HomeMy WebLinkAbout1934 FALMOUTH ROAD/RTE 28 - Health _ 1934 Falmouth Rd. , Centerville
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Commonwealth of Massachusetts � �- �tU
Title 5 Official inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1934 Falmouth Road
Property Address liaz
Big Brothers&Big Sisters Of Cape Cod
Owner Owners Name
information is MI.
required for every Centerville MA 02632 7-13-15
page. Cityrrown State Zip Code Date of Inspection rah
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lnspea'60111 sesutts must be submitted on this form.Inspection forms,stray not be altered in any
way. Please see completeness checklist at the end of the form.
Impfling out
when A. General Information
filling out forms �ppltuflu�q����
on the computer, 0 \\ •%N OF
use only the tab l• ! l®�� 4�.•....... Sq '%
. y-
1. Inspector: 0 ;• . t^
key to move your s
cursor-do not ,lames D_Sears =�� JAMES
key the return Name of Inspector C
y
CapewideEnterprises,LLC ; �,.•�, o ,�
Company Name ,
153 Commercial Street I N
Company Address 1
I
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S 1623
Te3ephone Number License Number
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B. Certification
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 S(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by t4 Local Approving Authority
7-14-15
spector'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 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.
****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.
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151ns-3113
Title 5 OFfidel Inspection Form Subsurlaoe Sewage Disposal System•Page 1 Orr 17 ',
Jul.141511:59p p.2
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers& Big Sisters Of Cape Cod
Owner Owner's Name
information
required for every Centerville MA 02632 7-13-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cons) j
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Inspection Summary: Check A,B,C,D or E/always complete all of Section D j
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. j
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Comments:
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The system is a 1500 Gal. Tank D Box and four infiltrators.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no'or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
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"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 ❑ NO(Explain below).
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l13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Pape 2 of 17
Jul 14 15 11:59p p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers& Big Sisters Of Cape Cod
Owner Owner's Name
required
is every
Centerville
re wired for eve MA 02632 7-13-15
page. Citylrown State Zip Code Date of inspection
B. Certification (cont.)
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❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cunt.):
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❑ 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 ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment-
❑ Cesspool or privy is within 50 feet of a surface water
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❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•313 Tile 5 Official Inspection Form Subsurface Sewage Disposal System•Pape 3 of 17
Jul 141511:59p p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers&Big Sisters Of Cape Cod
Owner Owner's Name
information is
required for every Centerville
11RA 02632 7-43-45
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,N 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 fleet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form,
3. Other:
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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
❑ ]z 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 a is less than 6" below invert or available volume is less
than day flow E4Cy/A;t;
15in•3113 TOW 5 OM OW Inspection Form!Subsurfaw Sawap Disposol Syolom•Pago 4 of 17
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Jul 151512:00a p,5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers &Big Sisters Of Cape Cod
Owner Owner's Name
information
required for every Centerville MA 02632 7-13-15
page. Cityrrown Slate Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 23 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ z 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 I
system passes if the well water analysis, performed at a DEP certified I
laboratory,for fecal coliform bacteria indicates absent and the presence I
of ammonie 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 j
and chain of custody must be attached to this form.] j
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- I
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 faits. 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.
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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
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❑ ❑ the system is within 400 feet of a surface drinking water supply i
❑ ❑ 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 11 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.
i5ins-3113 Titles Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
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Jul 151512:00a p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers $Big Sisters Of Cape Cod
Owner Owner's Name
information
required for every CenteMile MA 02632 7-13-15
page. Cityrrown 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?
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❑ ® Has the system received normal flows in the previous two week period?
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❑ ® 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 examiner]? (If they were not i
available note as N/A) I
❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
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® ❑ Were all system components, excluding the SAS, located on site?
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® ❑ 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 unacceptab)e)[310 CMR 15.302(5))
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D. System Information
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
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5ns•3r13 Tills 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 of 17
Jul 151512:00a p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers&Big Sisters Of Cape Cod
Owner Owner's(dame
information is
required for every Cendervilie MA _ 02632 _ 7-13-15
page. CityrTown state Zip Code Date of Inspection
D. System Information
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Description:
The system is a 1500 Gal. Tank D Box and four infiltrators. _
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Number of current residents:
1
Does residence have ? I
h e a garbage grinder?9 9 9 El ❑ No I
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ❑ No
information in this report.) j
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
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Water meter readings, if available(last 2 years usage(gpd)): j
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
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Commercialllndustrial Flow Conditions:
Type of Establishment Office's
NA
Design flow(based on 310 CMR 15.203): GaMns per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): NA
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
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Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
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Water meter readings, if available: 2013 -8,000 Gal's2014-36,000 Gars
t`'ins-3113 T41e 5Orfidei Inspection Fomr.Subwrow Sewage Diwo3w System-Page 7 of 17
Jul 151512:01a p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers&Big Sisters Of Cape Cod
Owner owner's Name
information is required for every Centerville MA 02632 7-13-15
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: NA
Date
Other(describe below).
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: —
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
[Sine•3M Tnfe 5 Of car rrepec(ion Form;Su oe Sewage Disposal Sysram•Page a a 1T
Jul 1515 12:01a p.9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers&Big Sisters Of Cape Cod
Owner Owner's Name
information is
required for every Centerville MA 02632 7-13-15 {
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed (if known)and source of information:
1996 Permit #96-639
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Were sewage odors detected when arriving at the site? ❑ Yes ® No I
Building Sewer(locate on site plan):
Depth below grade: 50"feet
Material of construction:
❑cast iron ®40 PVC [] other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40,
Septic Tank(locate on site plan):
Depth below grade: 41"
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: 1600 Gal. Precast H-10
Sludge depth: 3„
Minn•3113 Title 5 Omw Inspection Forth:subsurface Sswap Disposal System•Papa 0 of 17
Jul 1515 12:01a p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers& Big Sisters Of Cape Cod
Owner Owner's Name _
information
required for every Centerville MA 02632 7-13-15
page. Cityrrown Stale Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 27" -
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
t3°
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc_):
Tank at working level. Tank at 41"below grade. Inlet cover at 10", outlet cover at 27". In and
outlet tees. No sign of leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Dahe
ISins-3113 Tltlo 5 Official hwpedion Form:Subsurface Sewage Disposal System-Page 10 of 17
Jul 151512:02a p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
?f �� Subsurface Sewage System Form Not for Voluntary ryAssessmen Assessments
1934 Falmouth Road
Property Address
Big Brothers & Big Sisters Of Cape Cod
Owner Owner's Name
information is required for every Centerville MA 02632 7-13-15
page. CitylTown State Zip Code Date of Inspection
D. System Information (cons.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
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Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): i
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Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
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Dimensions:
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Capacity:
gallons
Design Flow:
gallons per day
Alarm present ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: bate
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Comments (condition of alarm and float switches, etc.):
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*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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tsins•3113 Title 5 prricial Inspection Form:SubsurfisoBSeviags,Disposal System•Page 11 of 17
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Jul 15 15 12:02a p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers& Big Sisters Of Cape Cod
Owner Owner's Name
information is required for every Centerville MA 02632 7-13-15
page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
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Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is'16"x16"-2' below grade. Box is clean and solid wlone line out. No sign of over loading or
solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required).
If SAS not located, explain why:
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15ins•3/13 Title 5 Oficlel Inspection FomK Subsurface Sewage Disposal System•Page 12 of 17
Jul 151512:02a p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers& Big Sisters Of Cape Cod
Owner Owner's Name
information is required for every Centerville MA 02632 7-13-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
4
❑ leaching galleries number:
❑ leaching trenches number, length: —
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❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Typeiname of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four H-20 infiltrators 11'x33'x2' ck D Box. Camera out from'irom D Box and from
vent. Clean and dry,like new.
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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
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Indication of groundwater inflow ❑ Yes ❑ No
ems•ins Tills!Official Inspection Form:Subsurface Semae Oiaoosal SYslem•Pace 13 of 17
Jul 1515 12:03a p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers& Big Sisters Of Cape Cod
Owner Owner's Name
information is required for every Centerville MA 02632 7-13-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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f5ins•3113 Title 5 D`ricial Inspection Form SUbsurfaoe Sewage Disposal System-Page 14 or 17
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Jul 151512:03a p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers& Big Sisters Of Cape Cad _
Owner Owners Name
information
required for every CenterviHe MA 02632 7-13-15
page. Cdyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate a)J wells within 100 feet_ Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
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15ins•3113 TWe 6 Ofkial Irmpection Form:Subsurface Sewage Oisposat System-Pace 15 of 17
Jul 151512:03a p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers& Big Sisters Of Cape Cod
Owner Owner's Name
information
required for every Centerville MA 02632 7-13-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
No
Estimated depth high ground water: 47'
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) j
❑ Checked with local Board of Health -explain: i
❑ Checked with local excavators, installers-(attach documentation) j
® Accessed USGS database-explain:
Well SDW 253
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You must describe how you established the high ground water elevation:
Bottom of leaching at 4'below grade U.S.G_S.Well SDW 253 47'.
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
!Sins-3113 Title 5 official Inspection Form:Subsurface Sswage Disposal system-Page 16 of 17
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Jul 151512:04a p.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1934 Falmouth Road
Property Address
Big Brothers& Big Sisters Of Cape Cod
Owner Owner's Name
information
required for every Centerville UA 02632 7-13-15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D,or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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t5ins-aM 3 Tits 5 Offidal Inspeabn Fortn:Subsurface Sewage Disposal System-Page 17 of 17
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No. � Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0pprication for Dtopooai bp5teut/Con.5truction 3permit
Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel. o.
�Q' i;'6 ;�'�s ��i��or����i��
Assessor's Ma199�p/Parcel 046 /�e-e. /� �` � � �f
Installer's Name,A,,d$$ress,and Tel.No.C' D igner's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder(/W
Other Type of Building /J1 H keNo.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow / ® gallons per day. Calculated daily flow J 3 1) gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alteratio (Answerwhen applicable) r ✓
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b p this of al
Signed Date /LIZA&
Application Approved b Date /,5�71--
Application Disapproved for the following reasons
Permit No. X ,69 Date Issued G' "
No.
Fee jr D7�
i THE COMMONWEALTH OF MASSACHUSETTS {
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACH.USETTS-
2pprication for Migogal *potent Congtruction permit
Application is hereby made for a Permit to Construct( )or Repair( r)an On-site Sewage Disposal System at:
Location Address or Lot No. /r Owner's Name,Address and Tel. o.
el
Assessor's Map/Parcel e* ell// //� ` /� a , �/
Installer's Name,Address,and Tel.No. / assigner's Name,Address and Tel.No.
Type of Building: (�
Dwelling No.of Bedrooms Garbage Grinder(/00
Other Type of Building My0ef)05; �1f*4" o.of Persons Showers( ) Cafeteria( )
i Other Fixtures
Design Flow / O gallons per day. Calculated daily flow J? 3/� gallons.
r Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alteration (Answer when applicable) o-5
-ZD�
9 Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this of Ealth /
Signed Date /2-IZ �h
Application Approved by Datey'-
Application Disapproved for the following reasons l a
Permit No. 2,� —-Date Issued' e -
— ——————— — ——-——— ————— — ———
cc rG' THE COMMONWEALTH OF MASSACHUSETTS
/�9 �, QG� • BARNSTABLE, MASSACHUSETTS
Certificate. of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( on.
by Installer ,/ /L; Z GO `
at / DG/" /' Zow has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction-Permit No. ted Z,7
Date Inspector74
s F
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE fiKIAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
---------------------------------------
No. A Fee-
THE COMMONWEALTH OF MASSACHUSETTS
f�9 O66 PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
30io0gar *p//gtem Congtruction Permit
Permission is hereby grant to4/" �L.f� /! % C'C�l e-1,414,,2r
to construct( )repair(✓ an On-site Sewage System located.at No.#.
a�y S ��1i!/S L•/1.�� 6�' ,��r��it`,�- L�,o yf fF�l^1/�`/,/�'' -���
street /
and as described in the above Application for Disposal System Construction Permit.
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be compleetteed,within three years of the date below.
Date: Approved by
Boardld Health
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NOTICE. This Form Is To Be Used For the Repair Of Failed
Septic Systems Only,
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL .
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, )�B/AD 4hereby certify that the application for disposal works
construction permit signed b me dated /�!Z���1 concerning the
p g Y g
property located at lag / / �� j� Cel3 i'/P�/ta meets all of the
following criteria:
h/ P P P ere are no wetlands within 300 feet of the ro osed se tic sY stem
ere are no private wells within 150 feet of the proposed septic system
e observed groundwater table is 14 feet or greater below the bottom of the leaching facility
re is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNED : DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
TOWN OF BARNSTABLE
LOCATION II 37 �!//hl�kT�l ��� SEWAGE #
VILLAGE �'� �`1// ASSESSOR'S MAP*LOT fe+'
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 7h </ !'F1"1��`✓� (size)
NO.OF BEDROOMS
BUII.DER OR 0 R
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Welland 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 o within 300 feet f aching facility Feet
Furnished by /`JOL�C'/
yam/✓
3
Town of Barns
table P#
Department of Health,Safety,and Environmental Services
Public Health Division Date
367 Main Street,Hyannis MA 02601
Date Schedule Time Fee Pd
d
Soil Suitability Assessmentfor Sewage Disposal
_
Performed By:
Witnessed By:
LOCATION & CEN kAVNVOR VIA 't( 1V
Location Address Owner's Name
Address ,
Assessor's Map/Parcel: Engineer's Name
NEW CONSTRUCTION REPAIR Telephone#
Land Use
Slopes(°/,) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
{
Y
RECEIVED
4
JAN 1 0 °1997
HEAM CC PT. x ;'
TOWN OF CARWTA--I, E
r
t u
t
F
R
IYY
e
Parent material(geologic) Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater &
"' ETET NATION FOR S�ASU�AL�+GH'WA
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
_ �� fmnndmnter Adinctment ft.
TOWN OF BARNSTABLE q`
LOCATION A04 /I di SEWAGE #
VILLAG Ile ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 1IG !'r2°J4 `� (size)
NO.OF BEDROOMS /
BUILDER OR O R
PERMIT DATE: IZ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 20U feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet oaching facility) Feet
Furnished by
p a
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