HomeMy WebLinkAbout0018 FIVE CORNERS ROAD - Health 18 Five Corners Road
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Commonwealth of Massachusetts �
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Five Corners Road L 4
Property Address
Owner
Gene_Cimini oo�
Owner`s Name _ ---Information --
is required for _ ---Centerville— NSA 02632 03/09/08
C every page. irytTown --- ---
State Zip Code Date of inspection f
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: t
only the tab key I
to move your s
cursor-do not Michael Kellett
Name of Inspector
use the return � - ----
key. Aardvark-Environmental Inspections r V
Name
ame
VILAP.O. BOX 896 s= �
Company Address_ — -- -----
k
East Dennis --
-
Cityrrown - _ _ 02641
508-385-7608 - _
State Zip Code-3
—__ _
-- ----
Telephone Number 51374- ----- -----2
- — _ _— .__ ------ _--- _-----
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 6(310 CMR 15.000).The system;
Passes Ej Conditionally Passes Falls
® Needs Further Evaluation by the Local Approvin
g Autho
rity
Y
03/10/08
Inspector's signature ----
Date ------
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection, if the system 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 DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and.the app authority.
""This report only describes core ns:atati;=ttame Af:inspection andatartder tha conditions of use
at that time.This inspection does not addre.8111 w the syatefYl.will perforl� in,the:future.under
the same or different conditions of use.
tail•One Title b bfflelal Inffipeebon Form;subsuftee Sewage Clfsposel system.gage 1 of Is
_ Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage
g Disposal System Form Not for Voluntary Assessments
18 Five Comers Road
----- - --- - --- - ----- —
property Address --
Gene Cimini
Owner Owner's Name -- -- - —
information is Centerville required for _-__ -MA 02632 03/09/08
every page. Cky/Town Mate Zip Code Date of Inspection
B. Certification (coat.) - —
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
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.
Comments:
B) System Conditionally passes:
one or more system components as described in the"Conditional mass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Wealth,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 Wealth.
*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 Wealth):
�] broken pipe(s) are replaced
obstruction is removed
fall•08/fib Title 6 Official Inspection Form!Subsurface Sewage olsposal system•page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Five Comers Road
Property Address
Gene Cimini
Owner Owner's Name
Information is Centerville MA 02632 03/09/08
required for _ ----—-- ----- --- ----- - - -- --
every page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cant.):
[I 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 Chit
16.303(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
�I 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.
fail+Ogftls Title 6 Official Inspection farm:subsufface aewage Disposal System.Page 3 of IS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form Not for Voluntary Assessments
18 Five Corners Road
Property Address
Gene Cimini
Owner Owner's Name
equired foati for Is r Centerville MA 02632 03/09/08
requir --------—_-_---__---
every page. Clty/Town State Zip Code Date of inspection
B. Certification (cunt.) — -- -
C) Further Evaluation is Required by the Board of Wealth (cunt.):
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 ali inspections:
Yes No
E] Z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
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.
® ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
fail•08me Title 6 Official Inepeetion Form;Subturfeca Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Five Corners Road
Property Address
Gene Cimini
Owner Owner's Name-- ---- --- -- - --- -- — ---- - - - - -
equired foatifor is r Centerville MA 02632 03/09/06
�uir � -- _--.-
every page, CItyfrown State Zip Code Cate of Inspection
B. Certification (cunt.)
D) System Failure Criteria Applicable to All Systems (cunt:):
Yes No
® ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Cl 0 Any portion of a cesspool or privy Is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this forma
z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ® The system ai s. 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 16,000 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
® 1:1 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 16.304. The system owner should contact the appropriate
regional office of the Department.
fall•0608 TMe 6 O ieial Inspeeflon Form:Subsurfaea Smage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface sewage Disposal System Form Not for Voluntary Assessments
16 Five Comers Road
Property Address
Gene Cimini
Owner _
Owner's NamerInform
equired
is Centerville MA 02632 03/09/08
required far -- - _-- --_-- - -- _ -
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 Wealth
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?
g E] Were as built plans of the system obtained and examined? (If they were not
available note as N/A
Was the facility or dwelling inspected for signs of sewage back up?
® Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
Information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ® 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)]
fail•OWN title 6 Cffielal Inspection form;Subsudaes sewage Uspegal System•Page®of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.r 18 Five Comers Road
Property Address -----. -- __
Gene Cimini
Owner
Information is 03/09/08er Centerville MA 02632 _ _
required for — -._---_.._ _ _-----_�--�-_ _
every page, CityiTown 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: 0
Does residence have a garbage grinder? Yes No
Is laundry on a separate sewage system? [if yes separate inspection required] 0 Yes No
Laundry system inspected? Yes No
Seasonal use? Yes No
Water meter readings, if available (last 2 years usage (gpd)): ----------__. _ -_-
Sump pump? El Yes ED No
Last date of occupancy: current
Date
Commercial/Industrial plow Conditions:
Type of Establishment: -----------
Design flow(based on 310 CMR 15,203): ----.--ns pa--__
Gallons per day(gpd)
Basis of design flow(seats/persons/sqA, etc.): -- — ---
Grease trap present? Yes [I No
industrial waste holding tank present? Yes El 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): -- ---
fail 08/06 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page i of is
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments
18 Five Corners Road
Property Address
Gene Cimini
Owner Owner's Name
information is required for Centerville MA 02632 03/09/08
--- ---- --- - ___ --------------___ --- -__ - - - - -- --- -------
every page. cityPrown State Zip code Date of Inspection
D. System Information (court.)
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: --_---
T'ype of System:
0 Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Aitemative 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:
10/17/84
Were sewage odors detected when arriving at the site? ED Yes ® No
feil•08106 Title 6 Official inspection Form;Subsurface tewage Dispesai SAtsm•Page 8 of 95
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
16 Five Comers Road
Property Address
Gene Cimini
Owner Owner's Name
Information is Centerville MA _ 02632 03/09/08
required for - — _-- -- _-_-- _.. _
every page, Cky/Town state Zip Code Date of Inspection
D. System Information (cont.) - -- -
Building sewer(locate on site plan):
Depth below grade: 3•6 - - ---- - -
feet
Material of construction:
® cast iron 0 40 PVC L] other(explain): --- -- ------ -
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic`dank(locate on site plan):
Depth below grade: 1.0 - --
feet
Material of construction:
concrete metal [3 fiberglass [] polyethylene [I other(explain)
If tank is metal, list age: --- - --- ------ ----- -
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ED Yes ® No
Dimensions: 1500 gel
Sludge depth:
1
'
Distance from top of sludge to bottom of outlet tee or baffle 29 291 — - ---- -
Scum thickness 2"----------- -------_ -_____---
Distance from top of scum to top of outlet tee or baffle
6r,
Distance from bottom of scum to bottom of outlet tee or baffle 151
How were dimensions determined? measured
fall-08/00 fide 5 Official Inspection Form;Subsurface swage oisoosal System,Page 0 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
er 18 Five Corners Road
Property Address - -_ .-- -
Gene Cimini
Owner - -
Owner's Name
Information is required for Centerville NIA 02632 03/09/08
---------- - --- - - - -------- - -
every page. City/Town State Zip Code Date of inspection
Do 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.):
The tank was sound and_t ght with tees in place and liquid at outlet invert.
Grease Trap (locate on site plan):
Depth below grade: feet - - ---_
Material of construction;
0 concrete E2 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:
0 concrete El metal [I fiberglass 0 polyethylene other(explain):
Bali•0we Tibe 6 Official inspection Form;Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F
18 rive Corners Road
---- - -------- ------------
Property Address -
Gene Ciminl
Owner Owner's Name - --
information is required for Centerville MA 026 state 32 03/09/08
�_ _
every page. City/Town -__ --
Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions: - ----- -- ----- ----- --
Capacity: gallons-
Design Flow: -- - --- ----- - -
gallons per day --
Alarm present: El 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 Sox(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert even
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The box was level and tight with q9 sign of ggrryov_er.
Pump Chamber(locate on site plan):
Pumps in working order: [I Yes El No
Alarms In working order: El Yes [I No
fail-08/05 Title 5 Official inspection Form,subsurface sewage Disposal system Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
- d Subsurface Sewage Disposal System Foam Not for Voluntary Assessments
c
> 18 Five Corners Road
Property Address
Gene Cimini
Owner — -
information is Owner's Name
required for Centerville -- - MA 02632 03/09/08
every page, cityrrown State Zip Code bate of inspection
Do System information (coat.)
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:
11 leaching pits number: __------- ._---_
® leaching chambers number: 2
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.):
This system nas two five hundred gallon drywelis which showed no sign of ponding or failure.
fail 08/00 Title 6 Official Inspection Form:Subsurface Sewage bisporel Sygem-Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
+$ Subsurface Sewage Disposal System Form -Not for Voluntary Y rJt Assessments
" 18 Five Comers(toad
Property Address
Gene Cimini
Owner Owner's Name
information is Centerville
required for _ Zip
MA 026 Code 03/09/08
every page. CitylTown State Z Zip- ._e -
e Date of Inspection --
D. System Information (font.)
Cesspools (cesspool must be pumped as part of inspection) (locate.on site plan):
Number and configuration —--- -- -
Depth o top of liquid to inlet Invert --- ----
Depth of solids layer ----
Depth of scum layer ---------- —
Dimensions of cesspool _--------__--____--
Materials of construction --
Indication of groundwater inflow 0 Yes ® No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
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.):
tali 08/06 Tins 5 bffioiai Inspection Farm;Subsurfsde Sewage Disposal System•Pugs 13 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Five Corners Road
Property Address
Gene Cimini
Owner ---------- --
Owner's Name
information is Centerville MA 02632 0_3/0.9/0_8
required for --.-..--.— _--- ---.-- _
every page, City/Town State Zip Code ®ate of Inspection
D. System Information (cunt.) -- - ---
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,
l h
1�
fail 08100 Yitle 6 Welal Inspectl6n Nrm;Subsurface Sewage bltp®sal System.Page U of 15
f
Commonwealth of Massachusetts
Title 6 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t 18 Five Corners Road
Property Address - - -
Gene Cimini
Owner Owner's Name - - -- - ---
information is Centerville MA 02632 03/09/08
required for ----------__----- ----- -—
every page, City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Site Exam:
Check Slope
® Surface water
Check cellar
[] Shallow wells
Estimated depth to ground water: 20- -- -- ---------- ------ --- -
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 Wealth-explain:
Checked with local excavators, installers- (attach documentation)
Accessed USES database-explain:
You must describe how you established the high ground water elevation:
USGS ma sp show an elevation of over 20 feet.
fail•08108 TiOe 6 Official inspeetlan Form:Suizuftce swage Ditpbtai Syslem•Page i 6 of 16
oFT�r�
Town of Barnstable
Regulatory Services
BARNSTABM Thomas F. Geiler,Director
MAn
1619.
pTfD MAY A
Public Health .Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601 s
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
not 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.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
mAP I
PARCEL. ,_
LOT 7 Cl
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 18 Five Corners Road
Centerville, MA 02632
Owner's Name: Stephen Hall
Owner's Address:
Date of Inspection: April 23, 2004 RECEIVED
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford MAY U 5 2004
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049 TOWN OF BARNSTABLE
Telephone Number: (508) 862-9400 HEALTH DEPT.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Need Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: April27, 2004
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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Five Corners Road
Centerville, MA
Owner: Stephen Hall
Date of Inspection: April 23, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined", please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Five Corners Road
Centerville, MA
Owner: Stephen Hall
Date of Inspection: April 23, 2004
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.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Five Corners Road
Centerville, MA
Owner: Stephen Hall
Date of Inspectiion: April 23, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS, cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 18 Five Corners Road
Centerville, MA
Owner: Stephen Hall
Date of Inspection: April 23, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ -Was the site inspected for signs of break out ?
✓ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example, a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 18 Five Corners Road
Centerville, MA
Owner: Stephen Hall
Date of Inspection: April 23, 2004
FLOW CONDITIONS
RESIDENTIAL
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: 1
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system (yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): pd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative 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:
Installed 8124199-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Five Corners Road
Centerville, MA
Owner: Stephen Hall
Date of Inspection: April 23, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 3'
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage
Recommend installing risers.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Five Corners Road
Centerville, MA
Owner: Stephen Hall
Date of Inspection: April 23, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
The D-box was level and clean. No solids were present
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
• Page 9 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Five Corners Road
Centerville, MA
Owner: Stephen Hall
Date of Inspection: April 23, 2004
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 gal. drywells (25'x 13') -per as built card
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.):
The drywells were dry. No scum lines were present. The interiors were clean The bottom to grade was approximately 6' A
video camera was used for the inspection.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
• Page 10 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Five Corners Road
Centerville, AM
Owner: Stephen Hall
Date of Inspection: April 23, 2004
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.
Ic
Ca
e 13
S, C�- -
3
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3 2° ly 6 y O
y
573 3a
10
Page 11 of l 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 18 Five Corners Road
Centerville, MA
Owner: Stephen Hall
Date of Inspection: April 23, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30'+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using a Barnstable topographic map and water contours map, the maps were showing approximately 30'+/-to ground water
at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
I1
TOWN OF BARNSTABLE --
LOCATION /-/ Fi i
1C� SEWAGE #
VILLAGE
ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACTTY
LEACHING FACILITY: (type)
(size) 5'
NO. OF BEDROOMS
BUILDER OR OWNERPERMITDATE: ���
9 a COMPLIANCE DATE:
Separation Distance Between the:
i
I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility
on site or within 200 feet of leaching facility any wells exist
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility
Furnished b ,�/ ��'' Feet
Y- - /- ,;-
q
- � t
S
a
i
_ u.
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Migaaf *pgtem Construction Permit
Application for a Permit to Construct(}Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components
Location Address or Lot No. Owner's Name, ddress and el.No.
�l o�rl 1 rC�i
Assessor's Map/Parcel
Sri 5 M e rc s4-cl An, c r lilef,
Installer's Name,Address,and Tel.No. ��-•CJ�l9 Designer's Name,Address and Tel.No.
�1/0-se,:74 10-r- 0 G�v��ds
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil ._�3`-fG//
Nature of R epairs or Alterations(Answer when applicable) /51'�/ 16i1'r S?/1i01 C,_:7 9Y Octal WY 7-1 C1=d��
l by "/
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 by this Board qS Health.
Signed .< Date
Application Approved by Date Z3"
Application Disapproved for the following reasons
Permit No. Date Issued
No. Fee J�+ r �•""'�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
r Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIPPrication for Zigaar *pgtem (Congtruction Permit i
Application for a Penn it to Construct(4-)-Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /T Owner's Nam ddress and el.No.
rvl�ln ✓�s^r��o�ti ir'C4
Assessor's Map/Parcel &I C
-f /" U T C
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel:No.
-c // S s�_.e_
Type of Building:
+ Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
`,,,Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /.fz o Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when/ap 66ii r l�J�
` ,SOH _Vno-/ b0 .ao/ - ,Q3CJ
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 by this Board oj Health.
Signed t2Fnl Date g- %`:3-19'
Application Approved by Date Z 3ti
Application Disapproved for the following reasons
Permit No. Date Issued
---------------------------------------- -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(v)r`Repaired( )Upgraded( )
Abandoned( )by tlo .
at S ✓= T— /l/i= has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated g Z
Installer ✓QStA:1`i 4)�_ L�k�rros Designer ,�05 � Qz .trr.-ao 5 �l ,
The issuance of this pl r�mit `h ofe6e construed as a guarantee that the s to- will functions de.si ;—Ad,f
Date 7 I Inspector
No. ! � � F ----------------l�—J��— I;i`, Fee ��''�•.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS' x
yZigpogar *pgtem Construction Permit
Permission is hereby,granted to Construct(pair( )Upgrade( )Abandon( )
System located at %3g, f✓i- ��i^r�i r s �o.rgr/
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 ermit.
/ c� c
Date: �/ Z �/9" Approved by _ / ,
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICA7:ION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS Corr.STRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated 5—�3- ----, concerning the
property located at/&/=/vi= meets all of the
following criteria:
e failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less chart or equal to 5 minutes per inch.
G - There are no wetlands within 100 feet of the proposed septic system
01�fhere are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
/There are no variances requested or needed
• The bottom of'the proposed leaching facility will tQbe located less than five feet above the
maximum adj)iged groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. «ill be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching faciL:ty will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the foilo*ing: .
A) Top ol.'Ground Surface Elevation(using GIS information)
B) G.W. Elevation -7—+the MAX 1191 G.W. Adjustment
DIFFERErICE BETWEEN A and B
SIGNED : � ...-
[Sketch proposes' DATE:
Plan of system on back .
q:health folder cart ]
i Q
O
\tom
pV
O
S
' S _
n
o ti
TOWN OF BARNSTABLE 9
LOCATION /S 1,2a�� SEWAGE # 99-5��
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ISoo
LEACHING FACILITY: (type) 2 /0/4/wl 111 (size)
NO.OF BEDROOMS 3
Is _BUILDER OR OWNER
`PERMTTDATE: S - 99 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 leac 'ng facility) Feet
Furnished by
r .
ro n Sy
o
° b
TOWN OF BARNSTABLE
FLOCATION Pr I vC co/fivi SEWAGE # 9 9' S�
VILLAGE LA716(VIILl. ASSESSOR'S MAP & LOT ���� UDG
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 4"60
LEACHING FACILITY: (type) D/�igd l S (size) C.S)C 13
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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 leachin facility)—� J Feet
Furnished by �O�C
Ci-
A
�1 I3 a O
3
�3
3 *11 ly
y 573 3a-
:.
RrelVEp.
eo AUG 5199
9ro
a
VEA TS
YEXEC �
'CE OF ENVIRONMENTAL AFFAIRS John Graci
I�IZ ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
�V ET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COPE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 18 FIVE CORNERS RD. CENTERVILLE l<p �Qa� Zcl
Name of Owner JOAN RITCH
Address of Owner: 54 MCMICHAEL DR.PINEHURST N.C.28374
Date of Inspection: 7/19/99
Name of Inspector:(Please Print)JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: n/a
Mailing Address: n/a
Telephone Number: n/a
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
Passes The inpection is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does
X Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:7/29/99
The System Inspector shal/su/bmit copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM FAILS TITLE V INSPECTION.THE MAIN CESSPOOL IS PONDING TO THE SURFACE,THE SYSTEM IS IN HYDRUALIC FAILURE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 18 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
n/a
B. SYSTEM CONDITIONALLY PASSES:
nLa 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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
n(a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
nta The system required pumping more than four 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19/99
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 the public health,safety
and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nLa_ (approximation not valid).
3) OTHER
nLa
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 18 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped n/a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:.
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 18 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 18 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-44.Q g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual):4
Total DESIGN flow: 44Q
Number of current residents:)
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NQ If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no): YES
Water meter readings,if available(last two year's usage(gpd): ]I&
Sump Pump(yes or no): NQ
Last date of occupancy: n&
COMMERCIALIINDUSTRIAL
Type of establishment: nLa
Design flow: nta gpd(Based on 15.203)
Basis of design flow: Wa
Grease trap present:(yes or no):DLO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:WA
Last date of occupancy: n&
OTHER: (Describe)
nLa
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nLa_ gallons
Reason for pumping: nLa
TYPE OF SYSTEM
_ Septic tank/distribution box/soil absorption system
X Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: nta
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1963
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19199
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK:
(locate on site plan)
Depth below grade: nLa
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
n&
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
nLa
Dimensions: nta
Sludge depth: nLa
Distance from top of sludge to bottom of outlet tee or baffle: nLa
Scum thickness:-aLa
Distance from top of scum to top of outlet tee or baffle:_i&
Distance from bottom of scum to bottom of outlet tee or baffle: nta
How dimensions were determined: n&
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
Wa
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nLa
Dimensions: n&
Scum thickness: nLa
Distance from top of scum to top of outlet tee or baffle:iiLa
Distance from bottom of scum to bottom of outlet tee or baffle n&
Date of last pumping: n&
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
nLa
revised 912/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: Wa
Capacity: Wa gallons
Design flow: n& gallons/day
Alarm present: NQ
Alarm level:jita- Alarm in working order:Yes_No_: MQ
Date of previous pumping: Wa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n&
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:Wa
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
IILa
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n(a
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19/99
SOIL ABSORPTION SYSTEM(SAS): _
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Wit
Type:
leaching pits,number: n/a
leaching chambers,number: 1lLa
leaching galleries,number: _nLa
leaching trenches,number,length: Wa
leaching fields,number,dimensions: nLa
overflow cesspool,number: Wa
Alternative system: Wa
Name of Technology: -D/A
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
Wit
CESSPOOLS: X
(locate on site plan)
Number and configuration: DBE
Depth-top of liquid to inlet invert: PONDING
Depth of solids layer: n&
Depth of scum layer. Wa
Dimensions of cesspool: 61C
Materials of construction: BLOCK
Indication of groundwater: n(a inflow(cesspool must be pumped as part of inspection)nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
MAIN CESSPOOL IS PONDING SYSTEM IS PAST THE EFFECTIVE DEPTH OF LEACHING,SYSTEM FAILS.
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n/A
Depth of solids: nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued)
Property Address: 18 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
tan
.e
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 FIVE CORNERS RD.CENTERVILLE
Owner: JOAN RITCH
Date of Inspection:7/19/99
NRCS Report name: nLa
Soil Type: nLa
Typical depth to groundwater: nta
USGS Date website visited: nLa
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-10+FEET
revised 9/2/98 Page 11 of 11