HomeMy WebLinkAbout0198 FIVE CORNERS ROAD - Health 198 FIVE CORNERS RD., CENTERVILLE
A= 168 110
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UPC 12534
No.2 OR
HASTINGS, MN
t�{ TOWN OF BARNSTABLE
LGC'ATION lqdt SEWAGE# P ��
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NG. '511&s A lam' r
SEPTIC TANK CAPACITY &M tX/Shev t
LEACHING FACILITY: (type) cx,11oAJ,&m6aS (size) J S.2 X Z3 X J
NO.OF BEDROOMS" 3
OWNER 62 r kc al N
PERMIT DATE: 3/27 ho COMPLIANCE DATE:
I^ L
Separation Distance Between the: /jofemt Cie,-615 5k/,10.00
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility SIP®` J0 Q1k J,eJ/ 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 f t ) Feet
E
FURNISHED BY
2- 10
3-)3 3c
4-H�I.� zec Sq,3
S-GG � -- 6- 72,1
G- 70.2
7- 71•`I
G �
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered;n computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Ifltlfltation for MispoSal bpstem Const rtion i9ermit
Application for a Permit to Construct( ) Repair/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /98 Cal VCIS 0 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel C eA1k '///JI r i�&-z e(,r t/l/
0 /
Installer's Name,Address,and Tel.No. 15M-'Y00-7/51 Designer's Name,Address,,-and Tel.No.
Type of wilding:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building hays f No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 3 /, gpd
Plan Date_% /y I 0 Number of sheets-1— Revision Date
Title
Size of Septic Tank /00 ) E'j(/ InJC Type of S.A.S. a 2
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /1V.5 r4l—L A/C'W 5.,Q, S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o e t
i e Date A
Application Approved by Date
Application Disapproved by Of Date
for the following reasons
Permit No Date Issued
Ifj * , �;.. - .-e. .-..., .,. - .... -snT,.i•Yi7-v+rT^�.#e.rn ;�l� .... ___.,,.___ __... _ ,� _. .wt,7 ..u. r..-. .e...,yr.rw..� r.• ->+. ...
µ Y
No. 1� ^�.a, ...,:r} .+ Fee h�
- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer._��_V
I
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftPficaton for MisposaY'bpstent construction Permit
f
Application for a Permit to Construct(�) Repair l7r) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or'Lot No. /Q8 /vC cv veers Ad Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel &fq C iPa/klil/Pr 2 ec,
In-sttaaller"'s Name,Address,and Tel.No. 1509"100-71Scf Designer's Name,Address,and Tel.No.
�/a ulnl _ZvC �tis�,�c�r,�,•►• Gw�✓�
Type of uilding:
¢1 ,
Dwelling No.of Bedrooms :3 Lot Size /j(,,"jam sq.ft. Garbage Grinder( ) µ
Other Type of Building h(ys p. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3'j� � gpd Design flow provided 3 /, gpd
Plan Date ��1�r /d Number of sheets �-- Revision Date
OF
Title
Size of Septic Tank /061D E'X/ Type of S.A.S. _VC0 C4Q JJQA) _A1'.1 q&!( 2 g X /
v
Description of Soil
j r
Nature of Repairs or Alterations(Answer when applicable) //U5 r,4 G, Al/'io S•A. S
Date last inspected: ! ,
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o wealth.1g j
� „ Date // CJ
Application Approved by �y Date ,
APPlication Disapproved by ! / f'�w f• --•. .. . Date is
� .
for the following reasons
Permit No�TC / Date Issued
i I THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( !r) Upgraded( )
Abandoned( )by ��,�, A B(nu)^3 ink
at G idr llarNr/S ��l Yi✓��Ki /tom has been constructed in Jac//c�dance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ® /, J?d'ated
Ga / A A - .
Installer �/t S /rJ�✓�✓ Z"N C Designer �l&'T IA-7-1.r ice.t 4/li/�<$
#bedrooms ✓, �, Approved design '3 1 f? gpd
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date ram' 2 Inspector ! C-
�j
_.�--- No. �D�-r��-------___-__--__---- -------�- ._---- --------•------•--------_—_____---Fee-
THE COMM 6/
ONWEALTH OF MASSACHUSETTS
. ' PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS
misposal 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair( 1/) Upgrade( ) Abandon( )
System located at /yjj y �od�/Y✓S j�f �r,�// d,�i���
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Constructio/n�Inust be completed within three years of the date of this permit. I
Date / (/J / Approved by
06/fa3/2010 07:06 5084775313 k; "._ _ ENGINEERING WORKS PAGE 01
Town of Barnstable
Regulatory Services
Thomas F.Geller,Director
t Public Health Division
Thomas McKean,DirWor
200 Main Street, Sysanis,MA 02601
F&x: 5os-790.6304
Oboe: 508-862-044
Date:
Sewage Permit# Assessor's Map/Parcel
InstM&er&Daftaff—C-992092LEM
Designer: In C- • Installer:
Address: r7 W• G'a s s �1 cal 9 Address:
On �, , �� /n was issued a permit to install a
(inswier)
septic system at L 9 8 " (ornB--;r /U 6 n t_ based on a design drawn by
address)
fS;'M.C-E,t1tA 7 E • dated I?
signer
^� I certify that the septic system referenced above was installed substantially according to
the desi , which may include minor approved changes such as lateral relocations f thsoile
distribution box and/or septic tank. Stnpout (if required) was inspected and th
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (Le.
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. Stripout(if required)was inspected and the soils
found satisfactory.
of MAs�ti
PETER T.
6!�,hVnsuffer'srSilgnature)) McENTEE
CIVIL
r i�
(Designers Signature) (Affix De
PLEASE RETURN TO PARNSTAME I E
OF E ffU NOT
A=CAM ARE RECEIVED BY THE A&MI
gNafEim fM=W=iguet Wdf=U0n fWM&C
Town of B�armtabe :: P
Departanent of Regulatory aServices
F 1►-7►�
,. :Pudic Heaith Division. note
•e q. 200 Main Street Hyannis MA 02601
1:
Date Scheduled 3 3 i) o Time Fee'Pd.''
SRd:
Suitabilit Assessment or Sewa a ors oral
�✓
Performed By Witnessed By: I l A1n` 1.y,,�,nS,:,
LOCATION& GENERAL.INFOI -NATION
Location Addres%s/ �� v`e �_ I Owner's Name ,
Ole Addressr.ve Cerra-e•�
Assessor's MaplPercel: / 1 U Engineer's Namer � Ke
:I NEW CONSTRUCTION REPAIR .� Telephone# $—7 3? `i 7 �' I
Land Use: ,n--ems'.04,-,V, ( Slopes(96) �� Surface Stones N� '
Distances:from: Open Water Body -7 t � R Possible Wet Area.7 t R Drinking Water Well ls� ft
Drainage Way l��cJ R Property Dine R .Other R
SKETCH:(Street name,dimensions of lot,exact orations of test holes&perctests,locate wetlands A proximity to holes)
Id
�y� ash
Parent material(geologic) Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated'Seasonal.High Groundwater ? 1 3 z-`i
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
_ Depth Observed standing in obs.hole:
Depth to wei-ping from side of obs.hole: in. Orounowipr A*Wmont $
Index.Well# Reading Date: Index Well level �-„ AdJ,tltetor, Ac(J 'dttituttdwaterlevel,,;,�
PERCOLATION TEST Dole— xis .—'
Observation
Hole# Time at 9"
Depth-of Pere:: Time at 6"
(24f�
Start Pre-soak Time® lime(9"•6") ,
End Pre-soak
Rate MinJlnctt _
Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be.conducted within 100' �f wetland,you must first notify,the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:ISEPTIGIPERCFORM.DOC
I
DEEP.OBSERVATION I OLELOG Hole#,
Depth from Soil Horizon Soil"TeXture Soil Color Soil Other
Surface(tn) (USDA) (Munsell) Mottling (Stru cture,Stones;Boulders.
Sk-
a
.
- ` 2,5
DEEP OBSERVATIONHOLE"LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color. Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones Boulders.
Consistenc rave
DEEP OBSERVATION'HOLE LOG Hole#
Depth`from. Soil Horizon Soil Texture. Soil Color Soil Older
Surfaco-.(in.) (USDA) (Muosell) Mottling (Structure,Stones,Boulders.
DEEP OB SEA VATIONHOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
USDA Munsell Mottling (Structure,Stones Boulders,
Surface(ta). (USDA) (Munsell)
Flood,'Insurancc<Rate Klan:;
Alove`500year flood 15oundary No_ Yes „
Within`SOU`year boundary No Yes.:..�.
Within L60year flood boundary No_. Yes
Depth of I+tatarall�Oceurrine Perviotts Meter-ia�
Does at least four°feat of naturally occumng pervS rtal exist in all areus.observed throtcghout,rae
area proposed for.the sotl.absorption system? —
I' .
If'not,:what.is the depth of naturaliy occurring pervious m0ti'al? -
Ceittifi_ cation l
e
ed
I cettffy.that on: date)I have passed the soil evaluator examination appro� 'by3th ,
Department of Envtronrnental protection and that the above analysis was performed by ma consistent"wttli
the recjui°red tratriin expertise and experience descrlbed to 10 EMR 15.017:
Signature:
Date GJ
Q,S.Ep'-WERCPORM.DOC
is 1 � I �
TOWN OF BARNSTABLE Date: /�
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY/
NAME OF BUSINESS:
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER: E d_da—
CONTACT PERSON: Q �G 4 C v'J e 4e
EMERGENCY CONTACT TELEPHONE NUMBER: V- `l d- MSDS ON SITE?
TYPE OF BUSINESS: 4, cf' f�y si��'�
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison"labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Appli nt's ign u Staff's Initials
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the
Town (WHICH YOU MUST DO according to M.G.L. - it does not give you permission to operate). You must first obtain the necessary
signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st Fl., 367 Main St., Hyannis,
MA 02601(Town Hall) and get the Business Certificate that is required by law.
rV DATE
Fill in please: ���1r1GrC,� P. CCOZ-eCjv1t-�-Sr.
APPLICANT'S YOUR NAME/CORPORATE NAME ja `CtZe(lI )t+ t r)(7pf %CX BUSINESS TYPE:-
BUSINESS YOUR HOME ADDRESS: e- t r
CGy- t
TELEPHONE # Home T le hone Number r C�5L46Q
NAME OF NEW BUSINESS Zrt�a� o"� a tiles
he building division? YES NO
Have you been given approval frgm t d g
Y 9 P
ADDRESS OF BUSINESS �' � 5' Ie'y C �Cat n ei j' 7 C� e c n+C✓ MAP/PARCEL NUMBER
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of
Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business
in this town.
1. BUILDING COM SIO ER'S OFF ICE *I-T-SANPREC-31ULATIONS.
T COMPLY WITH HOME OCCUPATION
This individu 1 h s n inform d f ny erm requirements that pertain to this type of busi
FAILURE TO
u, oriz ed ignature"" - COMPLY MAY RESULT IN FINES.
COMMENT74
vnLoAU i -UT �-
2. BOARD OF H ALTH
This individual h en it for f e pe i1 requir ments that pertain to this type of business.
COMMENTS: Authoriz ignature"" �.- MUST COMPLY WITH ALL
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature"
COMMENTS:
arnstabre
aY��ram,
Town of Barnstable B
y
""`"' '�a '
Regulatory Services Department
K'S Public Health Division
i639• ��
200 Main Street, Hyannis MA 02601 2007 m
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
1/11/2010
Richard Cazeault
198 Five Corners Road
Centerville, MA 02632
FINAL ORDER
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 198.Five Corners Road,Centerville; MA was last inspected
on 8/27/07, by Robert Bortolotti, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system.showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to.the following:
"Liquid depth in cesspool is less then 6" below invert or available volume is less
then 1/2 day flow."
The two year deadline for repair has passed, since our order letter dated 1/3/2008. We,
The Department of the Board of Health,have not been informed that you have taken any
steps to bring your failed system into compliance. Therefore, you are ordered to repair
or replace the septic system within 30 days from the date you receive this notification.
You may request a hearing before the Board of Health, a written petition requesting a
hearing on the matter, within seven (7) days after the day this order was received.
Failure to repair/replace the septic system within the deadline period will result in fixture
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
.Agent of the Board of Health
rj -
\ OO, IIONTWEA.LTH OF ASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.
i C EPARTME-NT:OF.ENVIR.ONMt!E TTAL-" R'OTECTIOIV
TITLE 5
OFFICIAL INSPECTION FOR�.%T—NOT FOR VOLUNTARY ASSESSMENTS
SUBBSURFACE SEWAGE DISPOSAL SYSTEM FORM.
PART A
CERTIFICATION
Property Address:
Owner's Name: ag
Owner's Addre 44 - / h
�l A ® CD r
Date•of Inspection '-7 � � �—
ra-�i l ACJ�C✓W�-�
Name of Inspector• (p;ease prim)
Company Nam
Mailing Address:.
Telephone Number: `z
CERTIFICATION ST_A'I'EMEN T
I certify that l 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 enperience.in the proper function and maintenance of onsite sewage disposal systems'.I am a DEP
-approved system inspector pursuant to Section 15.340 of Title.5'(3.10 CMR 15:000). ',The system:
Passes
Conditionally Passes
Needs Further Evaluation by the. Approving-Authority
Fails
Inspeetor's_Signat-ure:. Date:. r<�
The system inspector shall.subm_,ea con of this inspection report to the Approving Authority(B card-of Health or.
DEP)within 30 days of completing this.inspection.if the_system.is.a shared system or has a design flow of 10;000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
This report only describes.conditions at.the time of ins ectio and under. e conditions:of use at that
n n th
P y P .
time.,This inspection does not address'how th.e system will perform in the future'under-the same or different
conditions of use.
Title,5 Inspection Fore 61I572000 page 1
Page 2 of 11 .
OFFICIAL INS.PECTIONYORtM-N:OT FOR VOLLI TARP ASSESSMENTS '
SUBSURFACE SEWAGE'.DISPOS.A.L SYSTEM INSPECTION FORM
"PART A
CERTIFICATION (continued)
Property Address: 9��.2 J1��6' &/u
Owner:
Date of .. spection: .���
Inspection�Summary: Check A,B,C,D or E/ALWAYS complete.all of Section.D
A. System Passer.
I have not found`any information which.indicates`that any of the failure d iteria described'in 310.CMR
15.303 or in 310 CNIR 15.30'4 exist.Any failure crite.ria.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;lot determined(Y,N;ND)in the for the following statements. if"not determned:'please
explain.
The septic:tctank is metal arid'over 2Q.years:old or the septic tank(whether metal or not):is structurally
unsound,exhibits substantial infiltration or exfiltration or.iank 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 sewaga backup-or break out or high static-water level in the distribution box due to broken or. .
obstructed'pipes)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* 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
obstniction is removed
ND explain:
Page 3 of 11
` OFFICIAL Ii'dSPECTI{?N FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISP:OSAT; SYSTEMINSPECTION'FORM
PAR :A
CERTIFI CATION,(continued)
Property Addres
02
Owner _
Date of I pection: _7
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 fuTctionin gin a manner which-will protectpubtirhea.Ith,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.,Wate'r ,Supplier,if any).determines that the
system is functioning in a manner that.protects the public health,.safety.and environment:
_ The system has aseptic tank and soil absorption system (SAS)and the SASiis.within 100 feet'ofa.
surface water?upply..or tributary to a surface water:supplyi
The system has a septic tank and SAS and the SAS is within-a Zone 1-of a.public water supply.
The sysfein 11as 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 but50 feet or more from a
private water supply.well**.Method used to determine.distance
**This system passes ift he well water analysis;performed at aDEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is.free from polf ition from that facility and
the presence of am=onia nitrogen and nitrate nitrogen is equal to or]_ess:than 5 ppm; provided thatno other
failure criteria are triggered. A copy of the analysis:must be attached to this-form.
3. Other:
3.
U
j
Page 4 of. 11
QFFICIAL INSTECTIQN FORM:—,NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SE'WAGE�I)ISPOSAI:,.SYSTEM JNSPEC I ION.FORM
PART A
CERTIFICATION(continued)
Property Address: 91?j_-eW
Owner:
Date of ' spection:. Jo 7
D. System Failure.Criteria applicable to all systems:
You must indicate"yes" or"no"to each.of the-fallowing for ale inspections:
Yes No/
_ ✓ Backup of sewage into.facility or system component due to overloaded•or clogged SAS or..cesspool
_ Discharge-or ponding of effluent to the surface of the ground.or surface waters due to an overloaded or
clogged SAS or cesspool
i Static liquidl'eyeI:in the distribution-box above..outlet.invert due to an-overloaded•or.clogged SAS or
cesspool
Liquid depth in cesspool is'less.than 6"below invert or available volume is less than % day flow
Required pumping more'than 4-times in.the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the_SAS,cesspool or privy is..below high ground water elevation.
Any:portion.of cesspool-or privy. is.within 100-feet of a surface.water supply or tributary.to.a.surface
water.supply.;
_ Anyportion of a cesspool.or.privy is within a Zone 1 of a:public well.
7 Any portion of:a cesspool.:or privy is within 50 feet ofa.private water supply well.
—4 Any-Portion of:a cesspool or-privy.is:less than 1.00 feet but.greater.than.50 feet.from a private water
supply well with no acceptable.-waier 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.weil is free from pollution from that.facility and the presence of ammonia
nitrogen andinitra.te 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/No)The system-fails.I have determined that one or more of the above failure criteria exist as
described in 510 CIIR 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.1.5,000
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
'eyes"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 systen•in accordance with 310 CMR
15.304.The system owner,should contact the appropriate regional office of the Department.
Page S of I
OFFICIAL.INSPECTION FORS—NOT FOR:
VOLUNTARY ASSESSMENTSSUBSURFACE-SEWA`OE UISPOSA:L_:SI'S'FE�VI Il ''PECTTON FORIYS
FART B
CHECKLIST
Property Address:
Owner
Date of 'spection:
Check if the foflowing have.been done-You must indicate`dies"or"no as to each of the following:
Yes am- No _ - . . . . - . .
Pumping.information was.provid-ed by the owner,.occupant, or Board of Health.
Were anv 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 ?
C/ _ 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?
;f<th
_ Were the septic tank manholes uncovered; opened, and the interior of the tank inspected for the condition
bafr'Ies or tees, material of construction, dimensions, depth of liquid,,depth of sludae:'and depth of scum? .
Was the facility owner(and occupants if different from owner)provided with information.on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS) on the site has been'determined based on:
Yes no
Existing information.For example, a plan at the Board of Health.
Determined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CtifR 15.302(3)(b)]
5
1 J
Paae 6 of 11.
OFFICIAL-INSPECTION FO.PMI ' NOT.FOR-VOEUNT�'�RY:ASSESSPiIENTS
SUBSURFACE-SEWAGE:DISP.O,SAI1 SI'STEiM-IN.SPEC:TION FORIM
PART-C
SYSTEM::INFORMATION
Property Add:ressc
Owner:
Date;of I spection: n,L i QQ. )00-7
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):—3 Number of bedrooms(actual):
DESIGN flow based on'3 I0, 5.203 (for example: 11:0 gpd x of bedrooms):
Number.of current residents:. /
Does residence have a garbage grinder(yes or no):
Is laundry on.a:separate:sewa,,e system(yfs or no) .jif yes separate inspection required]
Laundry system inspected(ye�.or no):�7U
Seasonal use: (yes or nco: de)
Water meter readings, if av ilable last 2 ears usage: 71 2/ 6ae&o
( y (.Pd)):� _71 Y�'
Sump-pump (yes or
Last date of occupancy::
C OMMERCIAL[IND USTRIAL./1/0
Type of.establishment:.
Design.flow(based on 10 CMR'I5.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes:orno);
Industrial waste holding tank present(yes or no):_
Non-sanitary,,vaste discharged to the.Title 5 system(yes or no):_
.Water meter readings, if available:
Last date of occupancyluse:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part ofthe.inspecfion(yes r no)✓
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason.for pumping:
TeOF SYSTEM
Septic iank, distribution box,soil absorption system
Single cesspool
_Overflow cesspool
Privy -
_Shared system(yes;or no)(if yes, attach previous inspection records,.if any)
_Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be
obtained from system'owner)
_Tight tank _Attach a copyof the DEP approval
_.Other.(describe):
Approximate age,of all components, date installed(if known) and source of information:
Were sewage odors.-detected when'.arriving at the site (yes or no): .
6
Page 7 of 17
OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL�SYSTEM INSPECTION FORM,
PART C
SYSTEM-EN[ FORMATION (continued)
Property Address:
(il
Owner-
Date of spection:
BUILDING SEWER(locate on site plan)
Depth below grade:,
Materials of construction:_cast iron _40 PVC_other(explain):
Distance-from private water supply well or suction line:
Comments (on cohdition'of ibihts. venting, evidence ofleakage, etc.): .
SEPTIC TANK: (locate on site plan)
Depth below grade: f-
Material of construction:.—Zconcrete .metal_fibergglass . Polyethylene•
—other(explain)
If tank is metal list age:_ .Is age:confumed by a Certificate of Compliance(yes or no):_(attach..a copy of
certificate)
Dimensions: S
Sludge depth:
Distance from top of sludge to bottom of outlet tee or.baffle:. N
Scum thickness:_ 11
Distance from top of scum to top:of outlet tee or baffle` J ,�
Distance from bottom of scum to bottom of outlet tee-or baffle:
How were dimensions.deter:mine.d: ��
Comments (on pumping recommendations, let and outlet tee or baffle condition, structural integrity,liquid levels
a related to outlet invert, e idence of leakage, etc.):
Azi40)
GREASE TRAP. (locate on site plan)
Depth below grade:_
Material.of construction:_concrete_metal_fiberglass_polyethylene_other
• (expI•ain):
Dimensions:
Scum thickness:
Distance from top of scuri•m_.to top of outlet tee or baffle:
Distance from bottom-of scum to bottom"of outlet tee or-baffle:
Date oflast.pLmping:
Comnnents (on' pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 1.1
"OFFICIAL INSPECTIO FORM-—NOT.:FORNOLUNTARY.A�SESSKENTS
SUBSURFACE•SEW-AGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEMINFOR-MATION(continued)
Property Address: 1j
Owner:-
Date of In-?Peection: C ).'�Oc)
TIGHT or HOLDING TANK/ (tank must be pumped at time of inspection)(locate oa.site plan)
Depth,below grade:
Material of construction: concrete metal fiberglass polyethvlene other(explain)-.
Dimensions'
Capacity: gallons
Design Flow: gallons/day
Alarrn present.(yes or no):.
Alarm level: Alarm in working order(yes'or no):
Date of last pumping:
Comm ents•(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: v (ii present must be cpened)(Iocate on site.plan)
Depth of liquid level above outlet invert:
Comments (note if box is.Ievel and distribution to outlets equal,-.any evidence of solids carryover, any evidence of
topkage into or ou ofb��o77x, ete.): r _
�o /( 9 � (lL P 'A P
PUMP CHAMBER:/Y d .(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.):
V
Page 9 of 11
OFFICIAL, INSPECTION FORAM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWIAGE:DISPOSAL_SVSTEM INSPECT ON FORIM,
P.ART C
SYSTEM INFORMATION(continued)
Property Address: ,
v `
,el
Owner:
Date of I pection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS'not located explain why:
Type
leaching pits,number:.
•leaching chambers,number:
Ileaching.galleries, number:
leaching trenches, number, length:
Ieaching fields,:nurnber, 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,
e .):
_ _�!' ti - /I
0-4 h D
CESSPOOLS:A 0 (cesspool must be pumped as pain of inspection)(locate on site plan)
Number and configuration:
Depth'—tot) of liquid to inlet invert:
Depth of solids laver:
Depth of scum layer:.
Dimensions of cesspool:
Materials of construction:
Indication ofgroundwater inflow (yes or.no): .
Continents (note c-ondition-of soil, signs of hydraulic failure,.leyel of ponding, condition of vegetation, etc:):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs.of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of 1.1
OFFICIAL INSPECTIQ-iN'=FORM=.NOT FOR-�/OLU-,NT`AR3t ASSESSMENT.S .
SUBSURFACE SEWAGE.DISPOS,A.L SYSTEM INSPECTION FORYI.
PART-C-
SYSTElyI.INFORMATION(continued).
Property Address:
Owner:99A4 OeAze Jeo'
Date of Z spection.:. : ���0 .
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.'
i r3u��
10
�o
Page 11 of I 1
OFFICIAL INSPEC'T'ION FOR�iI —NOT FOR VOLU`NT_ARY ASSESSMENTS
SUBSURFACE SEWAGE DISP08AL SYSTEM.INSPECTION FORM
PART C .
-SYSTEM IINFORIFIATION(continued)
Property Address: C
Owner:
Date of I ection: . '7
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet ,
Please Indicate (check-):all methods used'to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site (abuttmc,'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-enalain:
You must describe how you established the high groundwater elevation: 7
11 .
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: L'l el, e,q/, Lot No.
Owner:- �j�C/,�Q/` CQ?Z_eQ11()7_ Address:
Contractor: t1i Address:
Notes:
STEP 1 Measure depth to water table
to nearest 1/10 ft. ................ .... .Date
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well..................................�12.�Grp Z
ell
O Water-level range zone .................... ...............................
STEP 3 Using monthly report"Current
Water Resources Conditions"
determine current depth to
water level for index well .............. . 047 Z .
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level-for index well (STEP 3),
and water-level zone (STEP 26) p� Z
determine water-level adjustment ...................................................................._..................,..
STEP 5 Estimate depth to.high water
by subtracting the water-
level adjustment (STEP 4)
from.measured depth to waterQ/
levelat site (STEP 1) .............................................................................................................
Figure 13.—Reproducible computation form.
15
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4N
' Town of Barnstable
�pF 1HE 1p�
Regulatory Services
saxivsrnai a Thomas F. Geiler,Director
16.19.
ArFp�rp Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
� �.
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Commonwealth of.Massachusetts
John Gi ad
Executive Office of Envnmental Affairs _-
_- iro D.E.P. Title V Septic Inspector
Department of P!O. Box 2119
Environmental Virotectian Te Iicket, MA-02536
F.weld rinnw.n, 508) 564-6813 -
G"mor _..
Trudy Coxe - - -
BseMary,EOEA
David S.Struhs '
Commissioner..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I
- PART A
CERTIFICATION
Property Address: Address of Owner:
Date of.Inspection: Q a�'_�S (if different) _ �C� ��i• ��S}- S e a"`�
Name of Inspector: �r.�cGc JOHN GRACI - LC,
Company Name, Address and Telephone Number:
TiitleIinspector �2wLg—
P.O. Box 2119
CERTIFICATION STATEMENT Teaticket, MA 02536
I certify that I-have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
.and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
maintenance of on-site sewage disposal systems. The.system: 1 -I.1j,
A e�
_ Conditionally Passes � r���
Needs Furth r Evaluation By the local Approving Authority O CT
Fails
Inspector's Signature: j
!/� Date: C . ate` q S " 7 .
t;
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of this
inspection. If the system is a shared system or has a design flow of i0,000 gpd or greater, the inspector and the system ow r 4u mil
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system o% ner and copie. sen: to the buffer, if applicable and the appro,ing authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
ave not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One VAnter street a Boston,Massachusetts 02108 a FAX(617)566-1049 a TeNphone(617)292-SM
Primed on Recycled Paper
,. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
s PART A
CERTIFICATION (continued)
.Property Address
Owner.
Date of Inspection:-.
BI'SYSTEM CONDITfONALLY PASSES (continued) -
_ . Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
- pipes) or.due to a broken, settled or-uneven distribution box. The system will pass inspection if(with approval.of the
Board.of.Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are-replaced
obstruction is removed _
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENYIRONkiEN'T:
the >�,sten) nd> a >eUtl( ianK anui suu dU�,of uon s ysiem and is 100 fcct iG a 56 {arc V.atc !,' . u
surface water supply.
The s\s!Inn- ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an 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.
(revised 8/15/95) 2
+�5 R�"�-�^@ vs'�'"x �-'"s'��xF � g '�`' ,+t.S � ��`e s1: � c�, �'a(�. • � / y4 a,��1 K � .......,.....�.... ,_. -
i„ .
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
- CERTIFICATION (continued)
Property-Address:
Owner:
Date of Inspection: - -
D] SYSTEM FAILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion-of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B - -
CHECKLIST _.
Property Address:
Owner: �`�
Date of-Inspection:
G �-lCtS
Check if the following have been done: -
L:::Pumping information was requested of the owner; occupant, and Board of Health.
_✓None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
��s built plans have been obtained and examined. Note if they are not available with N/A.
e facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout. .
(—All system components, excluding the Soil Absorption System, have been located on the site.
iI-The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
Ll-
_The size and location of the Soil Absorption System on the site has been determined based on existing information or
`/approximated by non-intrusive methods. -
: T,V.e farilir,• ro,,t' ".3-4 nrriinantc if differPni from owner) were provided with information on the proper maintenance of Sub-
_ _,...
Surface Disposal System.
(revised 8/15/95) 4
p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
�� SYSTEM INFORMATION -
Property.Address.'
Owner: -
Date of Inspection:, '
��ate• �_ s - - -.-- --
FLOW CONDITIONS
RESIDENTIAL:
Design flow: -&�?gallons
-Number of bedrooms: a
Number of current residents: Q -
Garbage grinder (yes or no):
Laundry connectedto system (yes or no):
Seasonal use (yes or no): e
Water meter readings, if av ilable: _
Last date of occupancy:
COMMERCIAUINDUSTRIAL � .
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title S system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
G
System pumped as part of inspection: (yes or noC j
If yes, volume pumped gallons
Reason for pumping:
TYPE OF EM
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)
Other(explain)
API QX� TE AGE of all components, date installed (if known) and source of information:
Sewage- odors detected when arriving at the site: (yes or no)�Q
(revised 8/15/95) S
T
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM-INFORMATION (continued)_ -
Property!Addressc _-
Owner:.
Date of agspectioh:
SEPTIC TAN KE� - -
(locate on site plan)
Depth below grade:
Material of construction: _Cfcocrete _metal _FRP _-other(explain) -
Dimensions: L 2 ' (p f I
Sludge depth:
(1
Distance from top of, Igdge to bottom of outlet tee or baffle:_
Scum thickness: �� S
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
(recommendation for pumping, condiriopyif inlet and outlet t s or baffles, depth of liquid level in relation to outlet invert, structural
.integrity, eviden of leakage, etc.) <`(\ L_
S
GREASE TRAP:_fI \/2�-
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP _other(explain)
Dimensions:
Scum tnickne��,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom ni <rt—, to hottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 9/!5/95) 6
'v�. y"`- -r.s �fom",'`4.....^` z F' .. - a"`•xm.�:., #' r.i t§'t �•,., h,.4 `�,. y F,; 15� '-.:" 4.w.-'t '�`
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: —
Owner:
-Date of Inspection: a� S
TIGHT OR HOLDING TANK:_D1
(locate on site plan)
Depth below grade:
Material.of construction: _concrete _metal _FRP_other(explain)
Dimensions:
Capacity: gallons
Design flow: eallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: le v\C�
Comments:
(note if levei and distribuuun o eyuai, e�Idence of solids carr)c,er, evidence of leakage into or out of box, etc.)
PUMP CHAMBER: \(>�
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART C
' SYSTEM INFORMATION (continued)
Property Address:s es
Owner: 1 t . 3l t n
Date-of Inspection: _
SOIL ABSORPTION SYSTEM (SAS): C--;- -
(locate_on site plan, if possible; excavation riot Faquired; but may be approximated by non-intrusive methods)
If not determined to be present, explain:---
Type: _
leaching pits, number: ` p00
leaching chambers, num r:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comm nts: (note condition of soil, signs of hydraulic failure, level of p nding, condition of vegetation,etc.)
Q y O GS
(1 .n
�.
CESSPOOLS:
(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 ground...�tc
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:`:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
i
h`1�rk'°`C'�R`h�a�-��e�+. 't"���2.�.'r��s�';�'"L `�"�-"`'�����,�.+.� �*S. �` A a� ' .j<;�+ ����'�'�`.,'!:;- „i ✓ };�� w*J�� ;:;�, .�4�E _':a. ;-;. _ <r•• -
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addy J -'(1
Date of Inspection: a G
-� S -
SKETCH OF SEWAGE DISPOSAL SYSTEM:
- include ties to at least two-permanent references landmarks or benchmarks
locate all wells within-100'
�u
B�
L0O n
g
A
AC �y.6
�g �1
DEPTH TO GROUNDWATER
Depth to groundwater _
method of determination orraapproximation: cror
,1
(revised 8/15/95) 9
r
TOWN OF BARNSTABLE
LOCATION `� �4-fit :1 ci SEWAGE#
VII.LAGE_C—f ASSESSOR'S MAP&LOT Q
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACTTYI—
LEACHING FACILITY: (type) 1 j 00 � (size)
NO.OF BEDROOMS
BUILDER OR OWNER �\
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility.(If any wetlands exist
within 300 feet of leac ' facili ) Feet.
Furnished by (� j(CLCs
6P�k . . s
BN
A-F 6eek
o
LID
I A AA ►�
Aa t�
A c
A 3t
?w
�$ w
g� `fig L
gq 34
r
z
--99 --EXISTING CONTOUR �a o0
x 100.98 EXISTING SPOT GRADE t mb ��° �� ® j'
97 PROPOSED CONTOUR ert Miq Rd Rd
-W-EXISTING WATER SERVICE Torom
H.W--OVERHEAD WIRES
h6 TEST PIT Route 28
QO• BENCHMARK
Westminster Rd
LEGEND
�c
,` Go
0r E Fie LOCUS
Q\,• J
LOCUS MAP
S 51'01'50" W NOT TO SCALE
100.00' xl .98 '----
I _o �105,44 �
SHED 11--13.2=--I
r- `
x Of.06
tu>• 11
104.37 x t:..
SWINGSET:
(LOT 4)
APN 168-110 �11 5.47
15,650ts.f. ' l t.l� +�-a2
i
t--10'
i 0 EXISTING LEACH PIT
105,21 -t-� I + 10 .43 CONTRACTOR SHALL LOCATE, PUMP, i
\\ Q + 5,24, SPIKE, FILL WITH SAND AND ABANDON
EXISTING SEPTIC TANK
PA TO (TO REMAIN)
s _ 105.03 105.29 0 tl I TOP OF TANK, EL.=104.25t
N
104.38 '� I +E04.67 i INV.(OUT)=102.92f
I co DECK 105.23
� PAVED I Ben chm ark Set
0) DRIVEWAY 105.54 OUTSIDE COR. BULKHEAD
w EL.=105.54 (Assumed)
Z 105,03 :
105.1 GS A
c6' }
1EXISTING t"
104.13 HOUSE(#198)
104----
GARAGE
`J04.58 04,75
�\ 104. 6 SHRUBS �105,15 �:
\ ........
103.28
104.05
p PAVED \\� 104.20:
DRI VFWA Y
.47
\� 102,48 103.82
0100.55 / 103.41
L=44.5 \�
`R 725.00' 103,0�\ 5 7.01,
�c B� 100.A-1-0:2 _ N 4*19'19 E
_ 1022 +
9B,15 98.76 edge of pavemen\� -102
Fj 99,77 00VE CORNERS100.45
1D1,18
ROAD 101.63
GENERAL NOTES: -
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER.
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
LOCAL RULES AND REGULATIONS. OF
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR ��� ti1Qss9
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER. o PETER T. G�
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING McENTEE
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN v CIVIL "' t
ENGINEER BEFORE CONSTRUCTION CONTINUES.
5. ALL ELEVATIONS BASED ON ASSUMED. 35109
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 09 G/$TE��O
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF S$ \ OWNER OF RECORD
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. Richard CaZQUIt
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 198 Five Corners Road
8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. II�l l o Centerville, MA 02632
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE /�
DIRECTED BY THE APPROVING AUTHORITIES. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 198 FIVE CORNERS ROAD, >CENTERVILLE MA
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). Engineering by: SCALE DRAWN JOB. NO.
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 1"=20' P.T.M. 133-10
Engineering Works
INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. f Inc.
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. (508) 477-5313 4/17/10 P.T.M. 1 Of 2
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL:102.5
FOR A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S.
SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S.
PROVIDE TWO ACCESS MANHOLES TO WITHIN 3"
INSTALL RISERS & COVERS OVER INLET INSTALL WATERTIGHT RISER & OF FINISH GRADE FOR INSPECTION PURPOSES
T.O.F. AND SET TO 6" OF FINISH GRADE. COVER SET TO 6" OF GRADE
PROVIDE ACCESS TO GRADE OVER OUTLET COVER F.G. EL: 105.5(MAX.)
EXISTING F.G. EL.=105.3f F.G. EL: 105.5f
f f /MAINTAIN 2% GRADE (MIN.) OVER S.A.S.
® S=19 (MIN.) @ 5=1% (MIN.)
4'SCH40 PVC 4"SCH40 PVC
6"
10"I � "/ 1
"14'
14" IL-
6 a669BEXISTING 48" LIQUID 6BaBBLEVEL ADD INV.=102.27 PROPOSED INV.=102.10 5.2Gas BAFf LEINV.=102.92t D-BOX E WIDTEXISTING SEPTIC TANK EXISTING INV.=102.00
2-500 GALLON LEACHING CHAMBERS
SURROUNDED WITH STONE AS SHOWN
H-10 RATED
TOP CONC. ELEV.=102.8f
NOTES: 1) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT ELEV.=102.5 ease
GRADE ON A MECHANICALLY COMPACTED SIX INV. ELEV.=102.00
ease
eases eases
INCH CRUSHED STONE BASE, AS SPECIFIED IN ease aBBaa
310 CMR 15.221(2). BOTTOM ELEV.=100.00
2) INSTALL INLET & OUTLET TEES AS REQUIRED. 3' 2 X 8.5'=17. 3'0'
3) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 23.0'
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. T.P. EXCAVATION OR G.W.
4) MAXIMUM COVER OVER SEPTIC TANK, D-BOX & S.A.S. LEACHING SYSTEM SECTION
SHALL BE 36". NO GROUNDWATER, EL.=94.1 -
3/4" TO 1-1/Y DOUBLE
WASHED STONE
SEPTIC SYSTEM PROFILE
3" LAYER OF 1/8" TO 1/2"
N.T.S. DOUBLE WASHED STONE
(OR APPROVED FILTER FABRIC)
_13.2L-1 SOIL LOG
Q i DATE: MARCH 30, 2010 (REF. P#12874)
vi SOIL EVALUATOR: PETER McENTEE PE, (SE#1542)
i WITNESS: DAVID STANTON R.S.
a_ 1 N HEALTH AGENT
ELEV. TP- 1 DEPTH ELEy. TP-2 DEPTH
rL96 _ _ 105.1 q 0„ 105.5 q 01
LOAMY SAND _- LOAMY SAND -
IOYR 4/2 10YR 4/2
" N 104.6 6" 105.0 g"
co O B B
LOAMY SAND LOAMY SAND
10YR 5/8 10YR 5/8
^� h) 102.1 36" 102.5 36"
, �0 C1 C1
DECK .
MED. SAND MED. SAND
2.5Y 6/4 2.5Y 6/4
94.1 132" 94.5 132"
1EXIS77NG NO GROUNDWATER, PERC RATE: <2 MIN./IN.(RECORD)
/HOUSE(#198) —
GARA�E r3E3
® ® ®®®®
G ®®®®®®®® 33"
®®®®®®®®
N Z ®®®®®®®®
S.A.S. LAYOUT 102"
DESIGN CRITERIA 4" KNOCKOUT
20" DIA. COVER
NUMBER OF BEDROOMS: 3 BEDROOMS
SOIL TEXTURAL CLASS: CLASS 1 4" KNOCKOUT 4" KNOCKOUT 62"
DESIGN PERCOLATION RATE: 5 MIN/IN
DAILY FLOW: 330 G.P.D. 4" KNOCKOUT
DESIGN FLOW: 330 G.P.D.
GARBAGE GRINDER: NO
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY 500 GALLON CAPACITY, H-10 LOADING
LEACHING AREA REQUIRED: (330) = 445.9 S.F. CHAMBERS
.74
USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 198 FIVE CORNERS ROAD, CENTERVILLE, MA
SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F. Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
BOTTOM AREA: 13.2' x 23.0' = 303.6 S.F. Engineering by: SCALE DRAWN JOB. NO.
TOTAL AREA:............................................ .................448.4 S.F. Engineering Works, Inc. NTS P.T.M. 133-10
12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. (508) 477-5313 4/17/10 P.T.M. 2 of 2