HomeMy WebLinkAbout0047 HEADWATERS ROAD - Health 47 Headwaters Road
Centerville
A= 228-179
//✓ S M E A D
No.53LOR
UPC 12543
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THE. COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplication for Migo$at 6pztem Cow5truction Permit
Application for a Permit to Construct( ) Repair(%/Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. �/ tip `t^i( s ' Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel .2 _f ,1 0 6tr�- (�—Or s 'S
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: ,,11
Dwelling No.of Bedrooms Lot Size V sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min..i required) J gpd Design flow provided y t J gpd
Plan Date /Z 1a !a Number of sheets Revision Date
Title
Size of Septic Tank `"_M(� G-G,L, Type of S.A.S.
Description of Soil nQ 10 Y
� 1
Nature of Repairs or Alterations(Answer when applicable) (,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signe Date
Application Approved-by Date
Application Disapproved by: Date
for the following reasons
Date Issued
Permit No. f'7�-�CrJ � '
/ I
e No. IP / D `,--r 3- , a Fee Q 0
THE-OON111110NWEALTH OF MASSACHUSETTS Entered in computer:
Yes
' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0[ppYicatton for Migpogar *pgtem Congtructton Vermtt
Application for a Permit to Construct( ) Repair(1,� Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. / C Owner's Name,Address,and Tel.No.
G� c 'ktt-
Assessor's,Map/Parcel; .� �(' "' t 4 C.) v� �v s
Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No.
5(-,I k- �c-�.�+L S')� A A\{ U 0 b E S�{,J-�" W c,r"S
Type of Building:
Dwelling No.of Bedrooms Lot Size / p Q V sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ) gpd Design flow provided y gpd
Plan Date LS �� �u S' Number of sheets Revision Date
Title
t Size of Septic Tank &C, Type ofS.A.S. t`�, (7'rl SC la"rr� ,ll-'c k71rS
Description of Soil ` W I S �8 /D Y Z?k- 1' X /D 'rb
Nature of Repairs or Alterations(Answer when applicable) & _C (C,-N
1
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signe( Date _
Application Approved by ` J Date a"
J '
i Application Disapproved by: Date
f
for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Comp Rance
THIS"IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) RepairedtK Upgraded ( )
Abandoned("' )by \1 r-)\.n o S
at �-1�} ti C. V i � - has been onslructed in accordance )
with the provisions of Title 5 and the for Disposal System Construction Permit No. 0& "t`l /0 dated
Installer Designer ,V F C3 ciq W
#bedrooms S Approved design flow gpd
The issuance of this permit shall
ynot be construed as a guarantee that the system wiltior adesigned. 4
Date Jo1p c�1 (0 Inspectors_
t ,
-----�---��----1 /--- -------------- ----=_ __
————
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Mt5po5ar *pgtem /Con5tructton 30ermit
Permission is hereby granted to Construct ( ) RepairV( ) Upgrade ( ) Abandon ( )
System located at t-1 -? tA-C C, coy.-'c u T? d
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty's
to comply with Title 5 and the following local provisions or special conditions..
Provided: Construction musttbbe coom leted within three years of the date f this perm.t.
Date / oC7��� Approved by
V
Y
Town of Barnstabler
Regulatory Services-
Thomas F.Geiler,Director
�$Pr,
Public Health.D' ;
�v�a��v�U{
d a "
McKean,Director.. � { �
{S d Thomasx+ >x a5'}
200.Main Stjoet,Ayadma7 MAM Y
F 1�!/A�4�x �;;y�Y� t x r
`rtF I
�:I Fllisler&Desi @PA tm C gas f *y
' �•� ��4�,�i�A k� n ,p ;t t }t r ��i.f{ 4+k r•_,
*i � r te: Ed d le. . /
{ l Sewage)Pernut# ?��• �I v Assessor's MaplParcel $!/?7
'Designer: Sr&0.40.IJ s Pe" Installer: VC
Adldress: e 3 .w-7� e A Address: [ e
pn 1 8 ®G jCL ��" ✓�. was issued a
(date) (installer)
permit to install a
r
septic system at s D f "el c cabased on a design drawn by
(address)
f � dated z a G
(designer)
} '0" I certify that the septic system, referenced above was installed substantially according to
the design, which way-include minor approved changes such'as lateral relocation of the
distribution box awd/or septic tank.
l certify that the septic system referenced above was installed with major changes (i_e.
t greater than 10' lateral relocations 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. _
(Installer's Signature V'O
Wesigner's Signature) (Affix Design s Stat�np Here)
Y' E RETURN TO HARNSTABLE PUBLIC HEAL'I'H DIV IQN. CERTIFICATE
OF CO1VH'LIA,NCE WILL NQT BE ISSUED UNTIL BOTH TIYYS FOR IVI AND A&
BUILT C ARE RECEIVED BY T d NCTARLT PUBLIC HEAL'I'YI DIVISI®�1.
THANK YOU.
QASWflcV)ezi8na CdtifioWion Form Reviaed.dcm
i
1 TOWN.OF BARNSTABLE
LOCATION �7 IhCf,�yJ YA S 7" 8 SEWAGE#
VILLAGE G``s Ak, ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY _l Sb Q C)
LEACHING FACILITY:(type) (size) Z6 to y
NO.OF BEDROOMS ` ` a /�"d
OWNER r�S
PERMIT DATE: COMPLIANCE DATE: , `O
Separation Distance Between the: cc ��__�
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 6Z �?�CN- 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) Ny\ Feet
FURNISHED BY
'3
lar
q o
J
"Z)
tp
C �
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, 5�� �"-� �, ,hereby certify that the engineered plan signed by me
dated IE5. *66 ,concerning the property located at
Ccw -✓� `-LE �226 /-7c meets all of the
following criteria:
• wo soil evaluations excavated for detailed examination(no hand augering) and two
percolation tests shall be conducted.
• failed system is connected to a residential dwelling only. There are no commercial or
/,is
usiness uses associated with the dwelling.
• soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch.
• ere is no increase in flow and/or change in use proposed
• here are no variances requested or needed.
• T e bottom of the proposed leaching facility will be located no less than five feet above the
Aaximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the.following:
A) Top of Ground Surface Elevation(using GIS information) 1
B) G.W. Elevation I +adjustment for high G.W.
DIFFERENCE BETWEEN A and B 3y j
SIGNED : DATE: �3
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptic\percexemp.doc
.r
r
Barnstable
L MKWE Town of Barnstable bcew
x Regulatory Services Department .
B RNSTADIx,
9a 39. , Public Health Division
�Ar�D MA'I A
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL 7007 3020 0001 3429 8899
May 5, 2009
Lee M. Branson
47 Headwaters Rd. Approved: _ _
Centerville, Ma, 02632
MLD Cert:
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 47 Headwaters Drive, Centerville was inspected
on April 10, 2009 by Jaime Cabot, Health Inspector for the Town of Barnstable. The
inspection was conducted on the basis of the rental registration in accordance with
Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed.
105 CMR 410.503 (A)—Protective Railings or Walls. lack of hand rail on stairway with
three (3) or more risers.
You are ordered to correct the above violations within thirty (30) days of your
receipt of this notice by installing protective handrails as required by 780 CMR:
Massachusetts State Building Code.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days after the date the order is served.
Non-compliance will result in a fine of$100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORD THE OARD OF HEALTH
as . McKean, R.S., CHO
Director of Public Health
Town of Barnstable
Q:\Order letters\Housing Violations\Rental Ordinance\Stair Railings.doc
Commonwealth of Massachusetts
_ Title 5 Official Inspection
Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville Ma. 02632 1/6/2009
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
'mp°irta"t
When filling out A. General Information
forms on the
computer,use 1. Inspector: ✓✓ lL
only the tab key
to move your Raymond Dumas
cursor-do not Name of Inspector
use the return
key. Dumas Landscape Const. Inc.
Company Name
564 Old Stage Rd.
Company Address
Centerville Ma. 02632
Citylrown State Zip Code
508-778-0249 S1437
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. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system: '
® Passes ❑ F Conditionally Passes `"
❑
4
ry
❑ Needs Further Evaluation by the Local Approving Authority
` M
tt- 1/6/2009 `•ACU
Inspector's S nature Date c`3 rr-
The system inspector shall submit a copy of this inspection report to the Appro ing 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.
LAI 11
Robert Cross Septic Inspection.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Dal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville Ma. 02632 1/6/2009
every page. Cityrrown 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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
Robert Cross septic Inspection.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
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
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.
Robert Cross Septic Inspection.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�. 47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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
P 9 9 q
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 Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Z 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.
Robert Cross Septic Inspection.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ ® 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.
Robert Cross Septic Inspection.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is Centerville, Ma. 02632 1/6/2009
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.
❑ ® 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)]
Robert Cross Septic Inspection.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
every page. City/Town State Zip Code Date of Inspection
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
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2007/0 gal
g ( y g (gpd)): 2008/25000 gal
Sump pump? ❑ Yes ® No
Last date of occupancy: 2006
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:
Last date of occupancy/use: Date
Other(describe):
Robert Cross Septic Inspecfion.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
Ci /Town State Zip Code Date of Inspection
every page. ty P P
D. System Information (cont.)
General Information
Pumping Records:
Source of information: 10/2006 old system at time of upgrade as per
installer
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):
Approximate age of all components, date installed (if known)and source of information:
10/18/2006 as per Board of Health
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Robert Cross Septic Inspection.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. approx. 20'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
All looks good
Septic Tank (locate on site plan):
Depth below grade: 12"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: 6'x10'x5'
Sludge depth: none
Distance from top of sludge to bottom of outlet tee or baffle n/a
Scum thickness none
Distance from top of scum to top of outlet tee or baffle n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
How were dimensions determined?
water 3/4 full no usage
Robert Cross Septic Inspection.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is Centerville, Ma. 02632 1/6/2009
required for
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.):
No pumping needed at this time
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
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):
Robert Cross Septic Inspection.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert level just below inverts
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.):
level and no carryover
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Robert Cross Septic Inspection.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
❑ leaching pits number:
❑ leaching chambers number:
4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology. 4 h20 hi capacity Infilltrators
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
all good
Robert Cross Septic Inspection.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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 i
Indication of groundwater inflow ❑ Yes ❑ No
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.):
Robert Cross Septic Inspection.doc•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 15
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Robert Cross Septic kqxmdMdoe•03M TWa 5 OWcal hapecbm Fom Subsaram Sewage System•Page 14 of 15
Commonwealth of Massachusetts
IL 9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Headwaters Rd.
Property Address
Robert Cross
Owner Owner's Name
information is required for Centerville, Ma. 02632 1/6/2009
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: 10+
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: 8/22/2006
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Info from plan on record obtained from board of health
® Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Eagle Surveying Design 9/22/2006
Robert Cross Septic Inspection.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
ACCESS COVERS MUST BE WITHIN INSPECTION 9' MINIMUM. INVERT ELEVATIONS : DESIGN CR I TER I A : GENERAL NOTES :
99. 48
6" OF FlN/SH GRADE FIRST 2 ' TO PORT 3' MAXIMUM COVER
INVERT AT BUILDING: 96.6 DESIGN FLOW:
BE LEVEL MIN 2' OF PEASTONE INVERT IN SEPTIC TANK: 96,35 3 BEDROOMS AT 1 /0 G.P.D. PER I . THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION
ff INVERT OUT SEPTIC TANK: 96. 1 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY.
4' DIAm PIPE
3/4' - 1 112' DIA. INVERT IN DIST. BOX: 95.2
6 �� gj DOUBLE WASHED STONE INVERT OUT D/ST. BOX: 95.03 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS
f 95. 03 /0' �° SET. SEE SITE PLAN.
6. 3 r GAS95. 95. 0 4. 17 INVERT IN LEACH CHAMBER: 95.0
BAFFLE SEPTIC TANK REQU/RED:
3 OUTLET 4 HIGH CAPACITY INFILTRATOR BOTT(.,W OF LEACH CHAMBER: 94. 17 330 G. P.D. X 20OX - 660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIAL ., AND
D-BOX
CHAMBERS W/3. 5 '+ STONE AROUND ADJUSTED GROUND WA TER: n SEPTIC TANK PROVIDED: 1500 GAL . MIN./a MAINTENANCE OF THE SEPTIC SYSTEM SHALL
1500 GAL l0 '• x 38 ' 1 x 10"d OBSERVED GROUND WATER: n/a CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL
SEPTIC TANK 6' CRUSHED STONE OR BOTTOM OF TEST HOLE 02: 87.9 BOARD OF HEALTH REGULATIONS.
COMPACTED BASE SOIL ABSORPTION SYSTEM REQUIRED:
DESIGN PERC RATE ( 5 M/N/I NCH
PROFILE NOT TO SCALE SOIL TEXTURAL CLASS - I 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
330 GPD / 0. 74 GPD/SF - 446 S.F. REQUIRED THAN 3 ' IN DEPTH SHALL BE CAPABLE OF WITH-
NSTANDING H-20 WHEEL LOAD$.
PROVIDED: 4 HIGH CAPACI TY INFILTRATOR
CHAMBERS W/3.5 'f STONE AROUND. A-460 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR
460 S.F. x 0. 74 - 340 GPD APPROVED EOUAL.
6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
s ,9°'9 4p-E SOIL TEST PIT DA TA & PRECAST CONCRETE AND WATERTIGNT. D-BOX SHALL
4 HIGH CAPACITY ® INDICATES INOICATES BE WATER TESTED TO CHECK FOR : EVEL WHEN THERE
INFILTRATOR CHAMBERS PERCOLATION OBSERVED IS MORE THAN ONE OUTLET.
W/J.5'= STONE AROUND 'CB/DH FND TEST - GROUNDWATER
1 " 7. BEFORE CONSTRUCTION CALL 'Div-SAFE
D- X' TP •I TP •2
I-888-DIG-SAFE AND THE '.00AI WATER DEPT.
FOR 0 0 N T
QI cV HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR LOCATION F U DERGROUNu UTILITIES.
vY 0- 98.4 0' 97.9
� �` Q LOAMY /OYR Q LOAMY /OYR
RED MAPLE TP.2 SAND 3/4 SAND 3/q 8. SEPTIC SYSTEM /NS TAL L ER SHALL NOTIFY THE
BM. CB/DH DES/GN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
EL 98.96 /2• 97. 4 18' 96.4
Tv.I LOAMY /OYR p LOAMY 7.SYR OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE
B SAND 4/6 D SAND 4/6 CONSTRUCTION INSPECTIONS.
24• ......... .......I................ .... 96.4 32' 95.2
1! C I MED-COARSE IOYR C / MED-COARSE /OYR 9. EXISTING CESSPOOL TO BE PUMPED DRY AND
W y r,s SAND AND 616 SAND AND 616 BACKF I L L ED.
m GRAVEL GRA VEL
O 12'
m 42' 48"
1'ZOO "m-l:
e +� 97 g ti SEPTIC TANK ^
Q
120. NO WATER 88.4 120- NO WA TER 87 9
Q w =! '
DA TE: JUNE 1. 2006
TEST BY: STEPHEN HAAS r
PERC RATE: C 2 MIN/INCH
Q
L
' I
LOT 2 16. 8001 S. F. \.�1�•-_- - - 1
1
CESSPOOLS 1
\ , 1
116.4 .
S E P T / C S Y S 7-EM O E S / G/\/
N 7g•40 . 0-w `
¢ 6J?/3 47 HE.4OW,4 TERS ROAD "AP 228 PARCEL / 79
- CRIDN FNb•
R /VS TA6L E < CE/VTERV1LLE-
RAJ MQ
r ! !LONS LEGEND
ROBER T cRass
ITREE�t J � ■ CB CONCRETE BOUND
p1 -W WATER L I NE ..
+ 1_J SCAL E : / - 20 A UGUS T 22 . 2006
Ocue; HYDRANT
to,
j o �TZJ-' -G GAS LINE
OHw- OVER HEAD WIRES
EAGLE SURVEY I N G I N C,
LIGHT POST _ 923 Rout e 6A
z
-E- UNDERGROUND ELECTRIC LINE Y a r mo u t h p o r t MA . 02675
-T- UNDERGROUND TELEPHONE LINE4j i I��/lh�� ( 5 O 8 ) 3 6 2-8 1 3 2
-CT V- UNDERGROUND CABL EV I S I ON LINE �1 ` ( 5 O 8 ) 4 3 2-5 3 3 3
I +40.4 SPOT ELEVATION
-40 EXISTING CONTOUR
Ea-0 PROPOSED CONTOUR
LOCUS MAP 0 1 0 20 40 [ JOB NO: 06-054 FIELD:CFW/EEK CAL C: SAH CHECK: CFW DRN: SAH