HomeMy WebLinkAbout0426 GREAT MARSH ROAD - Health 426 Great Marsh Road
Centerville F/R
A = 190 219
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No. 4210 1/3 ORA
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TOWN OF BARNS�^TABLE r\ 1 G
LOCATION T �rtr,-� �"��4'b� tY SEWAGE#
VILLAGE C1 .�CcxQ r\\ ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY \Q&a\W e �[wr.1uL �®h CsgL
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER ►y S f�.�� -"
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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No. _G Fee
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftPhCation for Mispo8af *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System 1 Individual Components
Location Address or Lot No. a (_r j-, ho , Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel <U ur's
Installer's Name,Address,and Tel.No. ,4A,IW Designer's Name,Address,and Tel.No.
S Y��►4 oU(o"
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 /v gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank DO (,o& O k S� Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
f-71 r-7- \ � QA,(l,ACA Q<!\ Qe,1 X C C — �� 1�1LIVY
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 ealth.
Signed Date e ► f 1 a
Application Approved by Date ( Z
Application Disapproved by Date
for the following reasons
Permit No. '10 0-— f?7 Date Issued S f
` No. G Fee
f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplication for bisposar *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. l., �L-�f.(� ( \�i�fS� Owner's Name,Address,and Tel.No..
Assessor's Map/Parcel Qd crr-s t,� \`
Installer's Name,Address,and Tel.No. Yw Designer's Name,Address,and Tel.No.
Scd'A1 c_7 h\-, O \
ntt J�1Y•�`�V oUto
Type of Building: ? I
Dwelling No.of Bedrooms 3 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 00 (5(A- P k(S� Type of S.A.S.
_.
Description of Soil �I
Nature of.Repairs or Alterations(Answer when applicable) QQ CJC^\.f
Date last inspected: 1
Agreement:
i
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
i
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 alth. _r -
Signed Date S / 0) ' a
Application Approved by Date i ( ( �--
Application Disapproved by Date
for the following reasons
Permit No. a0 _ ' 71 Date Issued "
r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓) Upgraded( )
Abandoned( )by S �[,�-�•
1
at L( a� [ nS� �_CJ has been constructed in accordance
with the provisions of Title5 and the for Disposal System Construction Permit No. 0 dated
Installer SLy t'C �nl�� Designer
#bedrooms Approved design fl gpd
The issuance of this permit shall not be construed as a uarantee that the system will function d si d.
f� v
Date U! Inspector
----------------------------------------------------- ---------------------------------------------------- -----------
o � — 13
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
isposaCpste Construction Permit
Permission is hereby granted to Construct(• ) Repair(v) Upgrade( ) Abandon( )
System located at 1`^G.t S�- (Z V C• V t I \k
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.
i
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Provided:Construction must be completed within three years of the date of this permit.17
tL
Date 5 � Approved by
Postal
m ERTIFIED M.AIL.-�91ECEIPT
D. Provided)
For delivery information visit
ur website at www.usps.conlo
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m Postage $ �P��l9 O
pCertified Fee �6>
C3 A Ito
p Return.Receipt Fee. t APR
(Endorsement Required) I W82
O Restricted Delivery Fee
r-1 (Endorsement Required)
CO
Total Postage&Fees $ .Jr
r- HUD/Cooper Citi West
8 Griffin Road
Windsor, CT 06095
Certified Mail Provides: �s,a eat aooa au�r'ooas uLoj sd
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■For an additional fee, delivery may be restricted to the addressee or
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COMPLETE THIS SECTION ON DELIVERY
SENDER: COMPLETE THIS SECTION
■ Complete items 1,2,and 3.Also complete A. Signatu
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or on the front if space permits. 4 t
D. It delivery address iff rent from item 1? El Yes
1. Article Addressed to: If YES,enter deliveryaddress below: ❑No
I
HUD/Cooper Citi West ;
8 Griffin Road 3
I Wi dsor, CT 06095 r 3. Service Type
I ❑certified Mail ❑Express Mail
_f ❑Registered ❑Return Receipt for Merchandise I
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number - 7.0 0.6 .�810 0 OD .3 5 2 4 5 713
(Transfer from service laben
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
f�
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
3
n; r1'Rwn of arnstable
PtPlic H alth Division
2004\4aintreet
t Hyaxnis, E 02601
N
fr"
Town of Barnstable Barnstable ~�
• Op SHE T
" Regulatory Services Department hy
I 1
I> RARNSTABLE, •I� m
MASS. Public Health Division
�A 039. 2007
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
5�1.3
.CERTIFIED MAIL #7006 0810 0000 3524 56W
March 30, 2012
HUD/Cooper Citi West
8 Griffin Road
Windsor, CT 06095
1 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5.
The septic system located 426 Great Marsh Road, Centerville, MA,was last inspected
• on 3/18/2012 by Michael McDowell, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails"under the guidelines
of the 1995 TITLE 5 (310.CMR 15.00) due to the following:
• Replace or repair leaking septic tank
You are ordered to repair or replace the septic system within two (2) years from
the date you receive this notification.
PER ORDER OF HE BOARD OF HEALTH
Thomas McKean, R.S. CHO
Agent of the Board of Health
•
Document]
TW n� r-s
� ¢ is /el
k� i
f
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. City/Town State Zip Code 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 Information
/f O
on the computer, r r/
use only the tab 1. Inspector:
key to move your
cursor-do not Michael McDowell
use the return Name of Inspector
key.
The Building Inspector of America
r� Company Name
2 Brookside Circle
Company Address
Wilbraham MA 01095 --�
City/Town State Zip CodeTz
1-800-626-4408 156
Telephone Number License Number ¢)
P
C-
B. Certification *'
I certify that I have personally inspected the sewage disposal system at this address and that-the
rn
information reported below is true, accurate and complete as of the time of the inspection. TFie inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/18/12
Inspector's Signature Michael McDowell MM/mjl Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Lo l z� '-R I 10
t5ins•11/10 Title 5 Official Inspection Form:Su urface Sewage Disposal System•Page 1 of 17
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: N/A
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is.metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as approved
by the Board-of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
The septic tank exhibits substantial exfiltration. Note: HUD owned house. House is vacant, all
utilities are off, and septic system has not been receiving normal daily flows for an unknown length of
time.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. City(Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
ND Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
[N The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will bass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health: NIA
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth-of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
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: N/A
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ NIA Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
Mrs•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth,of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ❑ N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ❑ N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ❑ N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ❑ N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. N/A
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
.
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ❑ NIA Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins-11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
f .
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page: CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current.residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? N/A ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 197 gpd
9 ( Y 9 (gpd)):
Detail:
The last years water usage totaled 144,000 gallons divided by 730 days equals 197 gallons per
day. (gpd)
Sump pump? ❑ Yes ® No.
Last date of occupancy: UnknownDate
Commercial/Industrial Flow Conditions: NIA
Type of Establishment:
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth & Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: HUD owned house, none at board of health.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the'current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts :.
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is
required for every Centerville MA 02632 3/18/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Septic tank is original with house (1985), distribution box and SAS were replaced in 2003 per board of
health records.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20 inches
feet
Material of construction:
❑ cast iron ❑ 40 PVC 4 inch ABS
® other(explain):
Distance from private water supply well or suction line: 27 feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Building sewer exits rear foundation wall 21 feet in from right front corner.
Septic Tank(locate on site plan):
Depth below grade: 16 inchesfeet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10'Lx5'Wx5'D, approx.1500 gallons
Sludge depth:
0-1 inch
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts:
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle N/A
Scum thickness 0-1 inch
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? With a tape measure &pole.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Fluid level was not correct. Fluid was 9 inches below outlet invert. Therefore N/A ratings are given
above. Half of the septic tank is below concrete slab patio. Was unable to measure exact length of
tank. Inlet has an inlet tee and outlet has an outlet baffle. Outlet has a riser to within 6 inches of
grade. Inlet has a plywood cover on patio. Recommend repair or replacement of septic tank.
Recommend pumping every 3 years.
Grease Trap (locate on site plan): N/A
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 official. Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
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): N/A
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwe,alth.& Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
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 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Fluid level was correct, that is, equal with outlet inverts (2). Top of distribution box is 14 inches below
grade. Distribution box is level and there is no evidence of solids carryover.
Pump Chamber(locate on site plan): NIA
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. City/Town .State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number;dimensions: 1 @ approx.
12'x30'
❑ 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.):
There is no evidence of hydraulic failure. Note: House is vacant, all utilities are off, and the septic
system has not been receiving normal daily flows for an unknown length of time.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): N/A
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
-Commonwealth of Massachusetts
Title 5 Official Inspection Fora
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
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.):
Privy(locate on site plan): N/A
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below Sketch is not to Scale
❑ drawing attached separately
=Inlet cover on septic tank XA=25'6" YA=23'10"
B=Outlet cover on septic tank XB=29'4" YB=27'3"
C=Distribution box XC=35'6" YC=31'6"
X
iJ
f
F 7,
( - C
Uz
T 1
s
1
1 �
F
`l ""'-n•�---•—..yu.a...�'-'^-•.-....-�.+ u_.r.e�+an..,... i....a....ev......-.:e..v..0__»...urn-.._».wu.a...e..:...va_.._.. ,
Ft
Qo (Area+_
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
-Commonwealth ofMassachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 7 feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed- _ Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Basement concrete slab floor is approximately 7 feet below grade. There is no evidence of chronic
water penetration in basement.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 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
0
,M 426 Great Marsh Road
Property Address
HUD/Cooper CitiWest 8 Griffin Road, Windsor, CT 06095
Owner Owner's Name
information is required for every Centerville MA 02632 3/18/12
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Fee
No. /Sri'-N 3 —46 , �W THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01p plication for Mi5pooar *pgtem Conotruction Permit
Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ����f'C- � ��✓� �C"� Owner's Name,Address and Tel.No. _
Assessor's Map/Parcel XF& 11 �/
Instal}ler's Name,Address,and Tel.No._ Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building �c !�'` No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow .5 5� gallons per day. Calculated daily flow jjre> gallons.
Plan Date 9—X"2 O i Number of sheets loll Revision Date
Title
Size of Septic Tank !-� is�Ti�� /e� �� L 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 Certifi-
cate of Compliance has been issue by this Board of Healtil
Sig ed -- Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. a_rn- 3 ` 5:_ Date Issued
!• '3•...rri •� ..t,L �.'s1�w.l' ,A I*�P�:G�fM w..trM';�"•W-•+.0 N
�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _ _ I
" Yes
PUBLIC HEALTH DIVISION -TOWN-OF BARNSTABLE., MASSACHUSETTS
01pprication for 33igogal *potem Con0truction Permit
Application for a Permit to Construct( )Repair( )Upgrade(><;Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. G/pit�j�T + � Owner's Name,Address and Tel.No.
Assessor's MapTarcel/pv a ,of
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building /f�J', No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 'y r�gallons per day. Calculated daily flow gallons.
Plan Date 9/3 03 Number of sheets / Revision Date
Title
Size of Septic Tank -•Xi�f'T/w /000,Q4e. Type of S.A.S. o� •'!` ��
Description of Soil
,
Nature of Repairs or Alterations(Answer when applicable) I
Date last inspected: ✓�
Agreement:
' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal syste}m
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss=bythisrd of Health
`p Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. n rr-, Date Issued----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(,y)
Abandoned( )by lT/!W �'B��O'�
at 6' Gr,0 42:47' . W_,4Ae� /P'.b• GC�v�''�.,�P.�/�6' has been construgtedlin accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.2-001 qS 7 dated 11010.3
Installer. lam//YJ 404194e�6y1 Designer-64l'/,O .f3'• i /It�o�"� �-
The issuance of this pe t shall not be construed as a guarantee that the system w'd as desi" O
Date s told 3 Inspectors •
No. O CC.% 3 —7 Fee �J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigoal *potem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(x)Abandon( )
System located at i 5:10 4K_ G'45&- r.;P` e2neQj!J W 4-,,6 -
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions. �-
Provided:Construction `must be completed within three years of the date of this pe •'t. *'"
G Date: 1 '� / 'S Approved by �...
i
TOWN OF BARNSTABLE
SEWAGE # cYo1� 7
LOCATION
VILLAGE
ASSESSOR'S MAP & LOT /LO—
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)
(size)
NO,OF BEDROOMS
J
BUILDER OR OWNED ,
PERMITDATE: P /� v� COMPLIANCE D. 3 .
ATE:
Separation Distance Between the:
Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility .
i
Private Water Supply Well and Leaching Facility (If any wells exist
Feet-
on site or within 200 feet of leaching facility)
I Edge of Wetland and Leaching Facility(If any wetlands exist / Feet
within 300 feet of leaching facility)
Furnished
,Q
.d
s r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP I �
PARCEL '
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A At
CERTIFICATION FAILED INSPECTION
Property Address:. �LYLPX�YZ NL' ,t9.h Ua&
i4
Owner's Nam -
Owner's Address: Al
A
Date of Inspection:
ff A
Name of Inspector: lease print, �1' Ic��-`� FRECIE"V
Company Name: �'Mailing Address- 10
Telephone Number: 9'- /
CERTIFICATION STATEMENT TH DEFT.��
I,certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete-as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a.DEP
approved system inspector.pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Inspector's Signature: / Date: (N US
The system inspector shall submit a copy of this inspection,report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of I0,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office ofthe.
DEP. The original should be sent to the system owner.and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will.perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 pace I
t it
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: t� go-41
Owner:Date of Inspection:
Inspection Summary: Check _A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
y c I ha'vve not found an'"inf 5� ' i y ormation which indicates that an of the failure crit
eria rteria described in 310 CMR
15:303 or in 310 CMR 15.30.4 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Healthy will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as'approved by the Board of H.ealth.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level;in the-distribution box-due to'broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will:pass inspection if(with
approval of Board of Health):
broken pipe(s.)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required:pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):.
broken pipe(s)are replaced
obstruction-is removed
ND explain:
2
Page 3 of l'l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ol(0 91,
Owner
Date of Inspection:
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 31.0 CMR.15.303(1)(b) that the
system is not iunctioning in.a ma.nner'whicti'.wiil protect public health,safety:and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a.manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private.water supply welt.
_ The system has a septic tank and.SAS and the SAS is less than 100,feet but 50 feet or more from a
private water supply well"..Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria•and volatile organic compounds indicates that the well is free from pollution from that facility and
-the. arnibionia nitrogen'and'riitraie nitrogen is equal'to or�less than ppm,provided that no other
failure criteria are triggered. A,copy of the analysis must be attached to this form.
3. Other:
3
� r
Page 4 of 11
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION(continued)
Property Address:
Owne
Date of Inspection: ��)-003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes l No
Backup of sewage into facility or system component due to overloadedorclogge&SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an_overloaded or clogged SAS or
/ cesspool
i/ 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.
1/ Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50.feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
\Pi5(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a.large system the system must serve a facility with a"design flow of 10,000 gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface
_ y ry s rf ce drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
. t
Page 5 of 1.1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE RISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection: 3
Check if the following have been done. You must indicate"yes"or"no"as to each of the following;
Yes No
Pumping n.formation.waspApvided by the.ow_ner;occupant. or.B.oard 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?
V4 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)
V17_ Was the facility.or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out? ,
Were all system components,excluding the SAS, located on site?
Were the septic tank manholes uncovered,.opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum?
l"_ 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 Seil Absorption System...(SAS)on the.site has been determined based on:
Yes no
_T✓ Existing information. For example,a plan.at the Board of Health..
v — Determined in the field(if any of the failure criteria related to Part Cis at issue.approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)).
5
Page 6 of 11
OFFICIAL-INSPECTION-FORM—NOT FOR VOLUNTARY
ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION
Property Address: VJ69 Aia Qj 3a"j
Owner: Ph
Date of Inspection: Olii4a >
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(:design): . Number of bedrooms(actual):
DESIGN flow based on 310'CMR 15.203 (for example: 11.0'gpd x#of bedrooms):
'Number of current residents:
//
Does residence have.a garbage grinder_(yes or.no): A,
/YU. . .
Is laundry on a separate sewage system (yes or no): [if yes separate inspection required)
Laundry system inspected(yes or no)V/ Q
Seasonal use:(yes or no):� ���
Water meterreadings, ifa�vy�ilable(last 2 years usage(gpd)):01--/3�,AX Oz"l
Sump pump(yes or no):/VO �'
Last date of occupancy:41�.Jj, L
COMMERCIAL/INDUSTRIAL'
Type of establishment:.
Design flowOased on 310 CMR.15.203): gpd
Basis of design.flow(Seats/persons/sgft,etc.): . ..
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):—
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: rjxz _
Was system.pumped as.part of the inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
- ' Reason'for.pumping: �.{..
TYP'OF SYSTEM
Septic tank, distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system.(yes or no)(if yes, attach previous inspection records, if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner')
_Tight tank -Attach a copy of the DEP.approval
_Other'(describe):
Apo ate 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
rPage 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: V'X0
r
Owner:
Date of Inspection: l `j
BUILDING SEWER(locate on site plan),/j-6"'
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):-
Distance from private water supply well or suction liner
Comments(on condition of joints, venting, evidence of leakage, etc.):.
SEPTIC TANK: t/ locate on site plan)
Depth below grade:
��
Material of construction: 1/concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: aC S
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: < 7
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 2-
Distance from bottom of scum to botto of outlet lee or baf e'. 3
How were dimensions determined.
Comments(on pumping recommefidatiod, inlet and outlet tee or baffle condition, structural integrity, liquid levels
a lated to outlet invert,eviden e of leakage,Fe
GREASE TRAP•2L�(tocate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: A. MA WOW
c
Owner. v
Date of Inspection: / 3
TIGHT or HOLDING TA`NN-(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no): y
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX:, " (if present must be opened)(locate on site plan).
Depth of liquid level above outlet invert:
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
1 icage into or out o�box, etc.):
e
PUMP CHAMBEY/IWY (locate on site plan)
Pumps in working order(yes or no)::
Alarms in working order(yes or no):.
Comments(note condition of pump`chamber;condition of pumps and appurtenances,etc.):-'
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION.(continued)
Property Address: 0 %
90-4-V
Owne
Date of Inspection: 3
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching.pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches, number, length:
leaching fields,number, dimensions:
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,
c.)., lZ. 'A XD
r
CESSPOOLS
(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition,of soil,sig is of hydraulic failure,_level of pordir.0, condition of vegetation;etc.):
PRIVY/)j(jy (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.):
I
i�
9
Page 10 of 11
OFFICIAL INSPECTION FORM=NOT FOR,VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: VA
o ,n
Owne nl
Date of Inspection: l6l3
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
L//v 4 u—
t�
o Cb�
10
Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMAT_IO/N� (continued)
Property Address: )
Owner:
Date of Inspection: /
SITE EXAM.
Slope
Surface water
Check.cellar.
Shallow wells
Estimated depth to ground water 2✓ feet
Please indicate(check).all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked-with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database=explain:
You must describe how you established the high ground water elevation: G /�
r
11
Pernit Nurnber: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: Lot No.
Owner: l7/- Address:
Contractor. S Address:
Notes: •. ���c5�`.�J`!��` s
STEP S I—E, 1 Measure depth to water'table
tonearest 1/10 ft. ....................:...................................................... .... .Date _f
month/day/Year
STEP 2 Using Water-Level Range Zone l
and.lndex Wefl'Map locate
site and determine: Cif I
A Appropriate index well............
OWater-level range zone ...............................................:.:.....
STEP 3 Using monthly report."Current
Water Resources Conditions"
determine current depth to
water level sor index well .......:...................
month/year
STEP 4 Using Table of.Water-level.Adjustments I I
for index well (STEP 2A), current depth
to water level for index.well (STEP 3).,
'and water-level zone (STEP 2B)
determine water-level adjustment-.......,
STEP 5 . Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measu red*depth to water
levelat site (STEP 1) .:..................................:........ ....:.................,......................................... r
Figure 13.--Reproducible computation Term.
,,dry
•-' y X
lot
' 3 5
2
• _ S
}
7 '
uy�
• U
L
i
1 �tt
1 t
t�
Y
1LJI
iy
t
1 i
9
7
x
s
s f
� 3
iA
i^ J
1
f
BORTOLOTTI CONSTRUCTION, INC.
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Andress Prop
Date of Inspec} Map,�+ arcplOwner�
CHECK IF THE FOLLOWING HAVE BEEN DONE: PART A — CHECKLIST
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 COLUMES OF WATER HAVE NOT BEEN INTRODUCED I
THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.
--'AS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A.
4—THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP.
LITHE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. 00 JUL
6 1995
LL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE.
SHE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSP �
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH O L g ,
DEPTH OF SCUM.
THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
APPROXIMATED BY NON—INTRUSIVE METHODS.
THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANCE OF SSDS.
PART B — SYSTEM INFORMATION
i
RESIDENTIAL FLOW CONDITIONS
No of Bedrooms No of Current Residents
Garbage Grinder
Laundry Connected to System, Seasonal Use
NON RESIDENTIAL:
Calculated flow
WATER METER READINGS,IF AVAILABLE:
i
i
Pumping Records and Source of Information: GALLONS
SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED =
Reason for Pumping: GALS I
TYPE OF M:
SY
Septic tank/distribution box/soil absorption system
Single Cesspool Overflow Cesspool Privy Shared system (if yes, attach previous inspection records, if any) i
Other(explain)
I
ApproxZ;7:1,
of all components. Date installed, f known. Source of information.
cS
i!'�d
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE?
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SEPTIC TANK:
[Depth below grade: Dimensions: , r S
Material of construction: Concrete Metal FRP Other}
Sludge Depth ��. Distance from top o sludoe to bottom of outlet tee or baffle
i
Scum Thickness Distance from Top of S to top of outlet tee or baffle cam
Distance from bottom of Scum to bottom of outlet tee or baffle
O
Comments:
J s 41e4 S
� o
DISTRIBUTION BOX: r i DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:
PUMP CHAMBER: Pumps in working order?
Comments:
SOIL ABSORPTION SYSTEM (SAS):
IF NOT PRESENT,EXPLAIN:
TYPE: —
Comments:
S
o Ze
CESSPOOLS: Number and configuration
Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
Indication of groundwater inflow(cesspool must be pumped)
Comments:
PRIVY:
Materials of construction
Dimensions Depth of solids
Comments:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
,INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES.LANDMARKS.OR BENCHMARKS.
'LOCATE ALL WELLS WITHIN 100'
es- �
a �
a
DEPTH TO GROUNDWATER: DEPTH To GROUNDWATER
METHOD OFDETERMINATION OR APPROXIMATION:
m� / ✓ .
Cl,
4001
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C — FAILURE CRITERIA
(Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.)
Backup of Sewage into Facility?
Discharge or ponding of effluent to the surface of the ground or surface waters?
j
I Static liquid level in the districution box above outlet invert?
I Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow?
I Required pumping 4 times or more in the last year? Number of times pumped
ASeptic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration?
tank.failure imminent?
Is any portion of the SAS,cesspool or privy, below the high groundwater elevation?
Within 50 feet of a surface water?
/I/ Within 100 feet of a surface water supply or tributary to a surface water supply?
I
/1 Within a Zone I of a public well?
Within 50 feet of a private water supply well?
, r
I Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools &privies only, not the SAS)?
_ 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,amonia nitrogen and nitrate nitrogen.
PART D — CERTIFICATION
INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS
�i COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399
�j
i CERTIFICATION STATEMENT
I
I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION
I REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS.
CHECK ONE:
I
I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC
�I
HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS
it STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM.
Ii I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
it 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS i
FORM.
�i`INSPECTOR'S SIGNATURE --:
' I I
II n
DATE: fly
Ii ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(d applicable),APPROVING AUTHORITY
I
r ..
z
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® Off• HEALTH
N .✓..................OF......-.......�`7'��. c--.....___.......__._......e.........
ApplirFatiou for Dispute al Marks Tomit.rurtiou rantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy" at:
. .............. .r/h��.Gr-_......... ....•................
�
a } ? on-Adde
! AP. l � / G..... _.. .....
Ow � Address�,t
..... •---------- lo..k :�..... .._.._._�.�.z ... ! �� ., r,
Installer Address
Type of Building Size Lot-,GCY....10 Sq. feet
U Dwelling—No. of Bedrooms------........ .........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ lip. of persons............................ Showers ( ) — Cafeteria ( )
P., Other fixtures ................................ .
Design Flow..........- -_.___ ---•-------_-gallons per person per da . Total daily flow....rS�G..........................gallons.
P4 Septic Tank—L gi'u capacity allons Length.-:. . Width '_= Diameter________________ Depthl')Z el.p..
W Disposal Trench—No. .................... Width.................... Total Length......_. __.__.____ Total leaching area..... .__.__sq. ft.
x
Seepage Pit No �__._-_____-- Diameter.... Depth below inlet-( --------._. Total 1 area. ..____
P -sq. ft.
Z Other Distribution box ( ) Dosing to ( ) '
'—' Percolation Test Results Performed by.. r4r, -9.....� t �!.._ . Date......
a
Test Pit No. 1 i.::tZ""_minutes per inch Depth of Test Pit.................... D to ground water�0144_.
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94 ------ ----------------------------•-.------------
Description of Soil......... Z �� ........i'vvv ......
x �.�---'----12
. - _..
-...........................................
-:;Pt•. -,e� '---- •• 1 ........
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•---------------------------•----------------------•-----------------------------------------------•--•--------------------------------------------------------------------------._.......---•--
Agr ent: )
T e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
e p ov i ns i �TI..I of the State Sanitary Code—The under ' ned further agrees not to place the system in
o ati ti r' of Compliance as een i ed by the boar of eal
... .. y.
Dat
` Ication Approved BY _ _s_._`'_I_._. `�1----------------- ..... 1 `� � '
Date
PPlication Disapproved for the following reasons:................................................................................................................
.......-•-•--•------•----------------------------------------•---•-----•--•------•---------•--------•-•-----------..._...------------------------------------------------------------------------.......
Date
2
Permit No......... - t ------------•-•-------•--- Issued-------••----- ....
-......................
D
r
s'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
A ,r�iia................OF.......::'.......... ...._..
Appliration for 14spas al Works Tonotrnrtion unit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: � X
....,r"rs.... ..../....... ✓`r� r� .
...... _ =- -----
! p' dL{ocation Address f or�Lot Now t f
i'...�,!`....� }!° 1 / t! r r',!_1 es " ! Gr �, i. s. /r?r �,✓i sst. i 7 r.
�+,r, �' Owner",-'-` ✓ C/ 1-11 �� Address �
11
a / Installer Address
dType of Building f ',." Size Lot..:': ...... :.._Sq. feet
., Dwelling—No. of Bedrooms--------- _ Expansion Attic ( ) - Garbage Grinder ( )
pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ..................................
W Design Flow_..._..: Z_________________________gallons per person per day. Total daily flow.__..._._ ....gallons.
WSeptic Tank—Liquid capacity.,..:_-'gallons Length___-------Z. Width:_'.:,�f.:._ 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
aPercolation Test Results Performed by......................................................................... Date_. fi�_i___. �,_.... �"•
Test Pit No. l.... .. _ minutes per inch Depth of Test Pit____________________ De; h to ground water_ :^ �Z:•.'_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
r ;:...... -v ----
•--•------
•-----------------------------------------------
DDescription of Soil---•-•.... '------.../.. -------- ''.• ..........................................................., st e" l. /"
x � - __r� _,G_. _________ e j _________________________
(� ='
._... = -
M ............................................. ..±...................��...........e�i...%,r ,...?'_...............?.f r.!-......-----•----------•------•-•---•............--^--------•-------
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
•... -•-•- ---•--•---•------•.......•-•.•-•--
Agr ent
T e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
e p ov'slons T TI.E of the State Sanitary Code—The undersigned further agrees not to place the system in
o ati ti 3, rti- k of Compliance has bee��ued by the boardiof health.
a / Dat
P ication Approved BY y{ .-�.:...` i_'_ - f 1 y l
-.. Date
PPlieation Disapproved for the following reasons:_................................................................................................................
.............................................•--•-•----------......--------------.....----------.....-----•••••-•-•-•--•-•••-•--••----------•---••---•-------•-----••-•------------•-••......--------•--
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................OF............. "7 '* ... .% 1' c..: :... ..............
(In if irat a of Tomplianrr
THIS ISrTO CERTIFY, That the Individual Sewage,Disposal System constructed (;d') or Repaired ( )
b i Z ,r t�!`r )i a✓ C � , , " -- ✓ err r
4,
r r . � /..a.�
Installer
at..................
has been installed-in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUE® A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..............• 5...---•--•--------------..... Inspector..
THE COMMONWEALTH OF MAS ACHUSETTS
BOARD OF HEALT� �.•
...........................................� . . OF........... ......... d , e%° _
FEE:*- ..........
Ravi 11 �on#rudioaa pernfit
Permission is hereby granted.... .....=......-••--•---•--•-•---•--•--------•-------•-•••-------••---•-•-----------•-••-•-•-....•------••.....--•-•-•................
to Construct�( ) or-Repair- ( ) an Individual Sewage Disposal System
at No............ --•••-.... C ' _�_ 't a�" ......--cis'....-...'-:..------.Str -
PP P ,, t
y o--------------------- Dated-�� -/"�--..a...............
Stree
as shown on the a application for Disposal Works Construction,, (/'^�• y '
-J
_• ---•---• Board of Health
DATE------------------------ ---
FORM 1255 A. M. SULKIN, INC., BOSTON
42-/, .Q-5 -
00�A. D,sF 13dx °; NATNAN
art , A r -
.c.
IV
� p1 A r T 1
,A
°°J I
oil
NJ � I
w � R
n smIr"( �' k6
U.•~,VT`T, �4 , '0
,' ,
yaw �o,aa 51au :4,40 Pt1( z 1 �. u ?' {�y
SEA T / l /I g S!�, 4"
LEGEND 5`0 � �v � D� r
EXISTINQ SPOT ELEVATION OAO CERTIFIED PLOT PLAN
EN181TIMQ CONTOUR --- 0 --�
FIMISNED SPOT ELEVATION LOT 9 GREhT /a'1ARSN !2�
FINJSHED CONTOUR 0
NOTE-:The location of any existing underground sewerage,
wells, or' other utilities shown on this plan. is approx- IN
imate only as determined from records and/or verbal
information. The contractor is responsible for the «Jf1
verification of the existing locations in the field. SCALE, p DATE , z 6 -5
i�DRED CLIENT.Of ENO/NEER/NO CO! IN . 1W&dbv� I CERTIFY THAT THE PROPOSED
_
ISTERE RE(i19TERED J08 N0. �ZS- BUILDING SHOWN ON THIS PLAN
� CIVIL LAND DR.BY mow,n CONFORMS TO THE ZONING LAWS
E!JGINEER RV _ OF BARNSTABLE MAS
712 MAIN STREET CH. 8Y' �ATE
,,HYANNIS., MA$S. 2 REG. LAND SURVEYOR
9HEFT,L OF
20 FT. M/N: IV Or,-, /F E/TNL=�4 THE SEPT/C TANK OR
LEACs•/110vo P/T A/tE MORE TNA/V /2' BELOrt/
/D FT MIN GRADES 24'O/AMETER CONCRETE COf/ER
SHALL ®F 6RDUFiHT TO GQA OE•�AN EXTRA
4'PYC P/PE
f�$ CO
CO/VCRLW-r i JYEAYy C^ST IRON {/�R SHALL !3E USEO .
t� M/N. P/TCN Y;
COVERS /
'/B OER N DR/YEyVA r
4 - 2 JG iyiN, CO/VCRLCTE
4 (A _ �y77�tApE CO VE R CLEAN SANG
BACXP/LL
L19VID LEYEL
'.: SCHEDUL640 G1F �I8•- 3/B"
M/N.PI N /D`�'� GAL. ° r • • • • • • • • p •e0 `yASHED S70NE
%q•Pex PT SEPTIC TANK DIST, •ve • • • • • • • • e .
BOX314
• • � • r e • • � .••
i o EFFECT%VE e •
• r • • DEPTH • • • v o WASHED STONE
• v • • • • • • • • -
.. PRECAST SEjSr-AaE
INV4wXT &4EVA7/4ONS - 75
Cr c
INYERT AT QUILDlNG l 02•D FT.
INLET SEPT/C TAFNK 0 ;-(s FT, %o_ F7 PIAM. C CIF T�`�Bul.4T1oN>
OV 74ET SEPTI C TANK
i INLET DISTR/8!?/ON BOX ` �' FT GROuNo NITER TiISLE
SECT/ON O F
Ot/TLETDI57W1D&fT/ON BOX 2 F7 SEI�VAGF CIS®SSA L. .SY.STEM
/NLET LEACH/Na PIT to,-? FT. -rAJU✓LAT/ON
L EACH/N! o/T ,a
DIMENSION 3 FT.
SCALE V
DES/6IV CRITERIA DI>+fElvs/o N �f �--f'T•
D/MENS/ON C 4—FT.
/vUAfSE'R OF EEDROOMS 3 1 a
GARGAGED/SPO.S•4L UN/r N/4 SO/L LOG
TOTAL EJ'Tft4Wr,ED FLOH1 33 o G.4Z.1DAY SOIL TEST ! SOIL 7FST*2 SOIL TEST ,
NUMBER Of Y.-ACNINT: P/TS � SO IL TEST
pAEOF 1P•� 3� S
S/DELeACHJNG PER P/TSQ, FT. fZ-E� �� c -�;
Z ; RESULTS 1dITNESSED dY ,
40TTOML.64CY//VGPERP/r-7-5 FT. PE�tCOL�1F/ON /IATIF / - M1I1r�IINCH
�.
TOTAL LEACNI/VG AREA 267 o SQ, FT. _ PENCOLA7"ION R.�TE 02 MIN.�INC�I
i RESERVE LEACHING AREA �'��••=�$Q, FT. •` °$ "-�'- �
NfJ 9 /
�A Fw. �s � < Sid;•, _ .
PH!. P _.,
�1.OR€D6E•,E79AGIN�RlNU CCZ,fNG.
.e No. 36 G MAIN 9T, HYANNIS. MASS.�O GAS�EftGta/'; a..i'r a i. _..-� 7t�.
NC GROUND YYs4TEe� terNCOUNTL�R�O G'L/ENT �oz*�SrA +F k o ptTE•'�6 6/`
A G/ri 0 LINO kVA TER AT FL Et!
JOB /VO_ �L+ �y5 �rEEr�OrF .3—
TOWN OF BARNSTABLE
LOCATION Rom' SEWAGE #
VILLAGE ��'�� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY,/0�� ��
LEACHING FACILITY: (type) (size)
NO,OF BEDROOMS
BUILDER OR OWNER (a
PERMITDATE: ���� `� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ;i Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�� y�j
1.ASSESSOR N
MAP :
P :
o --lQ _- --- -- TEST HOLE L E L O G S
PARCEL:
SOIL EVALUATOR
FLOOD ZONE: _`/<1U7"_. ✓�i '.- �`S �G _ ------ WITNESS : 01
-�'
4T REFERENCE DATE : NOTES:
` � 1 ----- _._.._. C --` - 9f� — PERCOLA ION RATE :
1) The installation shall comply with Title V and Town of Barnstable Board of
TH- ! TH-2 Health Regulations.
ZX ,,n 2) The installer shall verify the location of utilities, sewer inverts and septic
components prior to installation.
3) All septic piping to be 4 inch Sch 40 PVC at 1/8" per foot.
T 4) This plan is not to be utilized for property line determination nor any other
purpose other than the proposed system installation.
LOCAT I'O N MAP64 T ��, 5) All septic components must meet Title V specifications.
(� A�'�°Go�' .1
6 g Parkin .shall not be constructed over H10 septic components.
7) The property is bounded by property corners and property lines as depicted.
shall review i n onsi considerations to approve of total number
8 The property owner shades c d e
Yg pp
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p pt �� of bedrooms to be considered for design. Receipt of payment for the plan and
" "' Z � � L installation based on the plan shall be deemed approval of the number of
l �' `� ,� bedrooms. pp
I, '� I ` ' L nn,,�''(n� ,'1i' 9) The existing leach pit shall be pumped and backfilled per Title V Abandonment
! Procedures. i
10 V 10)Existing septic tank to be evaluated and must be a minimum of 1000 gal. and in
/ SEPT I C SYSTEM DESIGN condition meeting requirements of Title V.
FLOW E$T I MATE
1 a 1 �
,
BEDROOMS AT 1 GAL/DAY/B DROOM t�GAL/DAY
S'� I C TANK
l
GAL/DAY x 2 DAYS - GAL
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USE r GALLON SEPTIC TANK --�tk< , � --- --
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'1`
SO iL AE150RP ION SYSTEM
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SIIDE ARE
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BOTTOM ARE A: '
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./ SEPTIC SYSTEM SECT ION
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. n. , 6,,. SITE AND SEWAGE PLANao �'s LOCATION : 4Z(o
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PREPARED FOR :
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SCALE :
W r DAV I D B . MASON 'ZS DATE: /2
y. DBC ENVIRONMENTAL DESIGNS
EAST SANDWICH . MA
DATE HEALTH AGENT ( 508 ) 833- 21 77
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