HomeMy WebLinkAbout0100 FIVE CORNERS ROAD - Health 100 Five_Corners Rd. (Centerville)
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System contains a 1500 GI poly tank as well as a Dbox and a 60' Trench with perforated pipe in
stone. Dug down at 1/3 way app 20' into trench Stone was clean and dry with no standing water.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts 03&
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form = Not for Voluntary Assessments
r
M 100 Five Corners rd
Property Address N
OQ
Judy Oakley
Owner Owner's Name
information is
required for every Centerville Ma 02632 6/7/16
page. City/Town State Zip Code Date of Inspection N
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. inspector:
key to move'your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
ti"R" Company Name
8 Johns path
Company Address
B S Yarmouth Ma 02664
City/Town State Zip Code
508-364-9587 S103522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
_ information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluatio �Lo al Approving Authority
77
6/8/16
lni6pectors 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�o V&
t- f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is Centerville Ma 02632 6/7/16
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has-a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
5.
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® -Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
z Any-portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 Five Corners rd
M
Property Address
Judy Oakley
Owner Owner's Name
information is Centerville Ma 02632 6/7/16
required for every
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® 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:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
System containsd a 1500 GI poly tank as well as a Dbox and a 60'Trench with perferated pipe in
stone. Dug down at 1/3 way app 20' into trench Stone was clean and dry with no standing water.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 227 Gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: occupied
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped 12/20/13
Was system pumped as part of the inspection? ® Yes ❑ No
es, volume pumped:
1500
If
Y gallons
How was quantity pumped determined?
Tank size
Maintenance
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):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,••''r 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
13 Years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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.):
Septic Tank (locate on site plan):
Depth below grade: 1.5feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain)
1500
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is Centerville Ma 02632 6/7/16
required for every
page. City(Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
24"
31,
Scum thickness
42"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
1" Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No evidence of Ieaking,Tees and or baffles in place at time of inspection.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:. Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tees are in place and levels are normal.
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Normal levels
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.):
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.):
system is a conditional ass.
If pumps or alarms are not in working order, y p
P P
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1 at 60'
❑ 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.):
Stone is clean and dry
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. City/Town 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.):
No ponding no break out
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
DEG-'19-2013 13:38 From:BARNST HEf�LTH 15087906304 Tr,:50R_4289399
TOWN OF BARNSTABLE
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Separation Distance Ectwcen tlie:
Nfaximum Adju.swd Groondwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of lcaching facility) Felt_ i
Edgr,of Wetland and Leaching Facility (If any wtdands exist
within 300 feet of leaching facility) ECet
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. CitylTown 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 all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is Ma 02632 6/7/16
required for every Centerville
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth g g th to high round water: feeetet ft
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: 12/20/13
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Test hole data on plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 100 Five Corners rd
Property Address
Judy Oakley
Owner Owner's Name
information is required for every Centerville Ma 02632 6/7/16
page. Cityrrown 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
!Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
F
i
N. FeeTHE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS
2pplication for IBigogal bpztem Com6truction i3ermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete.System O Individual Components
Location Address or Lot No. /00 V Owner's Name,Address and Tel:No.
Assessor's Map/Parcel //_�j 0-7/ v -cs 0 M PLC,
Installer's N e,Address,Cand
ooTel.No. (� Designer's Name,Address and Tel.No*
�Q0 x f
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 13 3 0 gallons per day. Calcplated daily flow 3 t� gallons.
Plan Date ` 0�_,s Number of sheets l Revision Date
Title
Size of Septic Tank W vw pe of
Description of Soil :5
Nature of Repairs or Alterations(Answer when applicable) oa
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with.the provisions of Title 5 of the En ironmental Code and not to place the system in operation until a Certify-
Cate of Compliance has been issue d o ealth.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 2-0 d S— 3 f(o Date Issued P 'G C
.,--
No. OU 4 .4 �,.�_.' Wit, a, Fee `(1d"-
✓` ���~ - ��` Entered in computer:
r THE=COMMONWEALI OF MASSACHUSETTS Yes
' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2ppficatiort for Migpoga1 *pgtem Cow6truction Permit
,,Application for a Permit to Con`struet( )Repair( )Upgrade( )Abandon( ) omplete System El Individual Components
Location Address or Lot No. /00 /5✓,_- �ywryS Owner's Name,Address and Tel.No.
Assessor's Map/Paicel //_C O / v-r-S Co r 0,-
Installer's N e,Address,w and TeI.ONo. (O Designer's Name,Address and Tel.No.
v ,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
r
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �J 3 t� gallons per day. Calcu ated daily flow —3-3 gallons.
Plan Date —/ - k-0- Number of sheets � Revision Date
Title Y v#-C_-_
Size of Septic Tank 1W14 w T e of S.A.SS d r-w
NN-
D of Soil
l
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
_Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Env' onmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b3L4.his-Board of H alth.
Signed -- : .; ,., ,A!,,Date, -.;�,.-Gls .
Application Approved by 1)✓. > Date -0 S"
Application Disapproved for the following reasons -'
Permit No. i o ) S I l G Date Issued `G i^
.THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed ( )Repaired( )Upgraded( PI
-0001
Abandoned( )by a r S e oft-Ir- SM r�,,tc.=c
at t nc-) -�'i,d o �, ,, �,c KaAr, /'-t.kr VASc:; has been constructed in accordance
with the provisions of e 5 and the for Disposal System Construction Permit No. _ 714, dated 2=6 -o Y
Installer r�J�-e Designer
The issuance of this permit shall no be construed as a guarantee that the syste •-veil u ct} n a esi ed.
Date Inspector
r
No. a ()0 S — 3 6 Fee t)U
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migpogar *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( i,�band ( )
System located at 10
ti ,�v v\
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 thi n"9
Dater -7 ` ` yS Approved byA -C
d
9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems.Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, S+Aq hereby certify that the engineered plan signed by me
dated "+-1 -OS ,concerning the property located at
l0 O F'.,V E CnC-rVr .�C,j i 1 k meets all of the
following criteria:
• This 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 than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or.may conduct deep
test holes and percolation tests.at the site without a health agent present.
• 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 be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following: j
A) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation k—+adjustment for high G.W.0A = 10 9
DIFFERENCE BETWEEN A and B
SIGNi D : DATE: - - C)
NOTICE
Based upon the above information; a repair permit will be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASepric\percexemp.doc
i
Town of Barnstable
OFtNE Tq�, Regulatory Services
tiQ
; Thomas F. Geiler, Director
• BARNSTABLE,
M ; ,0� Public Health Division
'E0 39. Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 7/13/05
Designer: Shay Environmental Services, Inc. Installer: Robert Septic Services.
Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street
MA 02536 Yarmouth, MA
On 7/05/05 Robert Septic Service was issued a permit to install a
(date) (installer)
septic system at 100 Five Corners Road, Centerville, MA based on a design drawn by
(address)
Shay Environmental Services, Inc. dated_July 05, 2005
(designer)
XX I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
OF Afqo.
7:
I(Instler's ign e) o�° CAR MEN �E. �
a
St�1Y Cn
No. 1181
(Designer's Signature) (Affix ON4
�01
Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Si nature a
item 4 if Restricted Delivery is desired. ❑.Agent
■ Print your name and address on-the-reverse—— - -_X. "❑Addressee.
so that we can return the card to you. B.' eceiIA ve ,by(Print Na e) C. Date of Delivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delivery ad ss different from item 1? ❑Yes
1. Article Addressed to: If YES,enter belivery address below: ❑No
Mr Joseph Corona
100 Five Corners Road
Centerville, MA 02632 ,` 3. Service Type
❑Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D. j
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(Transfer from service label)
PS Form 3811,Augusi 2001 Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTAL SERVICftw �.� ` First-Class Mail
USPS
\ Permit No. G-10
• Sender: Please print yourfia[ne, address, and ZIP+4 in this box •
:PUBLIC HF,AL'I'H DIV?ISION
TOWN OF BARNSTABL E., C
200 MAIN STREET �
HYANNIS, MASSACH-.JSETTS. 026011
ldidl; 111 :111!11If111.111111hiIJJII
Postal
CERTIFIED MAIL RECEIPT
(Sornestic Mail Only;
fU
to
l ;�
Ln Postage $
L,
"D Certified Fee
Postmar
Return Receipt Fee l� Here
b (Endorsement Required) /
b Restricted Delivery Fee
(:3 (Endorsement Required)
C3 Total Postage&Feesru
0 Sent To
------X -.J_G45_!V- CU rlmc�_,---------------------------------
r7
Street,Apt.No.;
J
t3 or PO Box No.fU® �l_✓� �rr/Y /7��'S hf��t ll
--- ---
t3 City,S ZIP+4
PS Form :0, January 2001
Certified Mail Provides:
■ A mailing receipt
■ A unique identifier for your mailpiece {
■ A signature upon delivery
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
■ Certified Mail may ONLY be combined with First-Class Mail or Priority Mail.
■ Certified Mail is not available for any class of international mail.
s NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
e For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811�to the article and add applicable postage to cover the
fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry
PS Form 3800,January 2001(Reverse) 102595-01-M-1049
°F THE 1p�
Town of Barnstable
B'` ASS' �M * Regulatory Services
y nss. �'
�prFo MAC A�0 Thomas F. Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 19, 2005
Mr Joseph Corona
100 Five Corners Road
Centerville, MA 02632
NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V.
The septic system owned by you located at 100 Five Corners Road, Centerville,MA was inspected on
June 7t'2005 by James M. Ford, a certified septic inspector for the State of Massachusetts.
The inspection of your septic system showed that your system has failed under the guidelines of 1995
TITLE 5 (310 CMR 15.00) DUE TO THE FOLLOWING:
Cesspool and leaching pit were both over-full with sewage.
You have two years from the date of the system inspection to bring the system into compliance.
If there are any questions about this reminder,please feel free to contact the Barnstable Health
Department.
BARNSTABLE TH EPARTMENT
AM
COMMONWEALTH OF MASSACHUSETTS
F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a d DEPARTMENT OF ENVIRONMENTAL PROTECTION
A -
V S.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 100 Five Corners Road
Centerville MA 02632
Owner's Name: Joe Corona f "=
Owner's Address: Same s �+
l
Date of Inspection:June 3,2005 Job#05-158 •?L� ,
_ t
Name of Inspector: PATRICK M.O'CONNELL cr> co >
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779 r--
C--,) m
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 DF,P
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste ����N OFtM
Passes
Conditionally Passes ' • �yG
Needs Further Evaluation by the Local AD Droving Authority = T I K m c
X Fails = '
Inspector's Signature: Date: 6/3/05
INSP1„��.
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heath 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: Cesspool and overflow full over inverts.
****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 I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
i n Summary: Check A B C D or E/ALWAYS complete lete all of Section D o y p
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:
Title S Tncnortinn 1~nr 4n c/)nnn 2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
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:
Tit1a C Tncnnrtinn Fnrm A/1 S/)AAI) 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
f
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ _ Backup of sewage into facility or system component due to 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 ''/z 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
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X— Any portion of 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 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP 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.]
_Yes_(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 Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(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.
Titles 5 Inenantinn Anr 611 CPMAA 4
Page 5 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
Check if the following have been done. You must indicate"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_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
_X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance 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
_ _X_ Existing information. For example,a plan at the Board of Health.
_X_ - 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)]
Titla i Tnenartinn 17nrm All snnnn 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
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:3
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2003—46,000 gal.2004—77,000 gal.=168 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Cesspool pumped 6-8 months prior to inspection.
Source of information: Owner
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
_X_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:
unknown
Were sewage odors detected when arriving at the site(yes or no): No
Titles G Tn antinn T:nr 4/1;/Innn 6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 6"
Materials of construction:_X_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: No (locate on site plan)
Depth below grade: -
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:-
Sludge depth: -
Distance from top of sludge to bottom of outlet tee or baffle: -
Scum thickness: -
Distance from top of scum to top of outlet tee or baffle: -
Distance from bottom of scum to bottom of outlet tee or baffle: -
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: No (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.):
Title C inenontinn Anrw,4ii ennnn 7
f
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
TIGHT or HOLDING TANK: No (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: No (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: No (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.):
Titla 1;Tncnartinn Fnrm All 1%/70nn 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
X overflow cesspool,number: One
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.): Overflow pit full to top of structure,pit has no effective leaching.
CESSPOOLS: XX (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration: One with overflow
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: Block
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspool full over inlet end outlet pipes,has been full to top.
PRIVY: No (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.):
Titla G Tnonantinn 17nrm Ail rN1100n 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
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.
Five Corners Road
Water service
Garage #1 UO
43
30
46 69
Titla i Inenantinn 17nrm All vInnn 10
• Page 11 of 11
e OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 Five Corners Road,Centerville
Owner: Joe Corona
Date of Inspection: June 3,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water:
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:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A perc test will be performed prior to repair to determine groundwater elevation.
Titla S incnartinn Fnrm All VIOAA 11
TOWN OF BARNSTABLE
LOCATION V!Z 60le-AJF4S SEWAGE # —2605'—
VILLAGE C—ENT—a Q'P\ SSESSOR'S MAP & LOT I --0,
-36
INSTALLER'S NAME&PHO
SEPTIC TANK CAPACITY
i
LEACHING FACILITY: (type) `��.�� (size) or
NO. OF BEDROOMS
BUILDER OR OWNER J �'
PERMITDATE: _Gd`6Sne. P C MPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
I � r
1 �
I � 1
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Ao� -
COMMONWEALTH OF MASSACHUSETTS ;
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTI
t
TITLE 5 r e<F
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 100 FIVE CORNERS RD CENTERVILLE,MA 02632
Owner's Name: MRS.SAPANARO +4?z t
Owner's Address: 15 GRANT ST NATICK MA.01760 �
Date of Inspection:3/9/01 :
Name of Inspector: (please print) -JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: P:b. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
1
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 p
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
"
P P P g P Y PP Y
inspector pursuant to Section 15.340 03itle 5(310 CMR 15.000). The system:
X Passes t=
_ Conditionally Passes
_ Needs Further FAluation by the Local Approving Authority
Fails k "k
Inspector's Signature: Date: 3/9/01 k
The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within G. 't
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
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS
TO PROLONG THE SYSTEM'S USEFULL LIFE. {
****This report only describesconditions at the time of inspection and under the conditions of use at that time.This
inspection does not address how4hetsystem will perform in the future under the same or different conditions of use.
i
Til4. C In .�rrlinn Fnrni /,/15/10M 1
{ Page 2 of 11 t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
'. CERTIFICATION (continued) #':
Property Address: 100 FIVE CORNERS RD CENTERVILLE,MA 02632
Owner: MRS.SAPANARO `fi)
Date of Inspection: 3/9/01 _ .
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information.which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
x,, �•.`lye e�g �
Comments: ,
THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO 1,- j.
YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
B. System Conditionally Passes:
f
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, YY13
upon completion of the replacement or ryepair,as approved by the Board of Health,will pass. , i•r.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced "t=/'t
f\ 1 A
with a complying septic tank as approved by the Board of Health.
A metal septic tank will ass inspection if it is structural) sound not leaking and if a Certificate of Compliance indicating
* P P P Y � g P g •,3 , i
that the tank is less than 20 years old is available. "
ND explain: n/a
y
`• r0
n/a 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
_ obstiuction is removed ?
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed i e s .The system will ass
Y 9 P p g Y P•P O Y P
inspection if(with approval of the Board of Health):
_broken p '(s)are replaced
_obstruction is removed }�s,t�
ND explain: n/a
ii
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is 1
;t t
Page 3 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 100 FIVE CORNERS RD CENTERVILLE;MA 02632
Owner: MRS.SAPANARO
Date of Inspection: 3/9/01
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 ;r, .
not functioning in a manner wh0:.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'Itank 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 deiermine distance n/a '
;r
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and " a
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia t ii
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:
n/a
4
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 100 FIVE CORNERS.RD CENTERVILLE,MA 02632
Owner: MRS.SAPANARO i
Date of Inspection: 3/9/01
. us
D. System Failure Criteria applicable'to all systems: 5�
You must indicate"yes"or"no"to each of the following for alLinspections:
.3i.
.. 3�0
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or pondingof effluent to the surface of the ground or surface waters due to an overloaded or clogged -n
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 day flow
_ X Required pumping more than 4 times in the last year CLT due to clogged or obstructed pipe(s).Number of times i-;"WIr
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of 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;orl,privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP "s
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
M b.
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be ,1
attached to this form.] 'S ;
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 ,z.
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. ;:F
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following: �
The following criteria apply to lar e s stems in addition to the criteria above s
( g PP Y g,; ry ) r:
ttil� `
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
g
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered r:;
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threatk
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner y
should contact the appropriate regional office of the Department. 3 N
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Page 5 of 1 l
y• ..:.YC.hk.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS uH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM g
PART B ,y
CHECKLIST iF=
.
Property Address: 100 FIVE CORNERS RD CENTERVILLE,MA 02632 .R
Owner: MRS.SAPANARO
Date of Inspection: 3/9/01
Check if the following have been done.You must indicate"yes"or"no"as to each of the following: :f
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
_ X Has the system received normal flows in the previous two week period .
_ X Have large volumes of water been introduced to the system recently or as part of this inspection? +�,
X Were as built plans of the system-obtained and examined?(If they were not available note as N/A)
,r;J
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out? ti xL I'
X _ Were all system components,excluding the SAS, located on site? ,"".op,
X _ Were the septic tank manholes"uncovered,opened,and the interior of the tank inspected for the condition of the
r
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(arid 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:YL
Yes no ;:• ;;'¢.
_ X Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any-of'the failure criteria related to Part C is at issue approximation of distance is t �:
unacceptable)(310 CMR 15.302(3)(b)]
.f •�,sy;4 tY
I
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Page 6 of 11
' 1
,a a.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � i
PART C
;
SYSTEM INFORMATION
Property Address: 100 FIVE CORNERS RD CENTERVILLE,MA 02632
Owner: MRS.SAPANARO
Date of Inspection: 3/9/01
`7
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:0
Does residence have a garbage grinder(yes or no): NO "' l
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no): YES
Water meter readings, if available(last 2 years usage(gpd)): n/a .
Sump pump(yes or no): NO
Last date of occupancy: n/a '
COMMERCIALANDUSTRIAL
Type of establishment: n/a ; ' ;
Design flow(based on 310 CMR 15.2Q3): n/agpd `
Basis of design flow(seats/persons/sg8,etc.): n/a
Grease trap present(yes or no): NO .
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title;5 system(yes or no): NO
Water meter readings, if available: n/a Y
Last date of occupancy/use: n/a
OTHER(describe): n/a
t NU'
GENERAL INFORMATION ;
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO r;
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a F ';
4
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool t
_Overflow cesspool ,
_Privy :i;.
_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) `
=;3
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1965 ,F
Were sewage odors detected when arriving at the site(yes or no): NO
' ,wI
..f k
h
Page 7 of 11
z .
.j
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS - _-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM °
„t.
PART C 3
SYSTEM INFORMATION(continued) e
Property Address: 100 FIVE CORNERS RD CENTERVILLE,MA 02632
Owner: MRS.SAPANARO
1.
Date of Inspection: 3/9/01 : F,;
Ey.,q s
BUILDING SEWER(locate on site.plan)
Depth below grade:42"
Materials of construction:_cast iron _40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,'venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan) 1
Depth below grade:24" '
Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 6' X 6' BLOCK CESSPOOI,,
HMI
Sludge depth:0" °,•+'
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a °
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED t
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.): :3s
MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING
EVERY ONE TO TWO YEARS'DEPENDING ON USE TO PROLONG THE SYSTEM'S USEFULL LIFE.
ti-e
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction: concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a ~`;
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a s
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
fed,;
Date of last pumping: n/a {
Comments on pumping recommendations inlet and outlet tee or baffle condition,structural integrity, liquid levels as related } a
to outlet invert,evidence of leakage,etc)
; .
2
C1 7
1' 7
S S
t
Page 8 of 11
v }ram++
44
k
• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `
SYSTEM INFORMATION(continued)
Property Address: 100 FIVE CORNERS RD CENTERVILLE,MA 02632
Owner: MRS.SAPANARO
Date of Inspection: 3/9/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) a
l
Depth below grade: n/a
Material of construction:_concrete_metal fiberglass _other ex lain : n/a 't
( P ) i. .»
Dimensions: n/a ` .
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A t "
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a .
Comments(condition of alarm and float switches,etc.): .
n/a x
ua 41
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
n/a
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):NO ' s�
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): ;t ,
n/a z
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ryry}} a
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•'fit
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '` s
PART C r
SYSTEM INFORMATION(continued) '~
lj
Property Address: 100 FIVE CORNERS RD CENTERVILLE,MA 02632
Owner: MRS.SAPANARO
Date of Inspection: 3/9/01
A
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why: .
n/a
Type
n/a leaching pits, number: n/a
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a r~
n/a leaching fields, number: n/a
6' X 6' BLOCK CESSPOOL overflow cesspool, number: 1 ,
n/a :-innovative/alternative system
Type/name of technology: n/a
N„
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE OVERFLOW CESSPOOL APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. ,i
THE OVERFLOW WAS EMPTY AT THE TIME OF INSPECTION.THE STAIN LINES INDICATE THE LIQUID
LEVEL HAS BEEN I'TO PIPE. a .
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
3{ tN
Number and configuration: n/a `
,gy+
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a `
Depth of scum layer: n/a >;
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
° r
PRIVY: (locate on site plan)
.
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a A7L
,A•a,
, tk
-a..
IPage 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
• ar S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 FIVE CORNERS RD CENTERVILLE,MA 02632
Owner: MRS.SAPANARO
Date of Inspection: 3/9/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. P.a
Locate all wells within 100 feet. Locate where public water supply enters the building.
:1 9
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Page I 1 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 7;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r:
Property Address: 100 FIVE CORNERS RD CENTERVILLE,MA 02632
Owner: MRS.SAPANARO
Date of Inspection: 3/9/01
SITE EXAM 3' f
Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation: '
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavafors,installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET t
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�Z 203 499 40 ���
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US Postal Service
Receipt for Certified ail
No Insurance Coverage Provided.
Do not use for International Mail See reverse
Sent to a,/7? /r Dl7Cl r�
St7t Yu2rb cJ86
Post �taC ZIP Code. oI/6'O
Postage �5 ��$-
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
Retum Receipt Showing to
Whom&Date Delivered
a Retum Receipt Showing to Whom,
Q Date,&Addressee's Address
0 TOTAL Postage&Fees is
M Postmark or Date
LL 19V
a
Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge).
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q)
return address of the article,date,detach,and retain the receipt,and mail the article.
LO
3. If you want a return receipt,write the certified mail number and your name and address
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a
RETURN RECEIPT REQUESTED adjacent to the number. Q
4. It you want delivery restricted to the addressee, or to an authorized agent of the O
O
addressee,endorse RESTRICTED DELIVERY on the front of the article. M
5. Enter fees for the services requested in the appropriate spaces on the front of this
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. LL
6. Save this receipt and present it if you make an inquiry. 102595-97-8-01 45 a
'J'
Town of Barnstable
Department of Health, Safety, and Environmental Services
sABNSTABU, +
9� ,�A Public Health Division
�F0�A0�a P.O. Box 534, Hyannis MA 02601
Office: 508-8624644 Thomas A McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
June 29, 1998
Marie Saponaro
P.O. Box 86
Natick, MA 01760
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY
CODE H, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE BOARD OF HEALTH NUISANCE
CONTROL REGULATION NUMBER ONE
The property owned by you located at 100 Five Corners Road, Centerville was inspected
on June 19, 1998, by Jerry Dunning, Health Inspector for the Town of Barnstable, because
of a complaint. The following violations of the Nuisance Control Regulation Number
One Regulation and the Sanitary Code H were observed:
410.300: Discharging of grey water on to ground in rear yard.
You are directed to correct violations within five (5) days of receipt of this notice.
You may request a hearing if written petition requesting same is received by the Board of
Health within seven(7) days after the date order is received. .However, this violation must
be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate day's failure to comply with an order shall constitute a separate
violation.
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
PE ER OF T E BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
1
;1
i
N �a of &6
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410,00, STATE SANITARY
CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE BOARD OF HEALTH NUISANCE
CONTROL REGULATION NUMBER ONE
C, M a 0163a.
The property owned by you located at was inspected on 1997, by , Health Inspector for
the Town of Barnstable, because of a complaint. The following violations of the
Nuisance Control Regulation Number One Regulation and the Sanitary Code II
were observed:
Llt� • 3�r�
..1.tz,� do .�-� . -e o,�i 70
You are directed to correct violations within of receipt of this notice.
You may request a hearing if written petition requesting same is received by the Board of
Health within seven(7) days after the date order is received. However, this violation
must be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate day's failure to comply with an order shall constitute a separate
violation.
s
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are
corrected.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
r,L
PAR ] Real Estate System - General Property Inquiry] Help [ ],
Parcel Id: 168 036- - Account No: 93669 Parent :
Location: 100 FIVE CORNERS RD Neighborhood: 38AC Fire Dist : CO
Devel Lot : 6 LC31043-A Lot Size : . 36 Acres
Current Own: SAPONARO, MARIE State Class : 101
P 0 BOX 86 No. Bldgs : 1 Area: 987
Year Added:
NATICK MA 1760
Deed Date : 120192 Reference : C118269
January 1st : SAPONARO, MARIE Deed MMDD: 1292 Deed Ref : C118269
Comments :
Values : Land: 30600 Buildings : 63600 Extra Features :
Road System: 100 Index: 545 (FIVE CORNERS ROAD ) Frntg: 138
Index: 117 (BENT TREE DRIVE ) Frntg: 183
Control Info: Last Auto Upd: 102195 Status : C Last TACS Update : 102095
Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000
Tax Title : Account : Taken: Account Status : Hold Status :
Cancel [ ]
Press XMT for more data
Next screen [ ] Action [ ]
Owners Name [ ]
Road Index [ ] Road Name [ ]
Parcel Number [168] [037] [ ] [ ] [ ]
ff
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1
i
183 LONGVIEW DRIVE,
■ PALTSIOS E SON CENTER'VILLE, MA. 02632 scAIE. _; o APPR&E09Y: DRAWN BY•
'GATE:771-1410
REVISED
5 - .-. ..'... . . ... ......�.: -
BUILDI�N,G & REM:ODELIA
LICENSE # 006653 DRAWING:NUMBER
NEW ENGLAND REPROGRAPHICS b SUPPLY CO.
I
, �e�alfry
PIP FROM .,.....,,.•. :!�-ALL OUTLET ES OM THE
DISTRIBUTION BOX SMALL BE ;
t 2
N CO TE COVER
T T A FT.
CONCRETE CO
.
4 P.V.C.
SE LEVEL FOR LEAST 2
T A PIPES ARE TO BE 4 SCHEDULE 0Y,*NOTE: ALL
N PIPE Least 4 inches tall ��. .. .. '� � �VENT P E O Leo 2 ) r v
1 min. from 4( r f er ,- -.. 3 - S OUTLET Z � .� v,...•
0 Schedule 0 PVC w/Charcoal Odo 1!t � ,�: 1. i. r ;,,, F_.
- .'`.✓
D BOX cover must be KNOCKOUTS .
NEW Foundation house to septic tank . �^
i tank rovers must be
within 6 In: of finished grade A
Sepik a co e
t
E 100. Assumed - -,5.5' _ r
TO ELEV 00 (Assumed) hi s , . of finished rode 1z INLET
within n i g -OUTLET r , ,.
Grade over.Septic Tank 99:50 __-Grade over D Box 99.00 / , i� !D
Finish r = Elev 99. 0 6 8 f'
In sh Grade 0 ,
t fir! Y n
S - 15.5 4• - . 4 T & u
0.02 3 kOLE H 10 T Of System = ELEV. 96.75 SCH 0 1.75
op ye
7 ..cover
T. BOX
O DS
.. 14 NEW 10 or crest s• 0.010 per root- PLAN .SECTION CROSS-SECTION
EXIST, PIPE r 1,500 GAL. aR GREATER 1 4 Perforated P.V.C. -t/8-,/2 Washed Stone t+..cam,,,+. p'r"° •y,
FROM FOUNDATION m O 45 _ 4' !Hyatt Elev.=95.98 '. `2 `• '
SEPTIC TANK oyi \
5 .- 4 V r
N' POLYETHYLENE r 3/4 t8 wonted Stone Bottom o1 Leach Facility Elev.- 93.98 �
N y 3 HOLE_H-10 DISTRIBUTION BOX . °
ti r
CONCRETE FULL FouriDAn � ll H 10 � 1lB+r!
v II NOT TO SCALEDDAIt' 3 Rqy 1?
..Note: . All leach ik+eeto M mopped at ends w/PVC cops.
- � y it II i�0}Rant 1klPdi 8 d,
In.of 3 4-1 1/2'
- > >
■2rr5 A•yvr6A
SYSTEM PROFILE
6 / N � i Bottom of_Test Hole 1 Elev.=87.00
compacted atone y u ----------
LEACH TRENCH
Not to Saa!® � � GENERAL NOTES
> 1 TOTAL) LEACH TRENCHES CROSS=-SECTION (2 TOTAL)
5 1. Contractor is responsible for Di`safe notification
Dig
safe all underground i a d protection of a u de ground utilities and pipes.
T HAVE RISERS T .WITHIN W GR NOTE. ALL COMPONENTS MUST AVE SE 0 6 BELOW ADE : * o mows 2. The se tic tank an distribution box shall be set
level on 6 of 3/4 -1 1'/2 stone.
• f1 _ .
s a /e ,/2 3. Backfill should be clean sand or gravel with no
wa.h d stone !
stones Over 3" in `size.
4. This system .is subject inspection
i n r: installation
-
4 „ax ys � to aspect o during
b Carmen E. Shay Environmental Services Inc.
_ Y Y ,
5. The contractor shall in tall this in accordance s system acc da e
3/4"-1 w'a•"•d�«n• with Title V of the Massachusetts state code, the approved plan
_ ,�' oompoated.tan. ,
PERCOLATION TEST
FI VE C 0 R N..�7 R ,5.: R OA I�
.• ai.d P.V.C. pee- and Local Regulations.
6.` If, Burin installation the contractor encounters an
_ N07,TO SCALE 9. . Y
Date of Percolation Test. JUNE 29, 2005 soil conditions or site conditions that are different
P CARMEN HAY R.S. C.S.E.
Test Performed By. C E E 5 40 FOOT RIGHT OF WAY from l those shown <on the soil`to or in our design
( � 9 9
Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) Q
� - installation -must halt & immediate notification be
EXCAVATOR. ShayEnvironmental Services, Inc:
---------------------------------------,� ,____- -- --- -- -------- made to Carmen E Shay Environmental Services. Inc.
Percolation Rater :Less Than 2 MPI 0 34 (-
7. No vehicle or heavy machinery shall drive over the
i I , septic system unless noted as H-20 septic components.
a I
� 8. Installu T'te gas baffles o aquas on all outlet .tee ends:
9. All Distribution Lines shall be 4 diameter Schedule 40 NSF PVC es.
1 17.46 i I pipes.
Test Hole Test Hole i - 10. All solid piping, tees & fittings shall be 4 diameter
No. 1 ! No. 2 1 I Scheduie 40 NSF PVC es with water tight joints.
4 l I `�
PP 9 1
DEPTH SOILS ELEV. DEPTH Soils ELEV. l I o 11. Municipal Water is Connected -to ALL OF The Residence and Abutting
9
I ASPHALT I
0 99.00 0 - 1,02.5 ! Properties Within 1 F
4 PV I DRIVEWAY I � Properties th 50 . eat.
Loamy I i Loamy 1 I
VENT I I
Sand Sand a - THE PROPERTY LINES ARE APPROXIMATE AND
, i I
r I COMPILED FROM THE SURVEY PLAN GENERATED BY
10 YR 3/2 10 YR 3/2 :� D
p
O.-B. A. 98.33 � 0'-6' A 102,0 ED KELLOG, HYANNIS, MA ENTITLED
PLAN OF 'LAND IN BARNSTABLE, MA" LC-PLAN 31043-A
Loamy Loamy I
f0 DATED DATED MARCH 1. 1962
Sond Sand e. '
10 YR 5/6 10 YR 5/kS - AND IS NOT INTENDED TO`BE A SURVEY..:PLOT PLAN
" Be Be
- ss.10 - oo.t IT SHOULD "8E USED FOR NO PURPOSE-OTHER THAN
8 34 6 28
54 EXIST. GARAGE
Medium Medium THE SEPTIC SYSTEM INSTALLATION.
Sand Sand
TEST HOLE #1 Slab Fnd. ;EXISTING
ELEV - 99.00
3 'BEDROOM ZS Y 8/6 '2.5 Y 8/6
EXISTING CESSPOOLS TO BE PUMPED OUT AND FILLED IN PLACE OR `
. -. ,
3a-i44 C, 87.00 28 -144 G 90.50
:HOUSE REMOVED TO FACILITATE NEW SEPTIC SYSTEM .INSTALLATION
I _
G
4
N7 TCONTAINING
f5
f00
1
0 NOTE: ANY STRIPPED: OUT .SOIL LEACHATE
Screen Room
FROM HEXISTING LESS 00 S TO BE DISPOSED E L _
F _ -
=' OF AS ER BOARD OF NEALTH -5Pt01FICA1`IONS.
lab Fnd.S ,_
LOT 5
+
WE
TLANDS R WITHIN R
t ,. NO ETLA DS ARE PRESENT W H N 200 OF THE PROPERTY
y _
1
ASSESSORS MAP 168 ':PARCEL 036
D-Box p:
�.
o LEGEND
o �
Perc 1 O 00 GALLON
Depth to Perc. 34 to 52 ,� DENOTES PROPOSED
= PROJECT .BENCH MARK l ROLYEi•HYLENE 104X 1
Perc Rate Less Than 2 MPI SEPTIC T SPOT GRADE
Groundwater Not Observed
TOP OF FOUNDATION
No Observed ESHWT ELEV. _ 100.00 (Assumed) DENOTES EXISTING
X 104.46
ADJUSTED H2O Elev. = None TEST HOLE #1 \ SPOT GRADE
O ELEV'= 102.5
0 Failed r
Cass o I PL PROPERTY LINE
F O
o � 67 PROPOSED CONTOUR
O �o _ - - -97 EXISTING CONTOUR
Failed 00
Cesspool
1 GALLON SEPTIC TANK
DEEP TEST HOLE &
TYPICAL 500 G LLO SE PERCOLATION TEST LOCATION
NOT TO SCALE
.- 6 FOOT STOCKADE FENCE
H- 1:0 LOADING
3-24^ aAM. AccEss MANHOLES ( L 0 T #6
15,000 Square set
. . ,. 1
r
r
a,I
PLOT P AN
INLET _ _
l � � 5
OF PROPOSED SEPTIC SYSTEM- UPGRADE
INLET •.:� `� ` � �J :r OU
l THE ACCESS COVERS FOR THE SEPTIC TANK,
DISTRIBUTION BOX AND LEACHING COMPONENT PREPARED' FOR
-T,T, -r-- SHALL BE RAISED TO WITHIN 6' OF
O
r. FINISHED GRADE.
STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EQUALS `` v O S E P H W. C A R O `i A
ON ALL OUTLET TEE ENDS LOT #3S
PLAN VIEW
AT
# 100 FIVE CORNERS ` ROAD
3-24' REMOVABLE COVERS� x
I
C ENTERVI LLE _MA
3 min. clearance
IN 8'min.T 2• mina role! to outlet ,
-----__l min. T Design Calculations
't LI u-revel ., OUTLE f •�\{oF' "` s
INL£ .. 10'min. q 1e.. � .• •
s Z
ARED BY:
5' -7• a -- Lw 5• -7• Number of Bedrooms:3 Equivalent to 330 Gal. Da 330 Gal. Do Min. er Title V/ Y ( I Y P ) C tAE 4'-0' min. Garbage Grinder: No Ll uid d th 1 R 7l EN` E. Sl Z 1 1 l
b a w Leaching 'Capacity Proposed._330 Gal,/Day Minimum (Min. Per Title V) O
0
Septic Tank - 2 x 330 Gal./Day = 660 INSTALL NEW 1,500 GAL. POLYETHYLENE Septic Tank. SHA
0 20 40 50 ! VIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Usingercolation rate of <2 min. inch t
_ . 5• -8• - . • F P.O. BOX 627
10 o Proposed Leaching Trench Dimensions. 1 TRENCH -4 Wide by 54 Long by 2 Depth G� ER
s N EAST FALMOUTH, MA 02536
CROSS SECTION END SECTION Bottom Area: 0.74 al s ft. x 216s . ft. 159.84 gallons ANI7AR\P
9 / q q
TEL FAX : 508-539-7966
Sidewall Area: 0.74 gal./sq. ft. x 232 sq. ft. `= 171.68 gallons �'_
. . SCALE. 1 -20
Providing: _ 331.52 gallons
_ 9 9 -
SCALE. 1 20 DRAWN BY. CES - DATE. JULY 1 2005
MAY BE SUBSTITUTED FOR 1500 GALLON POLYETHYLENE-TANK GEORGE OBRIEN CO. I ,
Use: 1 TRENCH - 54,L by 4'W x 2'D
PROJECT SD768 FILENAME: SD768PP.DWG SHEET 1 OF 1
# E E
i
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,, ..,.�:.._:.,„>.w.,.,........,.:w»,.::;,...., .o...::.:u.,..w».,.......,..,�,.,...�.:,.m..,.....4,....>...,m,<.d..,.,+., rv>......�.,...�...a...ww.»:..m.,..e.. ,._�,...<,...-�...,<:..:",�:..,,..:'.�, i. �
,
183 LONGVIEW DRIVE.
PALTS
SCALE: �' ="j APPROVED BY: DRAWN BY;e-
.✓t �
NT R E . 02632
aE CE ERVILL , MA DATE: REVISED
M � ,
ULD G & M DE i`A
SON
771 1410
E 0 LNI
DRAWING NUMBER
N R
LICENSE # 00 653
aF ,
NEW ENGLAND REPROGRAPHICS&SUPPLY CO. J
O �O'9 �YJ P� ..o �D a(�
No.. ... .... Fs>�.. .. ....
THE COMMONWEALTH OF MASSACHUSETTS
®3 BOARD HEALTH
/� -- .. .---.---.OP........ . ...... . ------------------------------------
Appliration for Eligpviial Workii Tonstrurtion Prrmit
Application is hereby made for a Permit tp Construct ( ) or Repair (6') an Individual Sewage Disposal
Pk3' System at: -
.. . ...�'._ . .................'.
•• - ...... ---.--
n Location-Address;44--- ot�OL�Q'o• -
�'
----------------- ........ --------------- ..................................................................................................
Owner ............................................Address
r-a Installer Address
dType of Building/ Size Lot........:...................Sq. feet
aDwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ..................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic
Disposal Trench Tank—LiquidNo capacity......--__"gadthns LengthTotal Length Width...............TDial leaching area.._Depth._.....sq. ft.
Seepage Pit No..................... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (' ) Dosing tank ( )
`-� Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit......:............. Depth to ground water----....................
----------------------------•---•-=------•---------•---......_....-•-------........_......----------.........................................................
0 Description of Soil........................................................................................................................................................................
v --------------•---------------------------------------------•----..........---------------------•--•-------•--•-----------•-----------•-----------------------••-----•--------------------------------
W ---------------------•--------------------....--------------........---------------------------------- -•--- - ---------------
V Nature of Repairs or,Alterations—Answe when applic 1 _-- - ---- --- -----............... .. _....._..
-----------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitar Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b e issued by the bo dfofhnith.
Signed. .. . -_----
Date
Application Approved By---... .. .__ . ....... .... .. .... .. ..... . . • -
ate
Application Disapproved for the following reasons--------------------------------------•----_.____._.___.....______._.___._._._........._...........-.............
.................................•----------•--------------.......------------....------•---..........._._
------------------
Date
PermitNo.......................................................... Issued........................................................
Date
No......................... Fu$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
----------------------------------------OF...........................
Apphration for Bioposa1 Works Tonstrurtion Pumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....-------•....................................................•----...............---•---••--•-- •••-••••-•-.....-••••••••.............•--......_......-•-...•••---•---............................
Location Address or Lot No.
........................••--•--.................----•--•------....-••-••-••••••---•----•--•-•--•-- •••••-•....--•-••••••....••••---•••-••-•-•-•••...---•-
Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons--.--.-.-------------.-.-_ Showers ( ) — Cafeteria ( )
dOther fixtures -•-•-•--••---•--------•---•-•--•------------------------------•--•----•-•----•------------------•------••-•-•••••-•------•-•-.......-----•-•-••-••---
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter....----........ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter_---.-.------..---- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-----------------------•---•----...---•--•--•-•-••••......-•--•----•_.... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
4_1 Test Pit No. 2................minutes per inch Depth of Test Pit..--.--............. Depth to ground water.....---................
a •---------••--•------•------•-•-•-----•----••-----------•-••••-••-•-------•----------•-••-•--•--••••.........................................................
0 Description of Soil........................................................................................................................................................................
x
U --------------------------------•...................------------------.............--------•----•------------------------------- --------------•-•--------------•--------------._....--•---•-•--•--•--•.
W
----------------------------------------------------------------------------------------------------------------------------------------------------------------------.............................
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
--------------------------------•----------------------------------------------------------....---•--------••-----•-•-•---•------•---------------•-----------------•-•-...--------•-•-•--••---••-----_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ................................
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons--------------------------------------------------------•---------------------------•------•--•---•------•-•••...
.......................••--•----•---•---.......----------••-••-•-•------••---••--........--•••-•••••......-•---•••-•-----••-----•-•-------•-----••-•-••-•----••--•----••---.............................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:11:? r ........OF..............., i.��. �..
Tntif ratr of Toutpltam
THIS IS TO C aR TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....................... :..I ._....._.rC?� ��n�/{:�`
�. Installer
at.....<:......... ti. [Lc
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.............6.0-7............... dated--------._..--_.-.---.-..-.---------..----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Permissionis hereby granted........................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo.....................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
......---•--•-----------------=--------------- --- - --------•---------......---..........-•--_.
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS