HomeMy WebLinkAbout0190 FULLER ROAD - Health 190 Fuller Road
A= 189— 101
Centerville
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No.2-153LOR
UPC 12534
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
ys
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation for Disposal *pstem Construction 3permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System U4,diidual Components
Location Address or Lot No. /cl o •0 i (Z _ Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel Cep j rV A, 1 ® 4n/) 1- kr
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Gor on P0M P 0S
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) e J�X �Z PA �
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 of Hea h. (� r
Sign \J•(�'�M� Date �
Application Approved by Date t5 S l
Application Disapproved by Date
for the following reasons
Permit No. ;W1 5 Date Issued
No.,_�a ,5 �- Fee
THE COMMONWEALTH"OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
flpflcatiou for -Misposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System P Individual Components
I! Location Address or Lot No. /C1 0 U L,- C Owner's Name,Address,and Tel.No.
Iw Assessor's Map/Parcel C e,41 t ru ti 4 a + (0 I Ann 1 Y��
4� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
i
Go('�vn SUM o S
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
�I
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 f Health. ^ r I
Signe l*J Date J
Application Approved by Date s �5
Application Disapproved by Date
for the following reasons
Permit No. (-)Lol5 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
1 (Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(v ) Upgraded( )
Abandoned( kby
at + L r Rj. C&I e-(V has been constructed in accordance
t with the provisions of Title 5 d the for Disposal System Construction Permit No, �) dated /5 �5
Installer (So r a , gU mp U S Designer
#bedrooms N 1 1 Approved desi ow h f gpd
The issuance of this pe t hall not be construed as a guarantee that the system wil function as designe,.
Date �0 Inspector
:.
�� --------------------------------
No. 5 — ))� Fee, / -
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal *pstr Construction hermit
Permission is hereby granted to Con ct ) pair( ) Upgrade( ) Abandon( )
System located at Cl(3 �'�� Re
R` C•/ krV A
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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:Construction must �o �ed within three years of the date of this permit.
Date �.J / Approved b
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
190 Fuller Road
Property Address
Ann Tyler
Owner Owner's Name
information is
required for every Centerville MA 02632 5/6/15
page. Cityrrown 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
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
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LOCATION SEWAGE PERMIT N 0
VILLAGE
IN.STA LLER'S NAME & ADDRESS
B U I L OR O"ER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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Commonwealth of Massachusettsrv - w
Title 5 Official, Inspection Form
Subsurface Sewage Disposal) System Form-Not for Voluntary Assessments
190 Fuller Road
Property Address
Ann Tyler
Owner Owner's Name
information is
required for every Centerville MA 02632 5/6/15
page. City/Town State ZipCode
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Informati6n r.
on the computer,
use only the tab 1. Inspector: I' 1
key to move your �
cursor-do not James Ford t
key the return Name of Inspector
Y iI
F
Q Company Name
P.O. Box 49 i
Company Address
Osterville MA 02655
Cityrrown State Zip Code
508-862-9400 ' S12482 ��;�, -b-F.,�, a� ?f'
Telephone Number License Number
B. Certification
I certify that I have personally inpected 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 16.000).The system:
® Passes , ❑ Conditionally Passes ❑ Fails
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❑ Needs Furthe valuation by the Local Approving Authority
5/7/15
Inspe is Signature Date
The sy tem inspector shall submit a copy of this inspection report to the Approving Authority(Board
of H h or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer;;if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
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t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments
190 Fuller Road
Property Address
Ann Tyler
Owner information is Owner's Name
required for every Centerville MA 02632 5/6/15
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Chec, A,B,C,D or E/always complete all of Section D
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A) System Passes: 1.
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® 1 have not found any infb'rmation which indicates that any of the failure criteria described
in 310 CMR 15.303 or A 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments: j
a
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", "nof or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.;;
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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):
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(Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
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Commonwealth of MasOi6husetts
. Title 5 Officia'I :Inspection Form
Subsurface Sewage Disposaf system Form - Not for Voluntary Assessments
190 Fuller Road
Property Address ;
Ann Tyler
Owner Owner's Name
information is i
required for every Centerville j MA 02632 5/6/15
page. City/Town c 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 lPasses (cont.):
❑ Observation of sewagesbackup 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) Ire replaced ❑ Y ❑ N ❑ ND (Explain below):
is
l:
❑ obstruction is removed ❑ Y ❑ N
❑ ND (Explain below):
❑ distribution box,s'leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
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❑ 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)a're:replaced ❑ Y ❑ N ❑ ND (Explain below):
i,
❑ obstruction is re�, oved ❑ Y ❑ N ❑ ND (Explain below):
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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:
r.
❑ Cesspool or privj 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 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
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Commonwealth of Massachusetts
Title 5 Official ;Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
i
190 Fuller Road
Property Address
Ann Tyler
Owner Owner's Name
information is
required for every Centerville MA 02632 5/6/15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:;
t
❑ 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 so'
ptic 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. I
❑ The system has a septid;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:
t
**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.
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3. Other:
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D) System Failure Criteria Applicable to All Systems:
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You must indicate"Yes" or,,"No"to each of the following for all inspections:
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Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discha,ge 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 clog�'ed SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than /2 day flow
•Sins•3/13 hh Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
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Commonwealth of Massachusetts
Title 5 OM64..1 Inspection Form
Subsurface Sewage Disposa Sy -
�, , stem Form Not for Voluntary Assessments
190 Fuller Road '.
Property Address
Ann Tyler
Owner information is Owner's Name ,
required for every Centerville i MA 02632 5/6/15
page. Cityrrown i State Zip Code Date of Inspection
B. Certification (cont.)
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Yes No !'
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❑ ® Requited pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
k '
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
4
❑ ® Any pprtion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
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❑ ® Any p".rtion 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 p�rt,'ion of a cesspool or privy is less than 100 feet but greater than 50 feet
from 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 chin 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
criteriai 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 co 'sidered a large system the system must serve a facility with a
design flow of 10,000 gpdo 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—MPA) or a mapped Zone II of a public water supply well
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If you have answered "yes"tQ any question in Section E the system is considered a significant threat,
or answered "yes" in Section jQ: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 31.0 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
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Commonwealth of Massachusetts
Title 5 Officiaklnspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
190 Fuller Road
Property Address
Ann Tyler
Owner Owner's Name
information is
required for every Centerville MA 02632 5/6/15
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
® ❑ Pumpin 1 g 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 th`e 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?
I.
❑ ® Was the facility owner(and occupants if different from owner) provided with
informatlion 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"ihformation: 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
® ❑ approxid!iation of distance is unacceptable) [310 CMR 15.302(5)]
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D. System Informatiofi
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
l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
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F
i�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments
190 Fuller Road
Property Address
Ann Tyler ?"
Owner Owner's Name
information is
required for every Centerville MA 02632 5/6/15
page. Citylrown State Zip Code Date of Inspection
D. System Information:
Description: '
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Number of current residents: 0
Does residence have a garbage grinder?
❑ Yes ® No
Is laundry on a separate sev;Yage system?(Include laundry system inspection
information in this report.) ; ❑ Yes n No
Laundry system inspected?;` ; ❑ Yes ® No
Seasonal use?
9 ❑ Yes ® No
Water meter readings, if available last 2 ears usage
g ( Y 9 (gPd)):
Detail: E'
unavailable
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Sump pump?
❑ Yes ® No
Last date of occupancy: unknown
Date
Commercial/Industrial Flo Conditions:
Type of Establishment:
Design flow(based on 310 66 15.203):
Gallons per day(gpd)
Basis of design flow(seats/pf'rsons/sq.ft., etc.):
1
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank,present? ❑ Yes ❑ No
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Non-sanitary waste discharge'.d to the Title 5 system? ❑ Yes ❑ No
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Water meter readings, if available:
t5ins•3/13
44� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
.p
f ;
Commonwealth of Massachusetts
w Title 5 Officiall Inspection Form
Subsurface Sewage Disposal;System Form -Not for Voluntary Assessments
190 Fuller Road
Property Address
Ann Tyler €
Owner information is Owners Name '
required for every Centerville MA 02632 5/6/15
page. Cityrrown l
State Zip Code Date of Inspection
D. System InformatiOill (cont.)
Last date of occupancy/used Date
Other(describe below): '
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General Information
Pumping Records:
Source of information: i, Tank was pumped in 2014
Was system pumped as part:of the inspection? ❑ Yes ® No
i.
If yes, volume pumped:
,i
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
i�
® Septic tank, distribution box, soil absorption system
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❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system,(yes or no) (if yes, attach previous inspection records, if any)
t,
ElInnovative/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
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Commonwealth of Massachusetts
Title 5 OfficiA Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 190 Fuller Road
Property Address
Ann Tyler
Owner information is Owner's Name
required for every Centerville MA 02632 5/6/15
page. City/Town
t State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
system installed -7/10/1978
Were sewage odors detectd'd when arriving at the site? El Yes ® No
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Building Sewer(locate on site plan):
Depth below grade:
� feet
Material of construction:
❑,cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
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Comments(on condition ofjbints, venting, evidence of leakage, etc.):
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Septic Tank(locate on site plan):
Depth below grade:
12"
feet
Material of construction: ri
® concrete ❑ l meta ❑fiberglass ❑ polyethylene
i, El other(explain)
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If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 750 gal.?
Sludge depth: 2
t5ins•3/13 it
t! Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
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Commonwealth of Masslachusetts
Title 5 Official ' Inspection Form
Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
190 Fuller Road
Property Address i
iI
Ann Tyler
Owner Owner's Name
information is
required for every Centerville. t MA
page. City/Town 02632 5/6/15
State Zip Code Date of Inspection
D. System Informatio'n'(cont.)
Septic Tank(cont.) ^
Distance from top of sludge fa bottom of outlet tee or baffle 27
Scum thickness 1
,i
Distance from top of scum t�top of outlet tee or baffle
i-Distance from bottom of scum;to bottom of outlet tee or baffle 10
How were dimensions determined? measure
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Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to out invert, evidence of leakage, etc.):
The tees were present. The tank was pumped in 2014
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Grease Trap (locate on site plan):
Depth below grade: n/a
feet
Material of construction:
❑ concrete
❑ metal El fiberglass ❑ polyethylene ❑ other(explain):
d
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
1'•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 Fuller Road
Property Address
Ann Tyler
Owner information is Owners Name !
required for every Centerville MA 02632 5/6/15
page. City/Town State Zip Code Date of Inspection
D. System Information(cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
El other(explain):
N/a
Dimensions:
Capacity:
gallons
6•
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
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Commonwealth of Massachusetts
a Title 5 Official ,
Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
rt 190 Fuller Road d
Property Address
Ann Tyler
Owner Owners Name s
information is
required for every Centerville MA 02632 5/ti/15
page. City/Town 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 -
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-Box was broken down and full of roots.A new D-box was installed see permit#2015-118. The
cover is 3" below
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Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: El Yes ❑ No*
Comments (note condition of;pump chamber, condition of pumps and appurtenances, etc.):
i
x
1.
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
is
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
' d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
190 Fuller Road
Property Address
Ann Tyler
Owner Owners Name
information is i
required for every Centerville MA 02632 5/6/15
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type: li
® leaching pits' number: 1- 1000 gal.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenF•hes number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of,soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.): i
The pit was dry and the scum line was 2.5' up from the bottom.The cover was 10" below. There was
no sign of failure.The BTG was 8'
4
t.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
r
Depth of solids layer
i
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater infl6w ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
si
n
i
ti. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r( 190 Fuller Road
Property Address
Ann Tyler
Owner Owner's Name
information is
required for every Centerville MA 02632 5/6/15
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.):
i�
Privy (locate on site plan).-
Materials of construction: '
Dimensions
Depth of solids
I;
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): d
N/a
I
�F
I
1
r�
Ir
i
I
t5ins•3/13 7 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
c
Id
:i
Commonwealth of Mass'achusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposaf System Form -Not for Voluntary Assessments
190 Fuller Road
Property Address t
Ann Tyler
Owner Owner's Name
information is
required for every Centerville MA 02632 5/6/15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposaf.System: Provide a view of the sewage disposal system, including ties to
at least two permanent reWence 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
t
G ABASE;
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a 149 aS
3 419(0 314
y 33 �►�
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
V
,. Commonwealth of Massachusetts
Title 5 Officiall ' Inspection Form
Subsurface Sewage Disposal-System Form -Not for Voluntary Assessments
M ••'�� 190 Fuller Road
Property Address
Ann Tyler
Owner information is Owner's Name —
required for every Centerville MA 02632 5/6/15
page. Cityfrown f' State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
i
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 30'+/-
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date,of design plan reviewed: pate
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
i
Topo and water'contours map
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS'database-explain:
i
I,
You must describe how you established the high ground water elevation:
see above
,t
Before filing this Inspections Report, please see Report Completeness Checklist on next page.
t5ins•3/13
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
190 Fuller Road
Property Address
Ann Tyler
Owner Owner's Name
information is
required for every Centerville MA 02632 5/6/15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
�j
® Inspection Summary: Xt B, C, D, or E checked
N
® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
4'
® System Information— Estimated depth to high groundwater
f
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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C-77 '
No.. ....S 1�r' Fina..�5-n.0........_
THE COMMONWEALTH OF MASSACHUSETTS
/0 BOARD OF HEALTH
....................Town_. __ Barnstable
OF...... ..................... -
Appliration for Kiiiipwi al arks Towitrnrttnn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
.......90 _Fuller.Road
------------------------------------------•---•-••••. ---•••••-••--•••-----•-•--••••••-••--•-------•••-•----•-••••--•-•------ •- -
Loc tion-Address Centerville or Lot No.
Anthon.-_Paris
Owner Address
a Joseph..P.._._Macomber..&:.Son... ng.............. ...........Centerville........................................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P, Other 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.......................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•------------------------------•----------------•-••----------------------------•------------------•--••._..._.......:.._....
O Description of Soil............Sand...&..Gravel---------------------•--------------------------------------------
x
U
W ----------------------------------------------------------------------------------- --•---•-•--•----•-•...._._..---------------•--------------------------------------------------------------------•--
UNature of Repairs or Alterations—Answer when applicable__1 __0_0Q._ga_11-On-_.OXerf how
-------------------------------------------•----•-•-------•--------------------•---------..._..--•-----•---------.---------------------..........-----•--------------------------------...........-•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b 1 ed by the boaa d of 1h. /
Sig '6....6f
. _ --
' � Date
Application Approved By........... .r -U ----•--------------•----------- •... .- -' -
I V Date
Application Disapproved for the following reasons-------------------------------------•----------------------------------------------------------------........-•-
-•••••--•••--•--------------•----•------•---•------------------------------------•------•-------•----------•-•-•----•---•-------••-•---------•----•-•-----•-•-•......--- ------------------_----•-----
Date
PermitNo......................................................... Issued-----------7.............................................
Date
F>�s•� 4
No.-------• -• b. . ...........
THE COMMONWEALTH OF MASSACHUSETTS
5 ......
BO �RD . OF HEALTH
Appliratiou-rl i a 1 Works Cn �t trurtiun re it,,,,-
Application is hereby made for'a Permit to Construct ( ) or Repair 4( X) an Individual Sewage Disposal
`, "System at:, }
ri _•ri` ,°'a'Y F_ S:,.` t r.t_ .. . T ._.
rt �. ,Sse..P, eat ..------•-- ........................................................ e
yf ♦ ..... .................
�ocatron-`Address or LotNo.
------------
�t •�.���, �h Address
...
.l Own F -.- �• ��,LF ------------- ---•_---•-•3x�'.: �Gs:F x s aae i•_••____•----•..... ....................-_..
�.� sl�J i �✓ 2 4"i Nat
t'rP. Address
� { a ,,,,• ns a[rer � 4
d Type oftBuilding-. , s Size Lot................. Sq..feet
U DwALl'in No. of Bedrooms _•: .Expansion Attic Garbage e Grinder,
U � O.tber-;Type of Building ........................... No. of persons_ '`.:.... "`.:__ Showers ( ) —� Cafeteria {� )
Other fixtures --- - ------------------------------------
I esign'Flow......................' r ..gallons per person per day. Total daily flow_.................. ;gallons.
W � �t.c•r � .. S F r ,
WSeP.ic Tank—Liquid capacity k gallons Length................Width _ Diameter_.___ Depth r
x g Disposal Trench—No. .. .....:. Width:.................. Total Length .............. Total leaching area----- `_: sq. ft.
tSeeOage Pit�No----------_-------- Diameter :_---_----- Depth below inlet Total leaching area'_:_ sq. ft.
Z ` )0t'her:Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed.by..............................................•._. _.__........ Date........................... .
Wa �.w, Test Pit`No. 1................minutes per inch Depth of Test Pit....................rDepth to ground water........................
Test,Pit No. 2................minute's per inch Depth of Test Pit ......... "Depth to ground water
• R..• !
o Description of Soil.•.........._ a,_.
���Y1tX�'�i�r''r�s
U .........•••-•-......•.. ............. -------- -
W - - ------ d --.:. ---- - ---------------------
U
x ``Nature of Repairs or Alterations Answer when applicable___ .� n � --h or'9___ove rf 7���t.___
' ----- -
---------•-------•--••••......•• -- •..................................•--------
Agreement: :w `
sJ ` *The undersigned agrees tostall,the aforedescribed Individual`Sewage;Disposal System m;accordance`with
Ytl e.prov1sions of TI"a 5 of theIS6te-Sanitary Code— The undersigned fdfiher agrees not to place the system in
operation until a Certificate of Compliance has be�ed by the board., ,hety 1
Si ie _.. '• c. t! xtr � ' ' fij r ya 1'tl% yi
g =,✓ Date. s
,Application Approved By...... .......' -• C � !1I- �-t►
. - • �,� Date'
Application Disapproved for the following reasons:.................. ................. ..............--.....__._..__-••-_._ ..........
.,.,
Date. 1,
x ty ._
Date
Date a t
Permit No.......................... ssu
x THE COMMONWEALTH OF MASSACHUSETTS 3' s!
i " BOARD OF HRALTH
.�t3 .:..:.�
:Y _ . �rrtif iratr of f�� mptiana
4 THIS IS TO .CERTIFY, That the Individual Sewage Disposal,System,constructed ( ) or-, Repaired ( ,�
k __ frl d�L�{fL7 'Installer j ttr s
ki
.............
9 �� l ""av�c��,.�•a�.-'� 11'A'P":A b-++i,.[.as.' ---•- -._. ... ---°-t-�----�v-•- -$ * 4'
rhas been installed in accordance Ywitli the provisions of TI� , of"NThe State Sanitary Code as described m the
t application for Disposal Works Construction Permit No.__- _ __..._ : _.... da.ted.........7'-/-,0 _��
THE ISSUANCE OF THIS,CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE.THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
... s t
Inspector ,
a•.. 1 ,+b. t•vy'44,!4 Xr>::a.� �C.,?:• ��.'"�4f('N iT {�., '4A7.yvtr�5 w'�•� ,�4n,n y'Zz.3+s� "kd"t ..n.r+'o q
i� ,•✓' i y :w- r:4Y.�u, i ^,eh .•. '� ` 'lr � �..r - t `Y '•"K6��r ,��.^•.
'k(�"' ^
g THE.COMMONWEALTH OF MASSACHUSETTS
{- BOARD OF ,-HEALTH
1
l fi
}N t � e� ' ............. Y , tLk�;Te� OF. c� 'I'?�a )� .....,.. FEE.........��5 �....
Difivoo t1 Works T.oa�otr ion irmit
i\Per'mission is hereby granted .3 � �I" " SO ` T �------•---•-------------- h
to Construct ( ) or Repair ( ,)Xan Individual Sewage Disposal' System s
= ___•-------•--------- -- - . ' ,. i _
Street �t Z
.s
�s shown on the application for Disposal Works.Construction Permit ..... ......... Dated........7. 1d_._: [ '..:..
} a C \ oard of Health
z'
,.
...7,0C, .......................................... -7
W,
FOR IL255 HOBBS & WARREN', INC PUBLISHERS r"':+.` `'' - 1'•,,`t4.
LOCATION SEWAGE PERMIT NO.
92,
VILLAGE
, Le—A1zzfzfL,1j,11d i /0
INSTA LLER'S NAME & ADDRESS
B UIL OR 0"EERR
DATE PERMIT ISSUED .7--/0_ 71-
DATE COMPLIANCE ISSUED 7 mil) -76
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