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,w Title 5 Official Inspection Form
ili Subsurface Sewage Disposal System Form -Not for Voluntary Assessments fi a
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name w
information is Centerville
required for every MA 02632 10-10-19 "
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 S7# /q/ 9D
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l 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 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
10-10-19
nspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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
,w
�-i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
- > 112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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:r -
® 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 working order with no sign of failure.
2) System Conditionally Passes:
❑ One or more system components as described.in the "ConditionalPass" 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
f�� �/ Title 5 Official Inspection Form
q,i.
h.
wa
i,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r � ,
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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 ON ❑ 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 El ❑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
C Commonwealth of Massachusetts
r� 4. Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
! I,61 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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 '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed Pi e 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
I Y 9 PP Y
❑ ❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
�wl
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
U
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 1
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: 10-2019
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
,. Title 5 Official Inspection Form
w
Rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
J'
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
page. City/Town 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:
2005
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 12"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
i it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is MA 02632 10-10-19
Centerville
required for every State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
6. Septic Tank (locate on site plan):
6"
Depth below grade: 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
1500 gal
Dimensions:
12"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
20"
1"
Scum thickness
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"
Tape
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.):
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
r Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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.):
B. Tight or Holding Tank (tank must be pumped at time of i nspecti 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
1� ,w Title 5 Official Inspection Form
I i'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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 with water at working level and no sign of back-up from field.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
r , Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l fir;:
112 Emerson Way
J'
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in workingorder: Yes No*
❑ ❑
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* 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: 2-500'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
- o aAssessments
� i t Subsurface Sewage Disposal System Form Not for r Voluntary
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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 no visible stain lines.
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 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I�t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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
r Commonwealth of Massachusetts -
(,
Title 5 Official Inspection Form
i� W:•
ib) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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
33
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it:�-3 e
-3 3 '(0 64-36, 1
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
Iw
bl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is required for every Centerville MA 02632 10-10-19
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:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Original design plans 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
wa
��I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
U r,
>c:
112 Emerson Way
Property Address
Linda Carroll
Owner Owner's Name
information is Centerville MA 02632 10-10-19
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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-� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 112 Emerson Way.
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector: C
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. I Capewide Enterprises,LLC
Company Name
r� P.O.Box 763
Company Address
.Centerville • Ma. 02632
reran City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate.and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
El Needs r Eval f y the ocal Approving Authority �. •
9/12/2007
Inspector's Signa ure Date
The system inspector shall submit a copy of this inspection report to the Approving.uthority_(Boardr,
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 shallr submit the �
report to.the appropriate regional office of the DEP. The original should be sent to thl system Qwner�n
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.
112 emerson•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: I
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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
112 emerson•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment: -
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
112 emerson-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
112 emerson•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board'of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area.—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
112 emerson•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 112 Emerson Way
M
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate "yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
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?
® ElWas 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)]
112 emerson•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
112 emerson•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
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:
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 a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
New system 2005
Were sewage odors detected when arriving at the site? ❑ Yes ® No
112 emerson-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection- Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: feet
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 20'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage.System vented through the leaching chambers.
Septic Tank (locate on site plan):
Depth below grade: 1
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:. 110'6"x5,8"x5,7"
Sludge depth:` none
Distance from top of sludge to bottom of outlet tee or baffle na
Scum thickness none
Distance from top of scum to top of outlet tee or baffle na
Distance from bottom of scum to bottom of outlet tee or baffle na
How were dimensions determined? tank empty
112 emerson•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every 2-3 years.lnlet and outlet tees are-in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: -
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank.(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
112 emerson•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) '
Tight or Holding Tank(cont.) -
Dimensions:
Capacity: gallons .
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc:):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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 evidence of solids carryover.No
evidenceof leakage into or out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
112 emerson•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2-500gLLC
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.Leaching chambers were dry at time of inspection.
112 emerson•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
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.):
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.):
112 emerson-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
c
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
A System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
C.
�r
• t
1
TA,+w i
a
112 emerson•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
I — -
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
112 Emerson Way
Property Address
Jon Whitman
Owner Owner's Name °
information is required for Centerville Ma. 02632 9/12/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: Bottom of leaching 18'
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: 2005
Date
❑. Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
AS-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used:Gaherty& Miller model 12/16/94 groundwater elevations. Used:USGS observation well data
June 1992. Used:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations.
e
112 emerson•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
F4 1 0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZlppYication for Mi5p0a[ *patent Con6truction permit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. 7 71 —4 6 71
112 Emerson Way, Centerville Joan Begg & Jon Whitman
Assessor'sMap/Parcel 189/107 112 Emerson Way, Centerville
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4
Wm E Robinson Sr Septic Eco-Tech
PO Box 1089 Centerville 43 Triangle Cir, Sandwich
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder PO)
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 septic
system to plans of Eco-Tech, #ETE-1850.
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 En ronmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this ,;oard / Health.
Sign ` Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. OCO 5 `0`7 Date Issued `�
t ----------- ---—__------------- --- ------- —
�CD
No tot 1 0 0. 0
H F MASSACHUSETTS Entered in computer.
THE COMMONWEALTH O Yes
w PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
5pprfcation for )Digpogar *patent Construction Permit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. —
112 Emerson Way, Centerville Joan Begg & Jon Whitman
Assessor'sMap/Parcel 189/107 112 Emerson Way, Centerville
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4
Wm E 'Robinson Sr Septic Eco-Tech
PO Box 1089 Centerville 43 Triangle Cir, Sandwich
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder PI)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs orAlte ationsl(Answer whe a lic4ble Install a new Title 5 septic
System o p ans of c�' lec , NETE— 83 .
Date last inspected:
t'
Agreement:
The undersigned agrees to ensure the constructio4 and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of�t�e Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by thi &A Health.
Signed Date ✓ •�Y�
Application Approved by � Date U
Application Disapproved for the following reasons
Permit No. G)CO 5 Date Issued _
THE COMMONWEALTH OF MASSACHUSETTS
Begg/Whitman BARNSTABLE, MASSACHUSETTS-'
Certificate of Compliance
THIS IS TO CE TIEZ, tat th On-site Sewage Di gsal System Constructed( )Repaired ( X )Upgraded( )
Aband ed( �b v�m E o ) nson Sr Sep�ic Service
Iop2 ,gym y s V'd �,, r i
at has been constructed #t�ccordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2(Jo�-0-7k dated 3 y
Installer Designer P
The issuance ofithls 1 ermit shall not be construed as a guarantee that the system will fu!nnction as�'e�si�g e .
Date— �f-) Inspector
- y�,7 ----------------------- 't100,00
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
Begg/WhPUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
1i2;poga[ bpgtem Construction Permit
Permission is hereby gfanled to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 12 Emerson Way, Centerville
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this p r i,.
Date:_ 105 Approved y
TOWN OF BARNSTABLE 510
LOCATION ZZ2 EIV�er5o - SEWAGE # C�ZS- 079
VILLAGE ASSESSOR'S MAP & LOT ��`I ` 1U 7
INSTALLER'S NAME&PHONE NO. t. Q0b-;ASa,. 'SePhc St.:rv�cc 5D8 775 F-)
SEPTIC TANK CAPACITY �d0Il��►s
LEACHING FACILITY: (type)dX.S"pp kewc li (size) PY/22 1 x a
NO.OF BEDROOMS 3
BUILDER OR OWNER 13099 Aah i4VKGN
PERMITDATE: .319'lOS- COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1 +/ Feet
Private Water Supply Well and Leaching Facility (If any wells exist f
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
A
TAe4 vco o .
E
SAs
TOWN OF BARNSTABLEL
LOCATION 1/r� E^^e-j,=^' &..fr-'e SEWAGE # C�ZS" 0 79
1 �tn+cc�i�I c ASSESSOR'S MAP & LOT /�% `" At VILLAGE
IN,STALLAR'S NAME&PHONE NO W'"' t. y�ob�oLso.^ cP Tc.5ea'v�cc Sb, 1 7`71 X?-74,
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) dX %-b0 Qr�Cwc h (size)
NO.OF BEDROOMS 3 .
BUILDER OR OWNER Soo, +,,A i4en,—'
PERMTIDATE: 3 O. 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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Town of Barnstable
FtHE Tp�� Regulatory Services
HP �s
Thomas F. Geiler,Director
* .IARNSTABM #
9 14ASS. Public Health Division
i639' �0
'OrEn °' Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644
Fax:` 508-790-6304
Installer & Designer Certification Form
Date:
Designer: Eco-Tech Installer: Wm E Robinson Sr Septic
Service
Address: 43 Triangle Circle Address: pn Rny Jua
Sandwich Centerville .
On Wm E Robinson Sr Septi7yms issued a permit to install a
(date) (installer) Service
septic system at 1 12 Emerson Way, Centerville based on a design drawn by
(address)
Eco-Tech dated 12-7-04
(designer)
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.
-�H OFMgs��
+ DAVID S
(Installer s Signature) S COUGDNOWR 9 �;1093 0
s`��isTEP�
9iy1 T AP�P
(Designer's Signature) (Affix Designer's 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 E_ BARN_ STABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
Town of Barnstable
OF 1HE 1p�
Regulatory Services
" �* Thomas F. Geiler, Director snxxsrnsc.e. «
9$ b 9 •0� Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
I
FLOW PROFILE
TOP OF FOUNDATION RAISE COVERS TO WITHIN eZ
6 in OF FINAL GRADE VENT
EL - 49.10 +- PIPE
ONE INSPECTION RISER FOR
LEACHING GALLERY
All f D-BOX 2 1/2-ER OF STONEI/$
3" DROP
FLOW LINE TEE
10" = 14 i
PRECAST
48' GAS E r�XksA 3/4--I 1/4-
'L �i ,'�:� DRYWELL cK�4°
BAFFLE sssra :sy3ss;;rt STONE
6 in BOTTOM OF
45.00 STONE SOIL ABSORPTION
TL BASE 42.13 LEACHING SYSTEM
45.25 6 in STONE BASE 42.30 42.00 GALLERY
5.00 f t
IS00 GALLON (END v1Ew1 40_00
16 ft SEPTIC TANK 23.7 ft 5 ft / 12.5 ft
b) 14 ft
ESTIMATED —21.50
SEASONAL HIGH
GROUNDWATER
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SOIL TEST LOG
DATE OF TEST: NOVEMBER 12. 2004 DESIGN CALCULATIONS
SOIL EVALUATOR: DAVID D. COUGHANOWR, RS -
WITNESS REQUIREMENT WAIVED .- NO VARIANCES SOUGHT
DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD
GROUNDWATER
TEST PIT I PAORENTT MATERIAL: ENCOUNTER ROGLACIAEDOUTWASH SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS
ELEVATION - 45.7 PERC AT 60 in : 2 MIN/INCH IN C SOILS
INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED)
DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET D-BOX,
(INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING
SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY "CAN LEACH
0-14 FILL Abot - ( 24 x 12.5 ) - 300 sf
Asdw - ( 24 ; 24 12.5 + 12.5 ) x 2 - 146 sf
14-16 O LOAM 10 YR 2/I NONE FRIABLE A t o t - 446 sf
16-20 A SANDY LOAM 10 YR 3/6 NONE FRIABLE V t 0.74 x 446 - 330.04 G P D
20-42 B LOAMY SAND 10 YR 5/6 NONE FRIABLE USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED
42-80 CI COARSE SAND 10 YR 6/4 NONE LOOSE - 5% GRAVEL
80-I38 C2 'MEDIUM SAND 10 YR 6/3 NONE LOOSE-20i STONES
GROUNDWATER ADJUSTMENT LEACHING GALLERY
EXISTING LEVEL
BASED ON RTOWND ER OFTBARBSTABLE CONSTRUCTION DETAIL
GIS DEPARTMENT RECORDS. — DRYWELL UNIT STONE
c INDICATED GW 16.00 \. $ ' x 20 EFF DEPTH
INDEX WELL MIW-29
ZONE D 24.0 f t
READING 9.0 .
ADJUSTMENT 5.5
ADJUSTED GW 21.50 "
un
NOTES N nN
N �
1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN 3.s 8.5' 8.5' 3.5'
2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM.
24,0 ft NOT ro
3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS SCALE
OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15)
4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES
BEFORE EXCAVATING FOR SYSTEM.
5) EXISTING CESSPOOLS TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED
6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE SEWAGE DISPOSAL SYSTEM PLAN
7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN
8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES -TO SERVE EXISTING DWELLING
AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK
9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT JOAN BEGG & JON WHITMAN
PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 112 EMERSON WAY CENTERVILLE, MA
10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK,
11) SEPTIC TANKS SHALL BE INSTALLED LEVEL 'AND—TRUE TO GRADE ON A LEVEL ECO-TECH ENVIRONMENTAL
STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH
SIX INCHES OF CRUSHED STONE 'HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING 43 TRIANGLE CIRCLE SANDWICH MA 02563
- ETE-1850 DEC 7. 2007 2/2