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Postal
CERTIFIED MAIL,. RECEIPT
(Domestic Mail Only;
For delivery information visit our website at www.usps.come
It
t11
fU
OFFICIAL USE
Ln
zt" Postage $ ��
Certified Fee ` 0
1V�
C3 S Postmark �fl
Return Receipt Fee Z Here t
O (Endorsement Required) JON t.A 2012
p Restricted Delivery Fee e 4 GV IL
(Endorsement Required)
O Total Postage&Fees $
USt�f
r-1 sent To
a r :_QQJ C KQ ---------------------
orPO Box No. _�_ I god-----------------------------
Clty State.ZIP+4 Ci n, V� �a n/�
(� �lV I/I
Certified Mail Provides:
■ A mailing receipt
■ A unique identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS,a postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk ormark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT,Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9.047
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
LISPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
UWVI 0� ;;erho
H to I+o ICI V151 Dn
200
VA ()z Coo
1`11,1 Is L1111. Ili 11#, 11'1'.111.,fill 1t11,111;1,111M]IId
I
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. SigrNture
item 4 if Restricted Delivery is desired. ❑Agent
I ■ Print your name and address on the reverse X ❑Addressee
I so that we can return the card to you. B. R ed b (krinted Name) C. Veelelivery
I ■ Attach this card to the back of the mailpiece, ',' L V
or on the front if space permits. `4` ��g
D. Is delivery dress different from item 1? Yes
1. Article Addrels1sed to: I If YES,enter delivery address below: ❑ No
/► 3. Service Type
veie Mail ❑Expres mailIlQ / A ❑Registerred ❑Return Receipt for Merchandise
I ❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number 7 011 0470 0001 4525 7161 �!
(Transfer from service labeo
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
Town of Barnstable Barn
BOARD OF HEALTH e`°gC 1
anxxsrwsue. I
,� 200 Main Street, Hyannis MA 02601
fc:59. ek 2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.
Junichi Sawauanagi
CERTIFIED MAIL# 7011 0470 0001 4525 7161
June 11, 2012
Mary Quickel
435 Elliott Road
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located 435 Elliott Road, Centerville, MA was last inspected on
5/23/2012, by James M. Ford, a certified septic inspector for the state of Massachusetts.
The inspection of the septic system showed that the system "Passes" under the guidelines
of the 1995 TITLE 5(3 10 CMR 15.00).
It is recommended that the septic tank and leaching pit be replaced with a heavy
duty (H-20) load bearing tank and pit due to its location beneath the driveway.
Another alternative would be to relocate the driveway.
PER ORDER OF THE BOA OF HEALTH
y
Thomas McKean, R.S. CHO
Agent of the Board of Health
I
4
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\435 Elliott Rd.,Cent..doc
$ <, COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
—117
Property Address: 435 Elliot Roar! 1 .
Centerville'MA 02632
Owner's Name: Mary Ouickel
Owner's Address:
Date of Inspection: ' May 23 2012
Name of'Inspector: (Please Print) JamesM.Ford
Company Name: James M. Ford
.Mail yng Address: P.O.Box 49
w ' Osterville.MA 02655-0049
Telephone Number: (508) 862-9400
CEPTIFICAT�ON STATEMENT
'w I cer�xify that I have personally inspected the sewage disposal system at this address and that the information reported
c , ve
c below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
tratning and experience in the,proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system tnsp'ector pursuant to Ser�qction 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
✓ eeds Further Evaluation by the Local Approving Authority
ails
Inspector's Signature: Date: Mav 29, 2012
The system inspector shall su to copy of this inspection report to'the Approving Authority(Board of Health or
DEP)within 30 days of completing.this inspection. If the system is a shared system or has a design flow of.10,000 .gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
(J The septic tank and one of the leach pits are H-10 and in the.driveway-deeds further evahtation
Notes and Cormnent's
****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 wi
conditions.of use. ll perform in the future carder the same of different
- W
Title 5 Inspection Forin 6/15/2000 _ f
page 1
Page 2 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 435 Elliot Road
Centerville MA
Owner: Marti Quickel
Date of Inspection: May 23 2012
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain. ;
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
r
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 435 Elliot Road
Centerville MA
Owner: _ Mary Quickel
Date of Inspection: Mav 23, 2012
C. Further Evaluation A Required by the Board of Health:
✓ Conditions exist which require further evaluation by the Board of Health in order to determine ifthe system
is failing to protect public health,safety or the enviroiunent.
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
* The septic tank and one of the leach pits is M-10 and in the driveway
2. System will fail unless the Boardof 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 taiik!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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 435 Elliot Road
Centerville MA
Owner: Mary Ouicicei
Date of Inspection: Mai)23, 2012
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %z day now
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
_ ✓ Ally 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 colifornrbacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen-and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is,located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a,significant threat,or answered
yes in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section 1)shall upgrade the system in accordance with 310 CMR
15.304. The system owner-should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 435 Elliot Road
Centerville,MA
Owner: Mary Ouickel
Date of Inspection: May 23, 2012
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant, or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components, excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions;depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS) on the site has been determined based on:
Yes No
✓ Existing information. For'example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
r ,
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 435 Elliot Road
Centerville MA
Owner: Maw Ouickel
Date of Inspection: May 23, 2012
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 55.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
Does residence have a garbage grinder(yes'or no): n/a
Is laundry on a separate sewage system(yes or no): nLa [if yes separate inspection required]
Laundry system inspected(yes or no): . No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unknown
Sump Pump(yes or no): No
Last date of occupancy: Currently
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Punived i71 2017
Was system pumped as part of the inspection (yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ 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 tecluiology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known) and source of information:
Installed on unknown date
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 435 Elliot Road
Centerville MA
Owner: Maiw 0uickel
.Date of Inspection: May 23, 2012
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 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: 1000 gal. H-10
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: . 2"
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: 10"
How were dimensions determined:. Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.).
Cement Tees were vresent The liquid level was even with the outlet invert There did not appear to be any sighs of lealcaQe
The tank is H-10 and in the driveway. Steel cover to grade on the inlet was present.
GREASE TRAP: None (locate on site plan)
(
Depth below grade:
Material of construction: _concrete'_metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
is
.Page 8 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
i
Property Address: 435 Elliot Road
Centerville,MA
Owner: Mari)0uiclzel
Date of Inspection: May 23, 2012
TIGHT or HOLDING TANK: None (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 lastpumping:
Commnients(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site.plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.):
The D-Box was under the drivewa i and Unaccessible
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no) `
Cormnents(note condition of pump chamber condition of pumps and appurtenances,etc.):
I
i 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: 435 Elliot Road
Centerville MA
Owner Man>Quick-el
Date of Inspection: May 23, 2012
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2- 6'x 6'(1000 Qal)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Continents (note condition of soil,signs of hydraulic failure,level of ponding,damp_soil,condition of vegetation,etc.):,
Both pits are in the driveway. The H710 one had 5.'6'of water on the bottom The other one is H 20 and had 6 of water on the
bottom. There did not appear to be any signs of failure.
CESSPOOLS: None (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: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Conunents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
t 9
i
•Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 435 Elliot Road
Centerville,MA
Owner: Mary Ouickel
Date of Inspection: May 23, 2012
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.; Locate where public water supply enters the building.
6A(Agt
16
6
a�
3S
[aM to
10 �I
Page l l of 11
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 435 Elliot Road
Centerville,MA
Owner: Mary Ouickel
Date of Inspection: May 23, 2012
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 15 +/- ' feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed: .
Observed site(abutting property/observation hole within 150 feet of SAS)
V Checked with local Board of Health-explain: topographic and water contours nzaps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:.;
1
You must describe how you established the.high ground water elevation:
Usink Barnstable toyokraphic and Water.contours naps the maps were showing aWro imately 15'+/ to groundwater at this
site. .
This .
s report t has been prepared only for;.the septic system and components described herein. This septic system has been .
inspected and needs f ti-ther evaluation as of the date of inspection. This report.is not a warranty or guarantee that the system will
function properly in the fixture. There Eve been no warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report and/or.any components of the septic system which have not
been located and inspected,
11
" ;roe (lst floor):
/map and lot number .... . �. ./... r�.... oF T E Health (3rd(3rd floor):
f o �e Permlt number — ........ `� i
p ��� Z B6Hd9TAXLE, i
ineering Department (3rd floor): ,( vo r a
1639..
ouse number .....................................:........ ..:.:.................
APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only
TOWN OF BAR.NSTABLE
Z4113iUILDING INSPECTOR
APPLICATION FOR PERMIT TO
l
TYPEOF CONSTRUCTION .......V QqD...........................................................................................:...................... II
:............ ..........193G
O THE INSPECTOR OF BUILDINGS:
I
i
he undersigned hereby applies for a permit according to the following information: I
i
t
)cation 4..(a.E.......1 :......L. ,!-.�n:d:...�.PA-P...,.....L .N.T.E.A.V I�—L;.......M,�l:...:.......................................................................
roposed Use ...�2 {.ILLlri ,r.......d�!V✓..�; .............................................
oning District ........Fire District j
ame of Owner .4�tl�n.( .,5. <SYJI- NF1!......... Address`-..:Cv,f1.ti(..� �4; ...�iC? l1h.IT.A.i? �....I�A�..
ame of Builder r'V.L:.NL'.?I�f..: IJ.lG R1.(��'....0 .....................Address
ame of ArchitectC ...N. .. . . .... . ......Address ...S ............ _. ....... .... i'
k
umber of Rooms .. CZQO..k1S......�...... RT: ... ....................Foundation ....C(2N..4..12.C.7. ...................:.............................
Roofing ..!3: .� �-•. ..........................:. k
:lei'IOr ....Y.!Fl.�i.!(................................................. ... .... `
oors ......W..�.)(i.��....................................................................Interior
t
.
eating : .......:........................Plumbing ..........0.�L�-... L.................'........
•ep ace ....H.,?N.�. ................................................................Approximate Cost ........... '.d.��Q....................................... ..
!finitive Plan Approved by Planning Board ________________________________19________ . Area J.�, �J...:�Q.,... r.........
ogram of Lot and Building with Dimensions
Fee .........
-............D..J................
)BJECT TO APPROVAL OF BOARD OF HEALTH
4r
OCCUPANCY
U NCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction..
Name ���?: Ul. .° .. 1•:� 1. .��?:
Construction Supervisor's License ..�f.!` .�!.................
TOWN OF BARNSTABLE
L!?CATION �� �� , SEWAGE # `
VILLAGE ASSESSOR'S MAP & LOT C(
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /�e"e
LEACHING FACILITY: (type) (size) 90
r
NO.OF BEDROOMS
BUILDER OR OWNER%-�.I,,W LWW42!
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Mwdmum Adjusted Groundwater Table and 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 I lead 'n ihty) Feet
Furnished b '`
,®
i
WS
........ '' Yux... .7
THE COMMONWEALTH OF MASSACHUSETTS 1
BOARD OF H5ALTH
`. .RI...... ...........OF....... ......-...... may -
Appitrattun for Disposal Works Toustrurtiun rnmit
Application is hereby made for a Permit to Construct (V'f or Repair ( ) an Individual Sewage Disposal
System at:
... 9.�.44_g._....:. .ti.n.T.... � .S_t �. �. .car.rl...v-.....i.::�:...---•-------
-- ----
Location-Address or Lot No.
..........9ACe.h..Ar :'D.....A.-...E..Q.SI.M F....................... ..........------------•-•----------•-------------.
Owner Address
a ..... ..
Installer. Address U Type of Building Size Lot.--S.11j.-I_S.1...Sq. feet
0.4 Dwelling—No. of Bedrooms.............._..........................Expansion Attic (- ) Garbage Grinder (f/
a Other—Type of Building , 'SIDE'A?1ALNo. of persons_.....�---------------- Showers (e/) — Cafeteria ( )
Otherfixtures .......--•-•-•---•-......----•-•----------•----•-------•--•---•-•-----•--•-------------------------------•------ _
---------------------
W Design Flow.............. =. � allons per person per day. Total daily flow.............: -..............gallons.
WSeptic Tank—Liquid capaci .I-SM& . allons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .._........ - Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.......X.......... Diameter....6 V..... Depth below in ...... ........... T, tal leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing'tank ( ) L C` �- ;77
a Percolation Test RZ7.A...'minutes
Performed by._.CM t _._S_.....A_a.s_�...._... NC.:............... Date........................................
Test Pit No. per inch Depth of Test Pit.................... Depth to ground water---_----...__-___.......
fz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
ff
Descriptionof Soil -- ! ls.......�=- ..Gc-!fir. .....'�, �... .... ........
_ ..
........... °r --------------------------------•----------------......-- •---- .
x --------•-•-----------------------------------•.----------------•--•--------------••-----------•----.---------•----------------------•---------•----------------•-•-------------------•--------...__..--
U Nature of Repairs or Alterations—Answer when applicable._---__ s...............................................................................
-------------------------------•--------------------------•---------------....------......---------------•----------•--------...•-----------------------••-•-••---------------------•...-----••--......
Agreement: , ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i 1 5 of the State Sanitary Code— The undersigned further arees not to place the system in
operation until a Certificate of Compliance has been issued by the
ebbooard �h. _Signe A =----- ------ -----
�r.......................'r
Date
Application Approved By---•- - _ ---•----- --=-------- 1 ----
Date
Application Disapproved for the following reasons:.....................
--••-----------------•---.....----•---••----.....••---------••------------•------•-------------•-•-------...-------------------•--------•-----••----------------------•-•-------•-------------•-•-----...
Date
PermitNo.......................................................... Issued_.......................................................
Date
OR
�� .�
No.--- ........_....... F�$...�........._
r !
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF Hg,ALTH
..........................................OF........
1. !?" . � N .-.-.........
Appliration for Uiopooal Works Tomittrnrtion rumit
Application is hereby made for a Permit to Construct ( V11 or Repair ( ) an Individual Sewage Disposal
System tat:
1....1.1 0 "� 1-, f} C A 11.
Location-Address or Lot No.
.......... ...... A!:lAJN1...................... -------------------------------------------------- L=-!
Add re
W � ...... -'--------- ---------O ner ...1�1� ----••5-r=••-•---...h"-*ss".,
Installer Address
Type of Building Size feet
Dwelling—No. of Bedrooms..............�
................_..........Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building g t �� �No. of persons ?................ Showers
W yP g --------=---=--------------- P Cafeteria ( )
Q' Other fixtures -----------------------------------•-•--------
w Design Flow..............`t -_.Sf .......gallons per person per day. Total daily flow____•.___.._.._._.__.........gallons.
WSeptic Tank—Liquid capacity WAO_gallons Length............... Width................ Diameter................ Depth................
x
Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No-------A........... Diameter...to?__K_.'R..... Depth below inlet,. .------ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( .:) D P- le S' 77
`~ Percolation Test Res:lts Performed by............. _..............
___...... Date........................................
Test Pit No .f,',F:...._.^_...minutes per inch Depth ,of'Test Pit.................... Depth to ground water--_-_-__-____-_-.--_--_.
Test Pit No. 2................minutes per inch Depth of, Test Pit.................... Depth to ground water........................
---------- /' _
-
Descripti n o. Soil ------ -- ----•-------�•-il,u-_...."�_.... i-----�-- --- ---- .....-'
w
U Nature of Repairs or Alterations—Answer when appli. le...............................................................................................
a.
. ....-----••-----••
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of th.
=- Sign` .•�. � ��......._.. ...................,
Date
Application Approved By..... ........ ... ---- ---------
Date
Application Disapproved for the following reasons:..------
..-------••----------•------------------•-•------------------••••----•----------......--------•--•••-------•••--•----•-•-••-••-----•••------------------•••----•-------...---•-------------••---•......
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Q f HEALTH
U•'�
UU\\I
'up rdifiratr of Tontplionrr
T� S IS,T�CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
b41! -` =— � r =/ ��---nstalle�/ :_._._.__. ' I� — � .f� ................................. !,
at... - �_ ... ..................................................
has been installed in accordance with h provisions F' 'r _ 'w the prov siol s of T J 5 of The State Sanitary ode as described m the
application for Disposal Works Construction Permit No.................'�5......_.___.__.. da.ted_._� ..�`__r.__�.._._._.._.___.._...
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE �I
� SYSTEM VILL NOTION, SATISFACTORY.
DATE. ..9T/d� /j�� ......... Inspector--==.((f- ........................................................
-- -•------•----•---`--_-_..'..-.--•-'--••-•----•----
THE'COMMONWEALTH OF MASSACHUSETTS
wk'"`
BOARD (:,)V HEALTH ,
FEE....=
: .
�k� no�rttr#ion rrnti�
Permission s -ereby granted- '..-• •--•--....... ..A4*. --------------------------
to Constr ct R i ?,(� syIn ivWi Sew Di osal Sy
reet
as shown on the applicationfor Disposal Works Construction P ` t No.._.__ Dated_. ......................................
t' °'
�a
/� Board of Health
DATE -- ___.77-- ...........................................
FORM 123.5 HOBBS & WARREN. INC.. PUBLISIiERS
- e
TA�;� +
c, i
-457
LOCL.TAOKI 3s� 5EWW:C E PERMIT UO.
Richard Bourne Lot 8 Elliot Street Oyster Bay subdiv. Centerville
VILLAGE Centerville, Mass
WSTQLLER'S W&ME: 6, ADDRESS 9:? 7" Yo
Moses 11. Sherman Main Street Marstons "Tills, Mass
BUILDERS tJ &mF— �- ADDRESS
E. B. Norris & Son Inc Sea Street Hyannis, Mass
DNTE PERKA T ISSUED 8-1-77 --
D ATE COMPLI &KiCE' ISSUED : —
L
l� �� IPG 'I• 'r,
/ddd�
c
�.Lhai:d_
/-TAO SEW�.�E PERMIT k10.
R Bourse Lot 8 Elliot Rd OQster-'av Stu Centerville. Maa
VILLAGE Centerville, Mass _ _ —
1WSTQLLER'5 U&ME .6 ADDRESS
Moses H. Sherman Main Street Marstons Mills, Mass
BUILDER5 Q &VAF- ADDRESS
E. B. Norris & Son Inc Sea Street Hyannis, Mass. 02601
DATE PERMIT . ISSUED 8-1-Z7_
DATE COMPLI &NIC:E- ISSUED
-.a� ..:'i:.
I ���F�'`�''� '�c,
�� J
t� � (pu f �
.'/"�
� ..t �. �r
_ +
I �/� , _
1 1^ i
i'
�.w.=
1
.'��
t
Z2-
.;
- STW E rLLeC>
-- _— Di5-pUESicf-� t
AA 14
1V
Jy
' I �puS
, ... 1 •_sue .�•.,�rot.� .- i
N-4
/ 11 •� J 1 ', � 2(i' 9
Fr; ^.- lf— �drrGl IUi tiicl� E
Aj
- '.`'1 `-- J -�_•_ .�`/ --_ - - ` 1 --` jam_� --
,
< - %
iAOV.
z5o
�4�—
G:=C S i D W� i? T74 Vic.C
7
vIGLL- =*50 -Z!7-U E C_
-
-u—
_ SEP 1 8 1986
_ �-`��� /�•Lr 'T- �l!- r�- J �C=� � W rH � L2•.-eS 1'{G� Spa 1.� � \1
rIGNING ENGINEER MIDST SD?ETV f
'TALLATION AND CERTIFY IN W ► �^, ''- '����F��`
H SYSTEM y.; c ,� ��' `�► )�!.n,�% �.r.�" ' ,%�', . -`
"—ORDANC WAS INSTALLED IN STRICT -�_, r?C�1
E TO PLAN r:T+_-c
Ll
_ 71� _
t
0
� r �
\� I �c�o� 3►. �`n � �� `ter�� i •
V
D ✓ r�/T 4/?a�'✓
s/ems/77
�f/I /,tJ � E rBAG�r li'EgUi.P� �Ev,—s � �, ` � ►
� Oi9A"I 20• � -
✓�cJ8- -o
/If 7 _E� 7'
10 1V2
c�v9�SL
� � 1
O 0— O O.SA.cJ�M T O Al Z2,D, ` o M A .✓ '= S flit/ �J C- O ✓CRS OG
7 A Go,cJ .STjt' vc'7 -EO To
/!/O Lv�TER D. �- -, .-/� • C C ✓E.Q 6 F'
A
G^r.• � `.(` All � ��`�T
'" G �S'TGf/ ti�<> iy✓. Jac> �� d,9 -3/
`/
p
/il/ j/E/P T /,v'✓�i�T i
12,
/Al✓ER T /A/✓ER
IA///O orT
jr
Ti o/v r (f7 TyE
A/ .::!r 7----19 ,0 --Z. E" G D ,S �'� Vi9. 7/D Al G 451 /V7 17 %::5 s1 o Al
,8 C e/ r9 � 9 vX
L � .1 i9-s ,v o 7-E n „� �l � , / 9 7 7
G ✓� S O G 9 7 ,�:-7-
c/^� r` i`i'.�!v v�v� y0/i' G Co E 7-/7� E Q ,g.tJ!� Tiyc 7-OIVA,) OA= A9RRA-),5793Q4.,--
/2GS /� dcJTE 70
.�5 O U NI O lJ T r1) /✓2,v`4:5• !o y p R/✓E cJ f7 Y '1/L'7 T O Q L O G f� TES
Vr
1•
l 91'fG J i"F f 4,2.F S1977
/
/Y,/09 T� /vli'O�0 6 F,O L Ei9 G� i91PEi9 _ BG
4