HomeMy WebLinkAbout0080 GUILDFORD ROAD - Health 80 GUILDFORD ROAD, CENTERVILLE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is required for Crnterville Ma. 02632 11/29/2008
every 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: A. General Information
When filling out
forms on the ,y� jq (�
computer,use 1. Inspector: 'tf I s(Oa
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
� P.O.Box 763
Company Address
Centerville Ma. 02632 .
City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
--- Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
11/29/2008
Inspe ors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
ILIo
t5ins•09/08 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2
3
t
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is required for Crnterville Ma. 02632 11/29/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in porper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2
T
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for 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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is required for Crnterville Ma. 02632 11/29/2008
every 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:
❑ E - Any portion of the SAS, cesspool or privy is below high groundwater elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
_ necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
❑ ® this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
El ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual):
3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
330
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G M , 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is required for Crnterville Ma. 02632 11/29/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1000 gallon septic tank,Distribution box and four 3050 chambers.
0
Number of current residents:
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? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2008:14,000
g ( y g (gp ))' 2007:30,000
Detail:
2008:38 gpd 2007.82 gpd
Sump pump? ❑ Yes ® No
7/01/2008
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? - ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for
every 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:
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for
every 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:
New leaching installed 2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2011
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage.System vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: feet
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
T Dimensions: 1000 gallon . .
411
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
2"
Scum thickness .
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GM , 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for
every 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 ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of hydraulic failure.No
evidence of leakage into or out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
_ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is required for Crnterville Ma. 02632 11/29/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4-3050's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Chambers were dry at time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-.09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for
every 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):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Official Ins ection Form:Subsurface a Disposal System•Page 14 of 14 Sewage t5ins•09/08 P 9
• Map Page 1 of 2
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is Crnterville Ma. 02632 11/29/2008
required for
every 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: Bottom of 3050's 60'
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:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data. USED:Technical Bulletin 92-000-01 plate#2 annual ranges
of groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Guildford Rd.
Property Address
United Methodist Church
Owner Owner's Name
information is required for Crnterville Ma. 02632 11/29/2008
every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
No. Fee S �
i THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
• Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for �Dfgpogal *pgtetn Congtruction 3pertnft
Application for a Permit to Construct( )Repair(Y Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. 900,&y/ V�_,/ Qd Owner's Naame,Add s�/nd Tel.No. rn/1 �0
v/i�/V Pcp///�pr;;S`r ` �/uV C a$//
Assessor's Map/Parcel �a , r�s^7
In tall i N e, dre d Tel.No. Designer's Name,Address and Tel.No.
��Nc�ti � 'e� s�syv�
ems- PoA,01 sq. OSTO :,��=
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other ` Type of Building c No.of Persons Showers( ) Cafeteria( )
Other Fixtures
l
Design Flow gallons per day. Calculated daily flow ��O gallons.
Plan Date Z'A Ay Number of sheets Revision Date
Title
Size of Septic Tank /600 Gel Type of S.A.S.._7v NA�6
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 i u by this of Health.
S' ne Date �0 0
Application Approved Date ®f.
Application Disapproved for the following reasons
oe
Permit No. �o�Z Date Issued (10
———————————————————————————————————————
vj
jNo. Fee;
,rTHE COMMONWEALTH OF MASSACHUSETTS Entered n omp.te,.. Yes
PUBLIC HEALDIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplica.tion for Migogar bpgtem Construction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components '
Location Address or Lot No. gro, GL Teo vri QdCQM Owner's NV;n Add ss d Tel. oo.
Assessor's Map/Parcel / 9,; OS~
Installer's Nge,,Aol li, hd�No. am- Designer's Name,Address and Tel.No.
/ SP uvrltCo" T OSTo
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 33 gallons per day. Calculated daily flow �O gallons.
Plan Date S le, `! 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) NP Sl, ,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this a- d of Health.
S'gned Date
Application Approved b ^J Date
Application Disapproved for the following reasons
Permit No. 1 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( )
Abando ed( )bye -
at �) 64I)`_0 � has been constructed/in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. w`"I_771 dated 6 /1/6 N
Installer Designer—'-- -
The issuance of rrthis permit shall not be construed as a guarantee that the syste _ 'illy functio ®designed.
Date W (+)f u Inspector �
No. -------------------------Fee
-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
'Wi5po5af *pgtem Construction Permit
Permission is hereby g.an ed to Construc )Re air grad(n )Abandon
Ylocated,
( )
S stem located, y U 1 `` �
_
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:Constroction must be completed within three years of the late of this rmit.
Date:_ (D I Approv, b
TOWN OF BARNSTABLE
LOCATION 90 O' SEWAGE # &0 7/
VILLAGE e ASSESSOR'S MAP & LOT/
� v I
INSTALLER'S NAME&PHONE NO. J d_ M /A j4.a
SEPTIC TANK CAPACITY �4/
LEACHING FACILITY: (type) !/r PAo c_ !�, , (size). M X >3 X 2__
NO.OF BEDROOMS 3 11 II //
BUILDER OR OWNER UMI t4d �PY�e qp� �o'!u d-c4
PERMITDATE: �6601Jd Y COMPLIANCE`DATE:
Separation Distance Between_tbe:
Maximum Adjusted Groundwater
\Thble to the Bottom of Leaching Facility s / +� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) &,y 49u Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 fee f leaching i 'ty) A f � Feet
Furnished by
I
te1')*,0Af 4e- At
AMC, 15 r1
7 64'
,� r'
ae st��
r
r
Town of Barnstable
, '"E Regulatory Services
Thomas F. Geiler,Director
BARNSrAI`E'g Public Health Division
Thomas McKean,Director ,
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer &Designer Certification Form
Date:
Designer: '0 me 'Z Installer:
Address: 4$ P C,,on�I @�Y- �-J Address: ^,/95- /'an,,d 5 r
-- nfertit-6 & 1-0 V --
On t a m 6M / 1 A -�1�, was issued a permit to install a
(date) (installer)
septic system at based on a design drawn by
(address)
dated C 61, 5,1,
(designer)
ertify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
10 OF iNgs�Nlr,-p
STET
R.
( staller' a e) N
No,6Z7
h�_
esigner s e) (Affix DesiORMWMarrip Here) .
EASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
QF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Qs Health/Septic/Designer Certification Form
TOWN OF BARNSTABLE
LOCATION 90 (gut ua SEWAGE # ZOW J-,�
VILLAGE 0gwfeeV J & 1 ASSESSOR'S MAP & LOT/?a �y�7
INSTALLER'S NAME&PHONE NO. J e h M ��►e��I�y
SEPTIC TANK CAPACITY a
LEACHING FACILITY: (type) (size) >D X iv7 X :a_
NO.OF BEDROOMS II /
BUILDER OR OWNER U"i 1.ecl
PERMITDATE: -41Q 116 Y COMPLIANCE DATE: 1/v.10 y
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S / Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Z_utAv 494 6- Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 fee f leaching i 'ty) Feet
Furnished by
- t
lv,
11
f
DATE:_5/6/95
PROPERTY ADDRESS:__80 Guildford E_Qa_d
Centerville,Mass. 02632
------------------------
02632
------------------------
On the above date, 1 inspected the septic system at the above address.
This system consists of the following:
A. 1 -1000 gallon tank.
B. 1 -1000 gallon leaching pit.
Based on my inspection, I certify the following conditions:
A. This is a title five septic system ( 78 Code )
R. The septic system is in proper working order at -the
present time.
SIGNATURE:
N a m e:
Company:J.P.MAcomber & Son YNc.
Address:_BQx_6.C:-------------
_ Centerville Mass__02632
Phone: 508-775-3338
---------------------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
1
° JOSEPH P. MACOMBER & SON, INC. Y
Tanks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Ceo:arville, MA 02632-0066
775-3338 775-6412
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property SO &utL_VroP_D �_oAC> CaKxTE:0_%itLLC
Owner's name h+tb 'Pr2A.T;
Date of Inspection
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
y -None of the system components have been pumped for at least two veeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
r 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.
The facility .or dwelling was. inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
The septic tank manholes were uncovered, opened, and the interior of'
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined used
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.
OF e cuc).M f n CvU D AZ 1C�
(.• Nl 0 V E rid 13A6C D i 5 PO S*a,c� 1 T`,t I LC-•
k2 E 0 0GC C L 1 �=E 6 FA, sy sTr-� .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
3 number of. bedrooms
number of current residents
garbage grinder, yes or no
laundry connected to system, yes or no
O seasonal use, yes or no
If nonresidential, calculated flow:
12 /9 Z{ �, 37,000 zo•Z GFID
6/9� Z5, OOo = 15-7 G PZ> V Ems(
Water meter readings, if available:
l 2�J3 ', 37, 000 'z.o'z G P D L i rE
n�J US V
1 E-4`TL �'�J3 '• �
Y Last date of occupancy
(f:)LLU 91 Et7
- GENERAL INFORMATION
Pumping records and source of information:
MOXJ - O AJ 2
System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping: .
A e:r OF
Type of system nice-a� -
Septic tank/ /soi
Single cesspool l absorption system
Overflow cesspool
Privy'
Srecor ,haredssyifem( es or no) (if yes, attach previous inspection
Other (explain) ,
Approximate age of all components. Date installed, if known. Source a of
00 Sewage odors detected when arrivingat the site,
e, yes or no
r
i
• 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:_
(locate on site plan)
depth below grade: l8 TO ZA
material of construction: _concrete ' metal FRP other(explain)
dimensions:_
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of 'outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
DISTRIBUTION BOX:
(locate on site plan) .
depth of liquid level above outlet invert
Comments:
(note if level and distribution is *equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER: MO
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
10 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : ✓
(locate on site plan, if possible; excavation not re approximated by non-intrusive methods) required, but may be
If not determined to be present, explain:
Type
leaching pits and numberTK
leaching chambers and number bcccv4 Gem
leaching galleries and number �� CP,�cc
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations:. for maintenance or repairs,etc. )
IIJ O -SIGI�4 5 F I�YPt2�4 VLiL FAQ LU i2C�
U E'2.A C.C.. LoO1C 5 (zOp
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of .cesspool
materials Of .construction
indication Of groundwater . __ ____
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition. of soil, signs of hydraulic failure, level *Of ponding,
condition of vegetation, recommendations for maintenance or repalrs,etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition •Of soil, signs of, hyd:aulic failure, - level Of .pondin `
condition of vegetation, recommendations for maintenance or repairs,etc.
r'
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 l00 '
Fr2�l:.LT �►G HT C.�xS..
'�'�ur.iT cSTEPS
24�
GU I
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
�zo1.f L VC
� 2� 5
y l AVSA2 QsnT )e>LE
SEA
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
�y Backup of sewage into facility?
Discharge or ponding of effluent ' to
o the surface surface waters? of the ground or
Static liquid level in the distribution box above outlet invert?
�Q Liquid depth in cesspool <611 below invert or avai
flow? Table volume< 1/2 day
Required pumping 4 times or more in the last
number of times pumped year.
Septic- tank is metal? cracked?
infiltration? substantial exfiltration?a tank lly ufailure imminent?
al
Is any portion of the 9SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a su rface water.
CVO within.-100 feet -of a surface water suppl tributary water supply? _. Y or to a surface
No within a Zone I of a public well?
within 50 feet of a bordering w vegetated
(cesspools and privies only, g wetland or salt marsh
not the SAS)
I0 within 50 fe
et of a private water supply well?
t"o less than 100 feet
but greater than 50 feet from a
supply well with no acceptable water quality analysis?VaIf thee
w
has been analyzed to be acceptable, attach co
for coliform bacteria, volatile PY of well water analysis
and nitrate nitrogen,- organic compounds, ammonia nitrogen
i
SUBSURFACE SEWAGE DIS'POSAL INSPECTION FORM
P---R, D
�,- I`J
CEr;
Inspector : Peter Sullivan PE
Location : 80 Guildford Road Centerville
Date : May6,1995
Certification Statement
I certify that I have personally inspected tl v-3 :.a disposal system at this address
and that the information reported is true, <_::-;. ;:.i and complete as of the time of
inspection. The inspection was perfor; ; _' :.recommendations regarding
upgrade, maintenance and repair are car : ;:.1:,;:i vvi h my training and experience in
the proper function and maintenance of on.- r,,,0e disposal systems.
have not found any information which inclic:;tcs that the system fails to adequately
protect public health or the environment a c'` lined in 310 CMR 15.303 . Any failure
criteria not evaluated are as stated in the F:I�_.;!_J,?'RE CRITERIA section of this form.
Please note the summary.. of recomme;r: ,;,- -.s cs;onted in this form.
truly yours
eter Sullivan PE
Distribution:
Original to system owner
Buyer
Board of Heath
dr�,
44
J
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i
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7
Z�1,41 ,VZ cr f
J L D D 0 D
s-Z -.61-4 -.--Z
-4
Y.L,
45
e-k—
,7/
110 —7;7
14 s T
CQT
144n C,�j
7<_ z ;
L 761
46
morlwm"Mags wi"iff Raw rz
TOP OF FOUNDATION
-7
All CONCR=lr_
7, 10 W . ... ..
4-CAST IRO 9
OR SCHEDULE 40
4 SCHEDULE 40 P.V.C. (ONLY) t
P.V.C. PIPE MIN. PIPE- MIN. 91"MIN LEACHING TRENCH
PITCH 1/4-pER.F-C 36" MAX.
-pc 1/2" WASHED STONE
PITCH 1/4 -�.F7.
X1z
... . . .. . . .
xv GAS
0 0
E L
E 6
SEPTIC N K a a
INVERr.-Y M=66�.f.z , --I a I
TA 29
4:5— 7— GAL.. INV-
D'ST- INV=-;q7-J
BOX
6"CRUSHEZ! STONEM
STONE-i
7 7
PROFILE OPA
. 717 lk' GROUND WATER TABLE =,vl
SEWAGE DISPOSAL SYSTEM
SOIL LOG
DATE TIME NO SCALE
TrEs, MOLE I Er HOLE Z
;ELEV,.�- DESIGN DATA
NUMBER 0= B Z-R 0 0 h,.S
T
t Y' TO AL MA7Z:) FI-OW GALLONS/DAY
B=70161 LZACMING AREA
.......... ... SO.F7/1-RENCH
SiOt LEACHING AREA 3Q.FT./TRENCH
R
GARBAGE /61,it�7 0
SAL AZA &'�AiAiz) %4
TO7,AL LEACX.NG AREA ,P,17
PERCOLA7,10N 'PtR.INCH CHI
T L
TE L L
i I LEAc` N G AR EA PER PERCOLATION P.;:T-Q
rig.
GROUND 'tV,:77ZR 'M3L!
AP ROVE)
BOARD OF HEAL7Mri
.&,r_WATZR ENCOUNTER=:) OF
WITNESSED BY . AGENT OR OR
BOARD O;r cn
ENG I N EER
s
-7 00
1710N=R
f P
--—— -----------------------------------