HomeMy WebLinkAbout0039 HEADWATERS ROAD - Health 39 HEADWATERS RD. Lot 2 _
CENTERVILLE
A = 228-046-002
No. 42101/3 ORA
ESSELTE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 6-10-14
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:When filling out A. General Information
When
forms to thecompu (�
only the
tab
1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return p
key. DOUGLAS A BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA
Cityrrown State 02632
Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this addrr and thane
information reported below is true, accurate and complete as of the time of the inspection. Thi insp'estion
was performed based on my training and experience in the proper function and ►?ai)ttenancevf on
sewage disposal systems. I am a DEP approved system inspector pursuant ta-S�ection 15140 ofn
Title 5(310 CMR 15.000).The system: ,
® Passes is
❑ Conditionally Passes ❑ Fails _.
h f1
❑ Needs Further Evaluation by the Local Approving Authority
r:;-
6-10-14
Inspector�ignature 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.
V
!Sins•3/13
Title 5 Official Inspecti o Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
every page. Citylrown 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:
S.A.S WAS DRY AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS AT
TIME OF INSPECTION
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-3/13 Tide 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
C
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distrit�ution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspedion Forth:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owners Name
information is CENTERVILLE
required for MA 02632 6-10-14
every 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:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3/13 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
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
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:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'< 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 3
500 GALLON CHAMBERS SYSTEM DEEP DUE TO BASEMENT PLUMBING
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2012------93 GPD 2013------107GPD
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
• Commonwealth of Massachusetts
W Title. 5 Official Inspection ection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
C.O.0 ISSUED 11/6/1996
Were sewage.odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
El cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 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
Dimensions:
1500
Sludge depth: MODERATE
t5ins•3113 Title 5 Official Inspection Forth: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
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
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
Scum thickness LIGHT CLUMPING
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
RECOMMEND PUMPING EVERY 2-3 YRS
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
U. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
every 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.):
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
i
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`t 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ 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.):
CHAMBERS WERE DRY AND SHOWED NO SIGNS OF FAILURE 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M �t 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
every page. Citylrown 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.):
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is CENTERVILLE MA 02632 6-10-14
required for
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
v a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
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: 12.5
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: 6-2014Date
❑ 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:
DESIGN PLAN
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
< 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 6-10-14
every page. Citylrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
L 06.6 e b ht'`_l -
- OF BARNSTABLE
LOCATION `tom C SEWAGE #
)14 1 wi to
VILLAGE t--,t-i �,/r 1—� ASSESSOR'S MAP & LOT
:a r� CesJ� l S l r��s INSTALLER'S NAME&PHONE NO.�e���U�B-'r i r,,�C s "7
�S �� t ti� aak, SEPTIC TANK CAPACITY ►� d�-�mil_
LEACHING FACIL=: (type)
(size -
NO.OF BEDROOMS
\ BUII,DER OR OWNER_ S- 0— -=C-c.C -L-!c,/A-L(
~t,d,C 1 SSc3 P:�J L I
PERMUDATE:T k� COMPLIANCE
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (Ifany 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
Cf
f
I o�.
3 3L`
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
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:
When filling out A.A General Information
W
forms on the �� D
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not use the return Name of Inspector
key. DOUGLAS A BROWN INC
Company Name
rQ P.O. BOX 145
Company Address
CENTERVILLE MA 02632
City/Town State Zip Code
508-4204534 S 14297
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 I
Inspector'OSignature Date ;;1
The system inspector shall submit a copy of this inspection report to the Appr�Lng Authority ward
of Health or DEP)within 30 days of completing this inspection. If the system ii a share"yst or
has a design flow of 10,000 gpd or greater, the inspector and the system ownbr shall submit
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
"*"*This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09=
Title 5 Official Inspecti6M1 Fo dace Sewage Disposal posal System•Page 1 of 17 ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. Citylrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
SYSTEM IS VERY DEEP BECAUSE OF BASEMENT BATHROOM, LEACH CHAMBERS WERE
OPENED AND WERE DRY AT TIME OF INSPECTION
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):
t51ns•09= Me 5 Official inspe
ction Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes(cunt.):
❑ 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
Fins-09M Title 5 Olficlal Insp
ection 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
r 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins•09108 TdIe 5 Official Inspection Forth: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
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. cityrrown 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.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09MB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
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.
❑ ® 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): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins•09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owners Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO DESIGN PLAN SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 3
500 GALLON CHAMBERS SURROUNDED WITH STONE
Number of current residents: 2
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 years usage(gpd)):
Detail
2010----208 2011 268
Sump pump? ❑ Yes ❑ No
Last date of occupancy: CURRENTDate
Commerciainndustrial 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•09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. Cityrrown 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
rP Y
❑ 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 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owners Name
information is CENTERVILLE
required for MA 02632 2/15/12
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:
SYSTEM INSTALLED IN 1996
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑cast iron ❑40 PVC ❑other(explain)-
Distance-from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
®concrete ❑metal ❑fiberglass ❑ polyethylene
y El 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: 1500 OFF PLAN
Sludge depth: MODERATE
t5ins•09108
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? WOODEN 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.):
RECOMMEND PUMPING EVERY 2-3 YRS
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
t5ms•0901 Title 5 Official Ins
pection Forth:Subsurface Sewage Disposal System•Page 10 of 17
1
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is CENTERVILLE
required for MA 02632 2/15/12
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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•o9m Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
BOX LEVEL NO SIGNS OF LEAKAGE
Pump Chamber(locate on site plan).
Pumps in working order: ❑ Yes ❑ No
Alarms in workingorder:
❑ 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Properly Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ 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.):
CHAMBERS WERE OPENED AND WERE DRY AT TIME OF INSPECTION WITH NO SIGNS OF
FAILURE
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
t5ins•09= Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 14 of 17
c
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ms-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12 .every page. Cityrrown 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: 12.5 FT
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: 2/15/12
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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ms-09108 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
39 HEADWATERS RD
Property Address
COGGESHALL
Owner Owner's Name
information is required for CENTERVILLE MA 02632 2/15/12
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 17 of 17
OF BARNSTABLE e
LOCATION SEWAGE # /�"
VILLAGE - - o (J ASSESSOR'S MAP&LOT J 2� Cyr m9;
INSTALLER'S NAME&PHONE NO. - cnz dZ�i 1 Cam[S� -I 7i-
SEPTIC TANK CAPACTTy ! e7O-6At--
S LEACHING FACILM: (type) CAA-- (size
12 1 -IG NO.OF BEDROOMS
i
\\ BUII.DER OR OWNER
,C 1 s s e:.0 l t G I qC, PERMITDATE:— — COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If-any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
23
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=228046002&seq=1 8/23/2017
00
No. (t+ ' /J�V Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[ppYication for Migogal bpgtem Congtruction Vermit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. pj 2 Owner's ame,Address and Tel.No. �J
Assessor's Map/Parcel
e�l4q Rob ol-r Cal 9S`411 9
Installer's Name,AddS,and Tel.No. Designer's Name,Address and Tel No. 7- 72 72,
133 ql ne.& r ieX 6e
Type of Building:
Dwelling No.of Bedrooms — Garbage Grinder( )
Other Type of Building 4�1 No.of Persons Showers(/ ) Cafeteria( )
Other Fixtures
Design Flow� � gallons per day. Calculated daily flow gallons.
Plan Date e%?T i �Z Number of sheets Revision Date
Title
Description of Soil " /O f/ w 17 i O e e— O r
�- !U ii
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 y and eal
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. �/� — /� Date Issued —
00
No. /0 7 l/ V Fee
THE COMMONWEALTH OF MASSACHUSETTS
f ` PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Rppriration for ligpogaf bpgtem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. L,d j Owner's Name,Address and Tel.No. Py
Assessor's Map/Parcel
Installer's Name,Adds,and Tel.No. Designer's Name,Address and Tel.,No. / 77 /2 7�
7 Mori _'c_f>1q, ,,f ,
133 q1-iz&7'h ►2a1. 11, 46e
Type of Building:
Dwelling No.of Bedrooms —�— Garbage Grinder( )
Other Type of Building 4X�DG� No.of Persons 3 Showers( /) Cafeteria( )
Other Fixtures
Design Flow Q gallons per day. Calculated daily flow gallons.
Plan Date Se Pl' i Number of sheets Revision Date
Title
Description of Soil ti -- 1G�� Q l' G if 1 G l C0 — U G9 rr7 S rl
Nature of Repairs or Alterations(Answer when applicable) ;77>
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 y oard ealth./'r ------
Signed Date �7
� Application Approved by DateLj 1-3
j Application Disapproved for the following reasons
I Permit No. er Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certifirate of Comphance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( )on
by Installer
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. q l- W/ V dated
Date Inspector c
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
----------------------------------------
No. /2 �l Fee 1
< r
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
30igpogar bpgtem Congtrurtion Permit
Permission is he pby granted to
to construct(\/5repair( )an On-site Sewage System located at No.#
Stmet
and as described in the above Application for Disposal System Construction Permit.
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed with' three years of the date below. /
Date: t !l' v l� Approved by 1 . �
Board of Health
f
• `r � OF BS�RNSTABLEE a
LOCATION ' t + SEWAGE #
VILLAGE - i ASSESSOR'S MAP & LOTjl .Oyu �X
INSTALLER'S NAME&PHONE NO. y�Z d'L1�-t i i dka! — -7"rl_IsM
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 6t4— (size3- �
NO.OF BEDROOMS -b,zyLJ �-�
B� UILDER OR OWNER
PERMIT DATE:_ 'I �COMPLIANCE DATE: I/ •• / /
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on'site or within 200 feet of leaching facility) Feet
Edgelof Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furr4hed by
Tot Co O I
d�3 3�p
N 81 FEF.4p.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/45p.� �......OF..... ... . . .......... . ... .. ...........................................
Aplifiration for Mipaiial Works Tonstrurtion thrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Sys .,.
.......
catio dress No.
lAvla... ...... ...........
0 er wn C7.— Address
.... ......... .. .. .. ..... ........t....... ..................................... .................................................................................. .............
Insta e Address
Type of Building Size Lot .......Sq. feet
U I' ..
Dwelling—No. of Bedrooms............................................Expansion Attic /Ur'; Garbage Grinder
P4 Other—Type of Building ............................ No. of persons.....................__._._. Showers Cafeteria
Other fixtures ..... .......� _
...............**........... Total----------------------------------........*..........**......*---------*--------
Design Flow............................. per person�.r day. 4;�Ky flow... ....-3.0.................gallpris.
Liquid capacit;V00jallons Length.. Width.Y.i�5.. Diameter................ Depth..4—,.<_.
1:4 Septic Tank
Disposal Trench—No. .................... Width ....... Total Length..........I........ Total leaching area...................sq. ft.
T"
> DiWeter.........9...... Depth below inlet..o!�!� ........... Total leaching areae�..Z..6.jC...sq. ft.
Seepage Pit No.............�--?...
Z Other Distribution box 4-)-' Dosinge ( f1d_
Percolation Test Res Performed by..... la_l�. ...1F.W::/4
�'S'7_ r ... Date.
Test Pit No. 12�.........minutes per inch Depth of Test P6........... ..... Dept to ground water.l�...
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._._................_._.
P4 /............4....... ................k 1-----
.W Z 7PW lgw�....5 0 Description of Soil...........6*::77.�....I......"5 .-(:�....... AW
............................
................................................. er. ........... . . . ..................................................................................................
U ....*'# -------
........................................................................................................................................
-----------------------------------------*....... --------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned g es to install the aforedescribed. Individual Sewage Disposal System in accordance with
the proviM• ns of L'I',P ' 5 of the State Sanitary C e—The undersigned further W ees not to pla in
the syster4 I ,He
alth.,ed
operati un e ij to of Compliance has be -su 0 0
...... ..... ............ ............ ........ ..... ....................
a
in ove By....... ........... ..... .........................................
App ................................... ........7..... ..... ...........
Date
Appl` tion Di pproved the f owing reasons:........... .................................................I.....................................................
........................ ............ ..................................................................................................................................................................
Date
Perit No......................................................... Issued.......................................................
Date
-------------------------
12-31 -
........A-7....... FA..V........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.,r.�
......OF..... .. ........... ......................................
Appliration for Uhipoiial Workii Tong1rurflott runfit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Sys�t=�...
----------
..............................................r .../
or Lot No.
CA 7_CAI
ow. ;..K;L/............................. ...
Address
.... ............
----- Ins't'a C---//................................. .............................................Address.s.............................
Type of Building Size Lot.__ kZ.)..Sq. feet
Dwelling No. of Bedrooms.............................................Expansion Attic A)VI Garbage Grinder
Other—Type of Building ............................ No. of persons___......._.........___.____ Showers Cafeteria
Other fixtures .
Design Flow.................................��_gallons per person� day. T o t aI * flo w . Z . gaIIo ns.
1:4 —Liquid capacit/ ... Width.A�e�lWSeptic Tank gallons Length-- z.' .- Diameter................ Depth.4---
x Disposal Trench—No. .................... Width__.. ......._......
............. Total Length._............_....
. ... Total leaching area....................sq. ft.
> Di eter......... Depth below inlet.ZT.*.... Total leaching area,;Z4j,��. ...sq. ft.
Seepage Pit No--------------------- am
Z Other Distribution box Dosing.8nk
Percolation Test Results Performed by...... ..Y)-r . .... Date..//
�--4 , - �7 ...
...�_..minutes per inch Depth of'�T t'Pit No. Test PW...j1d Depth to ground wateio.v �:J
W Test Pit No. 2................minutes per inch Depth of Test Pit..._............._.. Depth to ground water......._............___.
P4 ----------------------------------
---------------------"------------**"*-------- ------------I------
--- -------
0 Description of Soil......... .0-- .. .......
eY..,d '54.,r. .....14.... 1�;P__ 1�w
7_
...................................................... ....................................................................
U ---------------6--------
W
...................................................................................................................................................................*------**........
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.......................................................................................................................................................................................................
Agreement:
The undersign agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the PAVIslons Of T 5 of the State Sanitary C�a e — The undersigned further place in
,M rees not to ace t
ope io tificate of Compliance has be ssu tKie b9aa/nd`'
of health.
.......... .......... .................................... ..................... ... ...... .....I...........
1* to pproved By..'. ... .......... ....... ...... ?................................................. .......m................................
7 Date
pplication th r Disapproved/�,ef� the flowing reasons:..............................................................................................................
.........................................................................................................................................................................................................
Date
�Permit No......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(Irdifiratr of Tomphatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or�Repaired
---------------- --------------------------------------------------------
--------Installer
................................................................ .... ............
at . . ................ ....
he State Sanitar
has been installed in accordance with the provisions of T it in the
application for Disposal Works Construction Permit No.ft�w............. date2p XS-7/49
...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM W14 FUOICT,ION SATISFACTORY.
DATE....1.Z Z. ................................................ Inspector................ ------------------------------------- .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................0 F.....................................................................................
N ..... FEE........................
Permission is h -b ed.
_D�pe y grant .......... ..... ...............................................................
to Construct-(--ej� lair an df rhial JX.sposal E , vi,
at No......... ...��7 j........... 1�44 a-_-
�6�
. . .. ......... ........0---------------
Street
as shown on the application for Disposal Works Construction Permi . . . . ........ Dated---- - ------------------------
Str et
e Mi 0. - ------
r --------;.........................
............ --------- ----- ....... .......... ...................
DATEA�---Z%fll................................................. ....----------------- ------Board o,f H,ealth
FORM 1255 A. M. SULKIN, INC.. BOSTON
51 W GLC-. FAmtLY - :6 BCOR0oM N
ij ►.1D.GA �gAGE GWNDER. / r- �..:
II t»1iy FLovy
5EPT1G TP►JK s: 330xl50% = 49�;6.P0
U54= l 000 GAL.
,I D15POSAL PIT V5E too GAL. 9 919
�� 5►pG Y�AIL ARCla =
BOTTOM AREAS .�0 5F• � <� i �•
�jC' S.F X 1. 0 A 5p
-7 OT A 6- P E 51(IN .g 2 5 CG.P D. n :p0 �� it,�`?7�" T I
II ToT AL TEA►LY FLOW - 33OCRP. \ ' � �` '9 • �x �•� � •
1. s
�I PE2c.oL.ATIoN RATES I''IN 2MM DP-1-5f55 ->.W,-�.-.•, ` ;
91•
,
o �-6 '
OF MqS�,. � T 9
icy AM OF Mqf 178�p 96•f
v WILLIAM
H V� S'9
C. ALAN _ � t/ /`'"G l
,I Iv N Y E . T�
Na. 19334 0 JONE5
'f� F '21!o. �100
Q�BT��' pQ• .� .,
s�1z
1 yyV r a
I
I
T
'Top FNU= •99-0
►oov INV.
DIST• INS. GAL, �S
SCPTIG
j� l o0o INY. % -rn•NK
- LEa�N
PIT INV. INV.
�c d,✓ WITuJr
WA(.,NGD
'� 6TvN6
. 7
!i GERTlF1EP PLoT PLAN
�.-
li NO• SCALE SCALE /': p' �ATa /Z//5/o3
PL_P.N REF6ZENGE
1 GE QT1FY THAT -TNT PL'1>I�St� NS�,5NowN
' K6.R�0►.1 GOMC�L`(5 YJITN-[HE S I c?�L1►J ,moo,- 3
I A►� 5 6'T�.GK R.6 Q v 1 R.E M E
Zo W►� O F BAZ K s-rAoLe AND l S
LocAT D WITH1►J T46 GL.00D L
DA-Ir E 12 I`� LBAxTEcz.e ha`(E INS•
REG I ST�2ErU'1-AN 0 S U 9•Y
THIS PLati 1 NcrT Cat\ =7�
b AW os-rEczvILLc- - MASS.
IN5.r?-UfA6NT Sv2V1:Y 6 -TH o1=FSE'T5 SUouLD I
No-r 5C- 'v5ED'TO C)e7F- !^I►-►� L•�T -INES APPLICANT 7'�4�'f�S /
S YS TEM PROFILE
NOT TO SCALE
FINISH GRADE
TOP FNDN.
EL . �'��" FINISH GRADE OVER OVER TRENCHES
FINISH GRADE 7G. o FINISH GRADE OVER DIST. BOX �i .7
°,a o° SEPTIC TANK
12" MAX.
k c o.4
a o.4:Q. •.., .•Q.a+Rd :4'::Q•o'6•'0:o'•P. A.YrIgp'.*.d " b'' • a' '
4 a. TO TA L L ENGTH OF TRENCH
n•,'0'.Pe ® ,� OUTLET PIPE LEVEL
3 :p: FOR 2 FT. MIN. - G
Q Q
•A• 'D :a Ob . •b., .o. v. .;. :D •o •:d• :d• .t. .e ,e• b6r. e O
'~C1• .°' Orr 0:• 'p`P q' ••A• Of}gy, 0 ,.... .. y
.bQ•O D (p C7.�(� Q• • / '0:1•. '•`O:. •:D'::r;,0,. O(4d ..i i'i
CN!/d di t y � •.
C. I. OR PVC TEES
p o b o
B .1500 GALLON DISTRIBUTION SOX
8SMT FL .
EL . io, o o:a c �' INSTALL ON LEVEL BASE
o..• 'o: �,°� .° PAECA S T CONCRETE � 500 GALLON DA Yl-✓ELL S
H / O AEINFOPCED
D:
O o
�•db:o.�.$:o•,'a' G:'n•`4::!! 'Q'l!`;®'.'Zlr"` Dp D'D• •e••'m" S T
••y:p's.•o.a7°.''p.o!?• .,pr,G •. 'b:`.�F..aa.:,e—••�.cO.�q•Pp®.[!t1��fL•^4:'Ab�4+: .
TRENCH EC .I'ON
SEPTIC TANK
Co � e -.c e-f Oe,s -e INSTALL ON LEVEL BASE s NOTtE: EXCAVATE TO ELEV. ^'/-+' OR
/ o L OWER TO REMO VE AL L IMPERVIDUS
MA TERIA L BENEA TH THE L EA CHING AREA MIN.
a P.EPLACE EXCA VA TED MA TERIAL WI TH oae 3" OF ?/B w-.?/2"
V S ,a• ao 'o;p: Q'. ? Q'®a 11` b'b b,'O • w��•w 7,�
CL EAN, CL A Y FREE SAND �� `d. �:b•,.o Q •q WASHED PEA STONE
JJ Oq `
3/4�, _ 1 _1/2„ WASHED m
' �► � � CRUSHED STONE c�
E L NO TE '- TRENCH WIDTH
G
1. ALL ELEVA TIONS SHOW ARE BASED ON ASSUMED
,. ... ' .,..__-._...___.
2. ALL PIPS IN Tt�'E ,SYSTEM MUST BE CAST IRON -NI -OF--TRENCHES._..? �, s_ � '
®�' SCHEDULE 40 PVC. l 1 NUMBER OF OR YhrEL L S 3
f BS H A TION PIT
3. THE BOARD OF HEAL TH MUST BE NOTIFIED -
0,
/ Yh0V CONSTRUCTION IS COMPLETE PRIOR P-8765
PERCOL A TION RATE.' .rio �r n,r� -7 r.. 'rl s2• �
TO BA Ch FIL L ING
4. ANY CHANGES IN Tf-•w S PLAN RUST BE APPROVED <'2 MIN./IN.
P11 MESSED B Y.'
BY THE BOARD OF HEAL TH AND CAPE G ISLANDS
0 f , SURVEYING CO., INC. EDWARD BARRY
0 1' 5. MATERIALS AND INSTALLATION SHALL BE IN RIV� BRD. OF HEAL TH
8 COAIPL IANCE WI TH THE STA TE SANI TARP DESIGN DA TA
/ ' i E.' AUG. �7,?g 9
CODE - TITLE V - AND LOCAL APPLICABLE DA T
G 1 '� RULES AND REGULATIONS A TION.S
NUMBER OF BEDROOMS
� fps 6. NORTH ARROW ISF Roil RECORD PLANS AND s„ 0oegn �)oy� �i CIO c1„; GyS GAl48AGE DISPOSA9L NO
IS NOT TO BE WED FOR SOLAR PURPOSES 13
� / 7. FLOOD HAZARD ZONE C (NON-HAZARD) �oa»"y sn C+ IovR y�y s d DAILY FLOP/ 440 GAL
�a B. YA TER SUPPL Y TOAIN PIA TER `8` C' 30" Low M7 an '
0 / / , SEPTIC TANK REQ D. 1500 GAL .
Q, d ,,� ry r r� d r �, 150 0 GAL .
i U �•�`"� " "" EA CHING REQUIRED ED
440 GPD.
ti Pr �y oo \ �,n �� -- 8� C SIDEWALL AREA = 186 S.F.
f o 'L \ ° � V 186 S.F.XO. 74 G/S.F. = 137 GPD.
` 3r �, �", ��' , BOTTOM AREA =441 S.F.
� 3�10 o
��ay �;k �� LEGEND sa,-lit 10YR /c .s�, , �r 441 S.F.X0. 74 G/S.F. w326 GPD
171 4 r LEACHING PROVIDED = 463 GPD
r� }
J 72 PROPOSED ELEVA TION /yv" y.ndw><r 7 ,yy„ iYo lyrnc/w�r sz• a
EXISTING CONTOUR
1 o SINGLE FA MIL. Y RESIDENCE 6
10 OBSERVA TION PIT
i s DISTRIBUTION BOX ti PROPOSED SERA GE DISPOSAL SYSTEM
''nn V a a and � �< \ '.
,{V /Y,1 �_-�7' o all. a n Q / r f �'r
Sa .1 � 7 F Y . / �`� LbC �
� # , ,r �,,,• N a Q. PR ABED FOR
df EP
redl, , o 01 SEPTIC TANK ROBER T COGGESHAL L
m p aQ
a. `e`p. hro p/y// jp 7 ti
7v a e _.— HOUSE NO. 39 (L O T 2) HEA DIVA TEAS POA D
�1 a Ma�6nn oaBo r?,F^rtl i jg1P t—.—! RESERVE AREA "
CEN TEP VIL L E — BA PNS TA BL E - MA SS
P d
N ^0 1y
} L O G(/.S ♦ Sa ao. il" _� 9y a 's - X -x✓0�.� �('�f'��k
^ p'!ln Rud er RO -•t`. � � ' s •
Gun 1 i 'q '�� D VID C�\i
l d� 4 c , Pu ler 6 PIPE INVERT ELEVA TION CHAR LE r q �j
�`� � H�,SanADPef ti71r�,��K K� DATE: Ste . /2 7`("r P�
ATE: CAPE 6 ISLANDS ENGINEERING .�,`
G��7�utJ v'I /� / a7 T
a "_ �` �✓� -z z r � CttF° �L SCALE AS NOTED 133 FA L MOUTH ROA D — SUI TE 2E
PLOT PLAN riST .5 2
'r' p `
PLAN 1r00. so /z 94 MA SHPEE, MASS. ;
MA,�
� SEC I PCL_ LOT - M.SE