HomeMy WebLinkAbout0049 HENRY F LORING ROAD - Health 49 Henry F. Loring Road
Centerville P
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
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. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use Inspector:
only the tab key 1. � I
to move your Scott Campbell
cursor-do not Name of Inspector
use the return
key. Cardinal Construction
Company Name
32 Ridgetop Rd.
Company Address
Cr Ma 02635
�n CityltyrTown State Zip Code
508-420-1295 S1388
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
❑ Needi Further Evaluation by the Local Approving Authority
8/25/2011_
Inspector's Wature 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.
"DI 112-l 1
t5ins•11/10 Title 5 Official Inspection Form: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
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
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:
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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):
Distribution box was replaced 9/10/2007 Certificate of compliance was issued on 9/10/2007 permit#
2007-398
❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
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 '/2 day flow
l5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
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•11/10 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
49 Henry F. Loring Road _
Property Address
Mark and Margaret Goad
Owner owner's Name
informrequired
is Centerville Ma 02632 8/25/2011
required for
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?
El N 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): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•11/10 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
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
.every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 2011
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts V41
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�( 49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Century 21 Seaside Village Pumped July 6 2011
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
_<L\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owners Name
information is required for Centerville Ma 02632 8/25/2011
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:
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: 1
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:
Sludge depth:
t5ins•11/10 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts y
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
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 0
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 0
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? Visual Inspect. Tape Measure
Sludge Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
System does not need to be pumped at this time, system was pumped July 6, 2011. Inlet and outlet
tees in place at time of inspection. Liquid level at proper working height at time of inspection. No
evidence of leakage into or out of tank.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is Centerville Ma 02632 8/25/2011
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 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
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville 'Ma 02632 8/25/2011
every page. CitylFown 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.):
Box is set level and has a 1'cement riser. Single line leaving box. No evidence of solids carryover at
time of inspection. No evidence of leakage into or out of box at time of inspection.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
SAS working properly at time of inspection.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
1 k
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 5
❑ 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.):
(c) No signs of hydraulic failure, no ponding or damp soil. Normal vegetation (Patchy grass)
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
Lt5ins1110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts `.
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
every page. Cityrrown 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•11110 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
'r< 49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is required for Centerville Ma 02632 8/25/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
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
I
�Zq
V
1jOr
t5ins-11/10 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
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is Centerville Ma 02632 8/25/2011
required for
every page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Current info. available
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
upTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
49 Henry F. Loring Road
Property Address
Mark and Margaret Goad
Owner Owner's Name
information is Centerville Ma 02632 8/25/2011
required for
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
b C
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary-Assessments -
e
wM 49 HenryF. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for. Centerville Ma. 02632 8/16/2007
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.
Important: A. General Information
When filling out ,�
forms on the (�
computer,use 1. Inspector:
only the tab key 5 ��
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage.disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4
8/16/2007
Inspector's Signa a Date
The system inspector shall submit a copy of this inspection report to the App `ing Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is shared•s_ysteFn_or
has a design flow of 10,000 gpd or greater,the inspector and the system owner hall submit the
report to the appropriate regional office of the DEP. The original should be sent 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.
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Henry F. Loring'Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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
49 Henry f.loring rd.-08/06 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
Z. distribution box is leveled or replaced
ND Explain:
Box cover broke n.SidewalIs of box falling apart.Pipe from tank to box needs to be replaced.
❑ 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 aseptic 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.
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�,M ,•�''L 49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
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
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:
❑ ® 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.
49 Henry f.loring rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 .8/16/2007
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.
49 Henry f.loring rd. 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
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
❑ 0 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)]
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
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): 2
DESIGN flow.based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2005:119,000
g ( y g (gpd)): 2006:144,000
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:
Last date of occupancy/use: Date
Other(describe):
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Henry F. Loring Rd.
Property Address
Joseph Scares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
New leaching installed 2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 49 Henry F. Loring Rd.
Property Address
Joseph Scares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 14"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 20'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: 18"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: 8'6"x4'10"x5'7"
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? measured
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
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.):
Pump tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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):
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is Centerville Ma. 02632 8/16/2007
required for
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 No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box cover broken.No evidence of solids carryover.Evidence of leakage out of box.Box needs to be
replaced
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
49 Henry f.loring rd.•08106 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
;M 49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
every page. City/Town 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: 5-infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is Centerville Ma. 02632 8/16/2007
required for
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
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.):
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
49 Henry f.loring rd.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 49 Henry F. Loring Rd.
Property Address
Joseph Soares
Owner Owner's Name
information is required for Centerville Ma. 02632 8/16/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
i
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: Bottom of leaching 35'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: 2004
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:
Used"Gaherty& Miller model 12/16/94 ground water elevations. Used:USGS Observation well data
June 1992. Used:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevation.
49 Henry f.loring rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2ppitration for �Digo!6al 6pgtem Conotruetiou Vermit
Application for a Permit to Construct O Repair O Upgrade Abandon O ❑.Complete System Individual Components
Location Address or Lot No. qCt Ck'Lot, (r- L��;.�G Owner's Name,Address,and Tel.No. l `
131(. Cc,4i4vac l- ST'
Assessor's Map/Parcel 1-7
n
Installer's Name,Address,and Tel.No. it"r Q1P�5 Designer's Name,Address and Tel.No.
/f Q .9-asc-Z 63
Gem.�..c i 1•c
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building fr l No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /OW Type of S.A.S. Z4l'1 n*,c
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /� WK.t *AJ L-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 '10- -00
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
OD-
- -No. � Fee �
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
A plication for -Miopo9;al *pgtem Cootruction Permit
Application for a Permit to Construct( ) Repair( Upgrade Abandon( ) ❑ Complete System � Individual Components
I
Location Address or Lot No. qC1
4"Ogl t,,, Lam,„� Owner's Name,Address;and Tel.No. ���" � eC,¢Cr
Assessor's Map/Parcel lr7
I Installer's Name,Address,and Tel.Nc P!S� II
/ i ,. Designer's Name,Address and Tel.No.
p 0
Type of Building: .• _ j
Dwelling No.of Bedrooms Lot Size ,---3 (,)-7 i sq.ft. Garbage Grinder
Other Type of Building r tr No.of Persons Showers( ) Cafeteria(` ) I
Other.Fixtures a
i
Design Flow(min.required) gpd Design flow provided 1 gpd
Plan Date Number of sheets Revision Date
Title
Type of S.A.S.
Size of Septic Tank �(�'�'Q
Description of Soil
I� I
Nature of Repairs or Alterations(Answer when applicable) I4GA
i a� D eke
j
Date last inspected:
a'
Agreement: -
The undersigned agrees to ensure,the construction and maintenance of the afore described on-site sewage disposal system in "
'i
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
fCompliance has been issued by this Board of Health.
Signe Date
Application Approved by Date
Application Disapproved by: Date
for the following reasons ,
s
Permit No. Date Issued
-------- ----
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded
Abandoned( )by
at 45 11 V _ �_ Lw'u itk Cama_(��-�(,I^( has been const ucte ccordance
with the provisions of Title 5 and the for Di posal System Construction Permit No. dated
Installer, L �,e Designer
I #bedrooms -3 Approved design flow gpd
J 4'" 1 c
The issuance of his e it shal not be construed as a guarantee that the syste fu: cfion as esi ned. I �
I {fI /
Date ' fj Inspector/ p ,0 /
—_-- --------------------------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS 4Z�
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Oigoal *p!gtem Construction ermit
Permission is hereby granted to Construct ( ) Repair Ppgrade ( ) Abandon ( )
System located at �� / (- et a PLC
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following-local--provisions or special conditions.
�j Provided: Co stitiction rpust be completed within three years of the date of th's e
Date Approved by
Town of Barnstable
�F'THE 1p�
Regulatory Services
Thomas F. Geiler, Director
snxxsrABM
' �0� Public Health Division
A'F1639. A Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: Iola
Designer: Installer: :: s �v�s
Address: Address:
On 'ate � was issued a permit to install a
(date) (installer)
. septic system at AS teased on a design drawn by
ddress
dated �� � C)4 _
esigner) �
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e..
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer ollow.
t
OF ATq
(Insta a 'Signa ure) o`' " CARMEN-
u SHAY N
No: 1181
P� �o
(Designer's Signature) 6 (Affix De � , ere)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVIS N. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
L: / /
'f �TOWN OF BARNSTABLE �70; ��(k`,1`
SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT 72—/9)
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY kQM0
LEACHING FACILITY: (type) ' �� B f (size) V
.OF BEDROOMS ,�1 �-� j:y�, E: lr Z6r- 10/40`/N�
II,DER OR OWNER G�v�
r;sRMTrDATE: COMPgANCE DATE: /0'22_-Oq
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
1. within 300 feet of leaching facility) Feet
Furnished by
o -
L4I
.1
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:A.
Yes
Lo-
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,.MASSACHUSETTS
application for Zigooar &pgtem. Construction Permit
Application for a Permit to Construct( . )Repair( )Upgrade Abandon( ) ❑Complete System $Individual Components
Location Address or Lot No. 49 pen V Owner's Name,Address and Tel.No.
Louts I kC CcQ�s-
Assessor's Map/Parcel
Installer's Nam Tess, d!;. o. , Designer's Name,Address and Tel.No. S�
erS su Al-e
� t
tp Y-6 53/d 5 3;
Type of Building: 1 ��pyy�u � Z�� i�-�2� �i.,
Dwelling No.of Bedrooms Lot Size 50 sq.ft. Garbage Grinder( P1109.
Other Type of Building 1Je No.of Persons a Showers(t/f Cafeteria
Other FixturesL-, t ( 1� awls,, 1
Design.Flow tea® gallons per day. Calculated daily flow 8r2>l gallons.
Plan Date lt% t S`csv Number of sheets 1 Revision Date
Title 14 1C or
Size of Septic Tank n. Type of S.A.S. o' X
Description of Soil; Spar�� 9- /��
Nature of Repairs or Alterations(Answer when applicable) -I'm o .
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 'tle 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this B d of Healt
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
-A 044
Permit No. Date Issued
f �. � R:, •rM,�l
No. Fee /l/�///
` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
'Yes
PUBLIC HEALTH DIVISION -TOWN`OF BARNSTABLE., MASSACHUSETTS
ZIppYication for Zigponl *pztem Cong;tructton Permit
Application for a Permit to Construct( . )Repair( )Upgrade )Abandon( ) O Complete System 1 Individual Components
Location Address or Lot No.49 ��,^� �Q` Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel � u \ LaUt5 KkC lC,t
F.� i SAMF_
Installer's Na►gea Ass, d�e�N o. �. Designer's Name,Address and Tel.No.
44
Type of Building: ` d)P I,
Dwellings No.of Bedrooms eQ Vot Size n Ib 0 - sq.ft. Garbage Grinder(e/a
Other Type of Building /� c�snn No. of Persons Showers(V) Caf (t,,�'
Other Fixtures l ,K, k-t
Design.Flow O gallons per day. Calculated daily flow 53k,20 gallons. "
Plan Date !L` 1�I :�'k C�A Number of sheets Revision Date ....-
TitleQ--
"'� .Size of Septic Tank t ,M c_ � - Type of S.A.S. �D ` X Tgerck
Description of Soil e Csx- p\cr� S /^l F t u7,i?A-TbQ-5
Nature of Repairs or Alterations(Answer when applicable) n_�r AM P\004.
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 bey this B and of Healt
Signe Date�� b
Application Approved by _ 7 / ' Date
Application Disapproved for the following reasons V / _
s
Permit No. `� ) Date Issued r
r
a THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO C T FY, that the On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded-()e)
Abandoned( )by >'
at L f V / has been constructed accordance
with the pr visio s of Title 5, n the fTrDisposal System Construction Pe t No bO -�i dated a OBI
Installer Dcsign,.r
The issuance of this xt t,,&.all not be construed as a guarantee that the system wil fulicti n as signed.
Date '�`�� �� Inspector ,. /
_._ . —————————————————————————————————
No. ..r J
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
;3i!5po5a1 *p5tem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade Abandon( )
System located at _ ) / s p ,!�r
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title`5 and the following local provisions or special conditions.
4 Provided:Cons.uc n mu be completed within three years of the date oPispe
Date: l �I Approved b J
-
a�`, Puy`:
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Rep RECEIVED
Order Number: 0424243
Gordon Siegel MAR 10 2004
340 Main St.
Centerville, MA 02632 � TOW ECALTH pEpTABLE
Laboratory ID#: 0424243-01 Description: Water-Drinking Water
Sample#: 242431 Samplins Location: 1756 Osterville-W Barnstable Rd W Barnstable NIA Collected 2/17/2004
collected by: G Siegel Received 2/17/2004
Routine +Ammonia 31s o
ITEM RESULT UNITS Mff MCL Method# Tested
LAB: IC Lab �-
Ammonia <0.1 mg/L 0.1 EPA 350.1 2/18/2004
Nitrates 1.5 mg/L 0.1 10 EPA 300.0 2/17/2004
LAB: Metals
Copper 's t 0:2 mJL 0.1 1.3 SM3111B 2/1$/2004
Iron <0.1 rng/L 0'.`I`- 0:3 SM 311-1B 2/18/2004-
Sodium- 17 mg/C 1.0- 20 SM3111B; 21,18/2004
LAB: Microbiology
Total Coliform Absent P/A 0 Absent 307 2/17/2004
LAB: Physical Chemistry
Conductance 150 umohs/cm I EPA 120.1 2/17/2004
pH 6.6 pH-units 0.1 EPA 150.1 2/17/2004
G�
EPA 524.2 - Volatile Organics by GC/MS OL
ITEM RESULT UNITS M MCL Method# Tested
LAB: GUMS
1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 2/25/2004
1,1,1-Trichloroethane BRL uq/L 0.5 200 EPA 524.2 2/25/2004
1,1,2,2-Tetrachloroethane BRL uJL 0.5 EPA 524.2 2/25/2004
1,1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 524.2 2/25/2004
,1,1 Dichloroethane BRL uo-/L o.5 EPA'524'22 2/-5/?00,4
t 1,1-Dichloroethene BRL u--/L 0.5 tJ-:0 EPA15524'2 ;?/35/2004
1,1-1)ich.loropropene BRL uJL 0.5 EPA524:2 2/25/20.04
1,2,3-Trichlorobenzene BRL ug/L 0.5 EPA 524.2 2/25/2004
1,2,3-Trichloropropane BRL ug/L 0 5 EPA 524.2 2/25/2004
Superior Court House, PO. Box 427, Barnstable, ,MA 02630 Ph: 508-375-6605
^��OF HapL'�T•.
M CERTIFICATE OF ANALYSIS Page: 2
9s Barnstable County Health Laboratory
`sn�tibc�'
Report Prepared For: Report Dated: 3/4/2004
Order Number: G0424243
Gordon Siegel
340 Main St.
Centerville, MA 02632
Laboratory ID 4: 0424243-01 Description: Water-Drinking Water
Sample#: 242431 Sampling Location: 1756 Osterville-W Barnstable Rd W Barnstable NIA Collected 2/17/2004
Collected by: G Siegel Received 2117/2004
1,2,4-Trichlo ro benzene BRL ug/L 0.5 70 EPA 524.2 2/25/2004
1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 2/25/2004
1,2-Dibromo-3-chloropropa BRL ug/L 0.5 EPA 524.2 2/25/2004
1,2-Dibromoethane(EDB) BRL ug/L 0.5 EPA 524.2 2/25/2004
1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 2/25/2004
1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 2/25/2004
1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 2/25/2004
1,3,5-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 2/25/2004
1,3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 2/25/2004
1,3-Dichloropropane BRL ug/L 0.5 EPA 524.2 2/25/2004
1,4-Dichlorobenzene BRL ug/L 0.5 5.0 EPA 524.2 2/25/2004
2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 2/25/2004
2-Chlorotoluene BRL ug/L 0.5 EPA 524.2 2/25/2004
4-Chlorotoluene BRL ug/L 0.5 EPA 524.2 2/25/2004
Benzene BRL ug/L 0.5 5.0 EPA 524.2 2/25/2004
Bromobenzene BRL ug/L 0.5 EPA 524.2 2/25/2004
Bromochloromethane BRL ug/L 0.5 EPA 524.2 2/25/2004
Bromodichloromethane BRL ug/L 0.5 EPA 524.2 2/25/2004
Bromoform BRL ug/L 0.5 EPA 524.2 2/25/2004
Bromomethane BRL ug/L 0.5 EPA 524.2 2/25/2004
Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 2/25/2004
Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 2/25/2004
Chloroethane BRL ug/L 0.5 EPA 524.2 2/25i2004
Chloroform 1 ug/L 0.5 EPA 524.2 2/25/2004
Chloromethane BRL ug/L 0.5 EPA 524.2 2/25/2004
cis-1,2-Dichlo roethene BRL UOL 0.5 70 EPA 5214.2 2/25/2004
cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 2/25/2004
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
Page: 3
CERTIFICATE OF ANALYSIS M
C Barnstable County Health Laboratory
9Sr�CHt_%5t^�
Report Prepared For: Report Dated: 3/4/2004
Order Number: G0424243
Gordon Siegel
340 Main St.
Centerville, MA 02632
Laboratory ID#: 0424243-01 Description: Water-Drinking Water
Sample#: 242431 Sampline Location: 1756 Osterville-W Barnstable Rd W Barnstable MA Collected 2/17/2004
Collected by: G Siegel Received 2/17/2004
Dibromochloromethane BRL usiL 0.5 EPA 524.2 2/25/2004
Dibromomethane BRL ug/L 0.5 EPA 524.2 2/25/2004
Dichlorodifluoromethane BRL ug/L 0.5 EPA 524.2 2/25/i004
Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 2/25/2004
Hexachlorobutadiene BRL ug/L 0.5 EPA 524.2 2/25/2004
Isopropylbenzene BRL ug/L 0.5 EPA 524.2 2/25/2004
Methyl-tert-butyl ether BRL ug/L 0.5 EPA 524.2 2/25/2004
Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 2/25/2004
n-Butylbenzene BRL ug/L 0.5 EPA 524.2 2/25/2004
n-,Propylbenzene BRL ug/L 0.5 EPA 524.2 2/25/2004
Naphthalene BRL ug/L 0.5 EPA 524.2 2/25/2004
p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 2/25/2004
sec-Butylbenzene . BRL ug/L 0.5 EPA 524.2 2/25/2004
Styrene BRL ug/L 0.5 100 EPA 524.2 2/25/2004
tert-Butylbenzene BRL ug/L 0.5 EPA 524.2 2/25/2004
Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 2/25/2004
Toluene BRL ug/L 0.5 1000 EPA 524.2 2/25/2004
Total xylenes BRL ug/L 0.5 10000 EPA 524.2 2/25/2004
trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 2/25/2004
trans-l,3-Dichloropropene BRL ug/L 0.s EPA 524.2 2/25/2004
Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 2/25/2004
Trichlorofluoromethane BRL ug/L 0.5 EPA 524.2 2/25/2,004
Vinyl chloride BRL ug/L 0.s 2.0 EPA 524.2 2/25/2004
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
'��pF NA�'�T`•.
Pay. a
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
ysSAc'HU`�/
Report Prepared For: Report Dated: 3/4/2004
Order Number: G0424243
Gordon Siegel
340 Main St.
t
Centerville, MA 02632 r .
Laboratory ID#: 0424243-01 Description: Water-Drinking Water
Sampling Location: 1756 Osterville-W Barnstable Rd W Barnstable NIA 2 2
Sample#: 242431 Collected /17/_004
Collected by: G Siegel Received 2/17/2004
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:-
Director)
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
TOWN OF BARNSTABLE
" 1T:
LOC?'�`i'U4 RIMi SEWAGE #
MLAGE C ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. --ELf
SEPTIC TANK CAPACITY 9� 62
LEACHING FACILITY: (type) In (size) (�A�_
NO. OF BEDROOMS n
BUILDER OR OWNER ' y ' � f P-0
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 "/A) K.dc.11z
. ., -
�,.
,. ,,,�*.
� � -
��
G
-l��
��
r4
SUBSURFACE SZAAOZ DiBPOSAL SYBTZM INSUCTION "RM
Address' of property
Owner's name ,� ,
Date of Inspection ��
p S.GS PART A
CRZCKLIBT '
Check if the following have been done:
V Pump ing information was requested of the owner, occupant, and Board of
/Health.
T_ None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the.
system recently or as part of this inspection.
_V As built plans have been obtained and examined.. Note if they are not,
available with N/A.
v • The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
V All system components, excluding the SAS, have been located on the
site.
L/ The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees, .
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
n existing information or approximated by non-intrusive methods.
• from owner e,
The facility owner (and occupants, if different � wer
provided with information on the proper maintenance •of SSDS.'
' ff •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART H
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
_c2 number 'of current residents
garbage grinder, yes or no,
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow: '
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
75�
of system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflowc P
ess ool
Privy
Shared system (yes or no) (if yes, attach previous" inspection
records, if an
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
Sewage odors detected when arriving at the site, yes or no ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
• SYSTEM INFORMATION continued
SEPTIC TANK:
(locate, on site plan)
depth below grade:_ 1
material of construction: concrete _metal FRP other(explain)
dimensions:
sludge depth
Z u" distance from top of sludge to bottom of outlet tee or .baffle
scum thickness
h'_ distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet. invert, structural integrity,
evidence of leakage, recommendations for re airs, etc. ) ,-
aT
DISTRIBUTION BOX: v
(locate on site plan)
cknD depth of liquid level above outlet invert
Comments: ,
. ..(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
PUMP CHAMBER: .
(locate on si4tl—a n)
pumps in working order, yes or no
Comments
(note condition of pump chamber, condition of pumps and appurtenances,i-
recommendations for maintenance or repairs,etc.) } �:
y F t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART B
SYSTXX INFORKATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type•
t� � wGr
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,•
condition of vegetation, recommendations for maintenance or repairs,etc.)
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as �
Par of inspection)t
r
Comments: . .
:(note condition of soil, signs of hydraulic failure, level .of .ponding :
condition of vegetation, recommendations for maintenance or repairs,etc.)"
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
•Comments::
w..
(note condition of soil, signs of .hydraulic failure, level of ponding,
: condition of vegetation, recommendations for maintenance or repairs,etc:) •
. 1 i
SUBBURFACZ BZRAGZ DIBPOBAL BYSTZM INBPZCTION ,FORM
PART 8
BY8TZM INFORXhTION continued
SKETCH OF SEWAGE I:SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
r .a
A,
, 3
• 4 1.
DEPTH TO GROUNDWATER
,.
i� depth to groundwater
No (,�-V v Fo\--vo
method of determination or approximation:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no,. or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determinedil, explain why not)
Backup. of sewage into facility?
J-4 Discharge or ponding of effluent to the surface. of the ground or
• surface waters?
21 Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 d
flow?
Required pumping 4 times or more in the last year?
number of times pumped.
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt .marsh w �
(cesspools and privies only, t the SAS)? '
within 50 feet of a private water supply well? }
less than 100 feet but greater than 50. feet from a private .water a
}
supply well with no acceptable water quality analysis? • If"the°.well
has been analyzed to be acceptable, attach copy of well water an
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
y
SUBSURFACE SEWAGE DISPOSAL SY8TEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector__,_av : '0,0,15
Company Name of .,U.avD&-*�1 L
Company Address 9.0 6 ov-1.=.o
Certification Statement
I•certify that I have personally inspected the sewage disposal system at
this address and that the information reported is* true, accurate and
complete as of the time of inspection. The inspection was performed and
.any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal . systems.
Chec one
have not found any information which indicates that, the system fails
°•to ;adequately protect public health or the environment as defined in .,
310 CMR 15,303. Any failure criteria not evaluated are as stated in : .
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the- environment as defined in 310 CMR 15.303. The basis for this
determination is provided i the FAILURE CRITERIA section of this
form.
Inspector's Signature
Date
Original .to system owner
Copies to: Qr ,
Buyer (if applicable)
Approving authority
f
1,
.y 1
L X
1
as 9
L-O-,OrlT10N � 7 SEWAGE PERMIT N0
h c 7- A fs*q'-Y F
VILLAGE
INSTA LLER'S NAME &-1, ADDRESS
,94
BUILDER OR OWNER
-B a X .33 6
DATE PERMIT ISSUED /
DATE COMPLIANCE ISSUED ��_� e - 77
r �iA A ,
P a
�®��
� �•���
�� ��. ',
I
�Y7.......... Fw&4
N .........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
--....OF.... ...._............. .........................
Appliration -for 4%iVusal Workii Tiantitrurtion Prrmit
Application is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal
Systemat: .-:( /....O- ... ---/� .......................................... ............. .......
or -T r rl ess or
.......... ------ ........................................... ..............--------------- 72--L-Ot . O .. ----------------------------------
0 n Addre
...........I.......... .... ..------------------
--------- --- .......... •.... ...... ...7- -
----------------------------
Installer- ------------------------------------ .......... Address
U Type of Bu ding Size Lot.... feet
Dwelling—No. of Bedrooms---___-_.- ......................Expansion Attic Garbage Grinder (
aOther—Type of Building ---------------------------- No. of persons.--_____.--_______-_-___--_- Showers Cafeteria (-el Other fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------
-
W Design Flow_.._.._.____ ............*-------gallons per pet-son per day. Total daily flow............. ---____._-._-._-_gallons.
C4 Septic Tank-Liquid capacity/0-0-gallons Length________________ Width-_-_.--_--.-.- Diameter__............._ Depth----------------
Disposal Trench—No. .................... Width. Total Length_-_-___-_-_______--. Total leaching area-------------- -----sq. f t.
Seepage Pit No...../........... Diameter/*'0"._._4R1�...
...... -epth beloV inlet____________.__.____. .Total leaching area------- ----------sq. ft.
Z Other Distribution box Dosin_Yan4 le 17
--------------
Percolation Test Results Performed by. _VI'k ......IQ-- - ---------V----------
Test Pit No. I------I/-------minutes per inch Depth of Test Pit____________________ Depth to ground water-------------------
LT, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
P1 i I ..................... M----------------
--- ------ --
0 ------ - --------------------Is- ------------ -------- -----------------1------------------_-_
Description of Soil . ....4---_-------------------------------
U --------- .................................................................................................... ----------------------------------------------
W ----- -----*
Z ---------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable-------_------- ---------------------------------------------------- ---------- ---------------
---------------------------------------------- ............... ................................... --------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned f� her agrees not to place the system in
operation until a Certificate of Compliance has been iss d by the board if h
Sign .. ..... .................... ----- .... - --------------------------------
Date
Application Approved By......... .../A-J-77------------
Date
Compliance has been iss d by the board Si g . .... ....
n . ...
Application Disapproved for the following reasons:------------------- -------------------------------------------------------------------------------------------
.............------------I....................................................................................----------------------------------- -----------------------------------------------------
Date
7
Permit No. Issued..41- .................
Date
—---------------------------- —--------
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
77,
O(Y-7 57�
THE COMMONWEALTH OF MASSACHUSETTS
�.--- BOARD OF HEALTH
...._.. /' �''�.� .— - - ------ OF...../..� r :'L.f.r�................................,r v€.
- ...-----------
Appliration -fear Bi-q.Vviittf Workii Tintmtrurtion Permit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
•� M
._............._.__f........................................................................................................................ ..._....._...._.__......................._........._...._...._..............._....__............_
Location.Address
- r or Lot-No. -
r _� . ..... n. t 4 F
f / Owner\ r/ - / Address ,
J
/ Installer Address
UType of Building Size Lot..../.:-:_:------------------ feet
Dwelling—No. of Bedrooms------------ -----------------
--------Expansion Attic ( ) Garbage Grinder ( .)
aOther—Type of Building -------------------------_- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------- --------•-------------------•--------------.-------•--r.----.---------------
W Design Flow--------------7,5 _----.-____--___-..gallons per person per day. Total daily flow------------- --------.........gallons.
WSeptic •.r,.ulc�-Liquid capacity_ _±--_ gallons Length................ Width................ Diameter---------------- Depth..__----__.._..
x Disposal Trench—No. .................... Width-__-_--_r_q----- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No..... Diameter./,�.:.?)___� Depth below inlet____________________ Total leaching area----.-------------sq. ft.
Z Other Distribution box ( ) Dosing tank-( 77
Percolation Test Results Performed by---x«u `I__:_.)_)_"�_e_:........ - .......... Date.. 7---
Test Pit No. 1...... ._minutes per inch Depth of Test Pit-------r............ Depth to ground water......_.-_---.--._.._.
!� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--.---___---.-----_-
------------•-•_Z-------------------- ................................... ............el------------------------- ----------------
f r >G4<
D Description of Soil r, a E'-�".cam`. g.Su✓_:.. ---- --- --=-�1 -ice
x /E ------------------- ------------
U ........................... E r d `-C '•---•--•---•----••--•-•---•---•--•-•----•------
W
--------------------------------------------------------------___________________________________________________________________________________________________________________________________________
V Nature of Repairs or Alterations—Answer when applicable.........................._-____.__----.-..___-._.---__--.__.___-._------....._-_-__-..--------
-----------------------------•------------------•---------------•-------•-----•----•-------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.............._./��' ![,- ,- _.. r t,. _ __ / r!
--•---•--------•••--•---- ------ -••--
-----•-•-------------
A Application Approved B f Date
PP PP Y--.-..__�.__... , -----------�-- �,�--G[,�l�l.�l.-d-7: ---��-=--1-----�-�-----------
Date
Application Disapproved for the following reasons------------------------------------- ------------------------------------------------ -- ................
----------------•--•----------------•----•••--...-•••-------•----------•--------•-------••-•------•----------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued...................-- te----- .......................
THE Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARDf�OF HEALTH
....�?' ,!�:.:f............OF....G. G�?.�L..................................
Trrtifirate of W"I Lim rfinnrr
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed (-)or Repaired ( )
a7-----------
......L r �_.a_'�.l. 1:_... G�. v i• _ ns �l{G T .�it�
I t 1
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as/described in the
application for Disposal Works Construction Permit No. .-_:�5_ -_____-_•---._--__ dated. ................
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.------•----------------•------------------•--••----------------•------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
:.................. ..OF.............. .. 1�c:'d'i :. •----------.........
No. FEE.... ....
i � tt1 / a�rk �(�> tr�trti�it Perrot
Permission / reby granted_.... Y_.._..__
to Construct (, or Repair (' ) an Itdividual Sewage Disposal �y
at No. st m'
r-r-=---=--- ----- 0
/ � «,;
f /
Street
as shown on the application for Disposal Works Construction Permit No.--_______________? Dated...L-<=.._ --2-1._...._.._....._..
DATE. oard�of Health
F♦ORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
L
t�1��IG►�l ��s,TA /
2 A.14. AeD.
ridt Lam( FLo�t/ _ 11O 3 = 33d
USA- l0C)0 GAL.
2 ;r-
�5�_�A.t_._ loco Gam .
� c/c1LL AtzEA lS= o
.� � t ,
ICAO SF �c 2.�� 3 1S
$d ITC�N( Z O FE >r �� ST.
CE;D s.5=. I .o
ToTA t- -C;)esl6Q = .425 -
-T C>Ta gal t_�f r—I�uC/ - 330 6.w. C of
rawK
Iu SmIQ' o>z LASS. �nP p.r
M/k/
�{ EOo C7
/Z5
9c Tor ruo =goo.o
TAT
97,
VIST
-Sox 94,45 Sevric
IWV. T-A 04 K
v�
95.8 i •.,
I LAN
l_�zn✓ FIT
VWiro
WASIaED '
e n C F_-V-T t F I C D p LcbT' V='L /.V--!
PZUF--tLE-- LOCATIO" L�U`iEr-,/ ALL
r2` 85,E LJo scc.ia cAt_t� l ''_ �n �AT� 1(
/✓b WQ a-EZ
1 G tr C•:T I h`( T 1-1�T T 1-1 G Fo v t,���5'��0�.: 5 uo�t►J >�.�.1,.1 R��r��.�►.���-
t-lC.l�[ Z�IJ Gcatilr'L�(S W I'�1� T1,1;=- �jl D� LI►-IE l_..lrr 12`%
Al.lt� :(='t 1.'`;ACI_ C'rl.JJl�ENtE.►.iTy oP �c'►iE
t a W►J o. , 2 ^Ark '� ;,C :IL ,31
.ilLZI,
- _� ����c• t� �� � — E3h.,cTC WN"l= I"c.--
'("1-I15 t7i_AI•-..I !', tJUT L;�>C� V�--� A�.l
05TEV-VkL..11"_ v /VCASi
1c.lyr J:.�t:=�,►; /,c�;_\�t�� ;- '("+It.. U�t�*; ["�, ,I.1ce:at� I CIA,t--AT--_ f
I_.l:i C�['_ l.f=>ir.i-'> ii�>� i��.1 iwl�=M I�.!l`= `LG"C.' . l�i Ind t=.•� _ -���ti t� `�M A(.-(r.•__... --
fi
m r a 1
, ,. JELIIVLV A ,
�IiA1�VJ�+iA11Y
a
+ .. .: ., , ,. ,. .TALI 0U1ilT PPES fApl. "_ ,: ,. : ',, .x.. .: ` '•Q., le
_ �: : 'i�TE.ALL PIPES ARE TO BE 4 SCHEDULE 40 P.V.C. 4 a, tau LEACBI G,. TEM_- ,•'0151RililTlOM Goat a+eLL ssE
10, Min. from VENT PIPE'a Least 2 Indl ) PROFILE Vlh'JY_ OF ADDITION TO N , ,5`Y5 �ar,•,Y
* Schedule 40 PVC w Gha►Cod Odor FYter SET LEVEL f0R AI LLST 2 k -'.. : CONfX1E1E,00bER �,,_ , ,F �Or /
Existi Foundotton house to septic tank /Existing _ 'art 4�
- , ,. f.t .. 1 -t)Wrtled 3' 0 8' Ptak .w ,
n:
- k o0wre mud be ,. a r, s
ton
:r Assumed t '+ f
TOP OF,f0UN0AT10N.., ELEV. 100 00 ( ) a N+.:of RrlLlled 3, , . 3 to 1 1 2 Woehed Crushed` 3-r ouTLEr .
wwltn 9r� o0 oar SAS= ee oo l /
Flom
Grad.over D-Bon 0e '` 4 . 4. g
Gracia am �k Yolk 99.00 _:• .. - : Itrl0ac0U15 +
.<. 12 qET ss+
.. t.. :.�,. r.. ,, ' �_,, Goner �„�
e $ rp�
_ e' fi, r
s 0.02 : 3 FIOLE H 10 Lead- Elev. 25 1 / /
DIST.BOX lNMIr1
EXIST.-,. Creates 4
,v la' .1 to a' Y *� a , e e
„ ; . a 1,0130 GAL:,. S- 0.01 ,Mr foot . 4' -.SCH. 401.75' n
,
n eq . 25 _ Ef ective Depth ova,/ !` A J
- T �. . ,. . .SEPTIC'TANK" $ „ .,
fRoll EX1S .faMDA W !
. PLAN SECTION N 1 CROSS-==SECTIO
y
,,, a,
N o
0 83 10 inches
f
caNCl+srE Flat sartaA aD > p m ,n 7 ( ) 31.25 pI
e 3 HOLE. H-10' DISTRIBUTION BOX
> - 37.25 ,
•: a rl.ers 4-1a � r•
PRO LE >
e dole
S STEM Fi -, , :..
> .. > .. � E�fective Le h � ,, ,. „< ,'. � NOT TO SCALE ,• +d
! aompaoc.e Yt o � : as .. � r� .... :. ,�,.. . Will
,
Not to:Scate_ _ > 4• N SOIL ABSORPTICIN SYSTEM (SAS> ' �"+ ^
4 c , .
.
a in.of 3/4-t 1/2
$ 10 INFILTATRDR HIGH CAPACITI� (H 20 LOADING)/ GEORGE D'BRIEN ::GENERAL NOTES
6: [flecthr�rldtA
compacted .ton. - OR EQUIVALENT Not to Scale
• .. ( ) 1: C ntractor is-;res sible for'8i'safe notification .
x o 0 9
a' NOTE ". ALL:--.COMPONENTS MUST HAVE RISERS TO WITHIN 6 13ELOW GRADE a Bottom of Teat Hde I Oev.•87.00 m Ppoonn
t44' NOTE. OVERALL HEIGHT OF INFILTRATOR.6 18'',/EFFECTIVE HEIGHT IS 10"' ,Nand ,protection.of all."underground utilities :end pipes.
No ormwd otw oae.rvee O i i rt ti x.shall be set ,w "septic,leevel s tr6" ofk3�4 1 s 1 2 atone.'
2: fi "� a
/ /
tt r r vef.w h no
3•:Backfi should be~;cietih sand o g o d
. -
stones .over' ,gin,.size.
This system is subject to inspection during installation
4. by Carmen E. Shay',-Environmental Services, Inc.
,
LOT 125
" The ,controctor,shall Install this system in accordance
-(- # with`Title'V of`the Massachusetts state code, the ,approved plan
5
:Z " and Local Regulations. ".
....PERCOLATION . TES
tf''dun ',..installation'the contractor encounters an '
6• ,
:,Date':, f"Percolation Test: OCT. 14, .2004
' soilconditions or site conditions that„ore"different
o
Test.Performed By.':CARMEN E. SHAY, R.S., ` C.S.E. f on the, soil
Barnstable B.O.H. 1 0.00` installationexmust n alt do immediate�noificat on be design
Results Witnessed By. WAIVER ( per ) 0h
" E3(CAVATOR: UNKNOWNInc.
P otion Rote: ' t.Etss Than 2 MPI O 24 ` made to* Carmen E Shay"-.-,Environmental Services, In
ereoi 7.-'No vehicle or heavy;machinery shall drive over the
sap - .
tic system ,unless n`oted.as.H 20 septic components
• 8. Instal{`Tuf-rite gas baffles"or equals on' all outlet tee ends.
4»•d.
PV
9. All Distribution tine's'sholl be larneter•Schedule 40 NSF C pipes:
Al solid`piping,";tees dt fittings shall 'be 4" diameter
Test Hole
10.
NO. 1 Schedule0 NSF.PVC pipes with water'tight joints
DEPTH WILS ELEV, 11. Municipal Water is Connected .to ALL OF The Residence and Abutting
o sB.00 Properties Within 150 Feet. ,.
IY 4.75' 37.25 29'
THE - P
TE AND
i
LOT,#124 COMPILED FROMTHEE SURVEY PLAN�GENERATTED BY
BAXTER & NYE, INC. OF OSTERVILLE,'MA ENTITLED
a"-g" A 9B 50 o f �' a �_ » o� -,:CERTIFIED PLOT PLAN OF LOT 1122 HENRY LORING DRIVE ,' CENTERVILLE
c• AND AIS DTJOTDINTEN DATED
BNOVEME A SURVEY PLOT PLAN
LoornSandr LOT #121 cri
10 VR 5/e �
s"- 24" Be es.00 r D-Box IT SHOULD BE USED-FOR NO PURPOSE OTHER THAN
kted.-FTne TEST HOLE #1
THE SEPTIC SYSTEM INSTALLATION
Sand do Grove! ELEV.=. 99.00
f r a/4 .:
"EXISTING LEACH PIT TO BE PUMPED OUT AND
124 -84* +� ` 86.50 REMOVED TO l AC 1-ITATE NEW`SEPTIC SYSTEM INSTALLATION
I bled. NOTE: ANY STRIPPED OUT`SOIL CONTAINING LEACHATE ,
Sind .; .:. ' ,
2 r is/e 4 EXIST. 1000 gat. FROM THE 'EXISTING LEACH PIT TO BE DISPOSED
84'-144" .. ee.5o -Septic Tank
_ Failed ,
: OF AS PER BOARD OF HEALTH SPECIFICATIONS.
__PROJECT BENCH MARK O _- ENO_-WETLANDS-AREL_PRESENT.,WITHIN 200' OF THE PROPERTY,
--Leach Plt
TOP OF FOUNDATION - --
ELEV. _ 100.00 (Assumed)
ASSESSORS MAP 172 PARCEL 181
•
DECK
LEGEND
Perc #1 - -PROPOSED
i
Depth to Perc: 28',to 46"
104X 1
DENOTES
Perc Rate- Less Than 2 MPI
EXISTING
Groundwater Not Observed SPOT GRADE
No Observed-ESHWT 2 DRDR00.1f DENOTES EXISTING
X 104.46 SPOT,GRADE
ADJUSTED H2O Elev. = None HOUSE
#49 ,PL PROPERTY LINE
CARACB
LOT #123 96 PROPOSED CONTOUR
-"--97 EXISTING CONTOUR
I I I ..
LOT #122
' I I � DEEP TEST HOLE &
A
2-18' DIAM. ACCESS MANHOLES ' i i PERCOLATION TEST LOCATION
16,808 Square Feet
fr ► I ��� •-=• 6 FOOT STOCKADE FENCE
b _ IASPHALT
DRIVEWAY�
{.. OUTXT
II P LOT PLAN
THE ACCESS COVERS FOR W SEFnC TANK.
` 79.71
�. r R = 1181.89' OF PROPOSED SEPTIC SYSTEM UPGRADE
D15TR�U110N 80% AND LEACHM COMPONENT
r► •-s •.r •-•- •.--:•.r -� SET DEfPER THAN a Mai S BELOW WSHED
ZEE -A,R ?: a . - ;GRADE SHALL BE RAISED TO VA7M 6' OF
STEEL REINFORCED PRECAST CONCRETE FROSHED GRADE :' i ' i PREPARED FOR
�` .
PLAN A EW / \
LOISE M . McCAIG •
. INSTALL 7UF-IITE GAS BAFFLES OR EQUALS
•&r.
/-3-24'REMOVABLE COVERS
AT
*,
4.
H.�'N.R �Y L O R LNxG DRIVE
#49 0 ING DRIVE
HENRY L R
min. deararoe _
-
' INLEt 6'rnk+ r w4i. iraet to outlet tY eatr
40 FOOT' RIGHT OF WAY)
ouTLaT = ENTERVI LLE MA
r 5• =T -
5 -r . � .. Design Calculations- .Ij of
9
'
'
•-0'min.
� REPARED BY:.
am Dan. depth Number of Bedrooms: 2 E uivalent to'220 Gal. a 330 Gal. Do Min: per,,Title`f s VE
• q � Y ( � Y P �Garbage Grinder: ,NoA. Ledching Capaclty Proposed, 330 Gal./Day Minimum (Min. Per Title VS tic Tank 2 330 Gal. '_ 660 � EXIST. 1.000 CAI. Se tic Tank.
ep r /DaY , P •' NYIRONb[ENTAL 'SERVICES,' INC.
ABSORPTION AREA: :Usin ercolotion rate of <2 min. inch l; +.
SOIL B g D � :.. ..
R SECTION ;, END--'SECTIONBottam.Area: 74 al ft.,,:;x',„37o ft. _ ;273.s allons_ F P.O.- BOX 627.,
C 05S . ;9 /s4 c ER ,
I ,. ST
i I .74 . IL,`- x 78 s . ft. _ 58 allons . .,
S dews l Atisa. .0 9d% q 9 F M A= 2 6
... �. _ ,_4 ,, ,, ► ., : .:r _ .., s N� .EAST• AL OUTN,-: M ,fl 53
- I .s
qNI TARP
,
.., Providi 3 8 t..,
TEL FAX 508 548 0796,
- r TYPICAL 1000 GALLON -':SEPTIC TANK
S ALE: 1"= 0 ;
NITS -HAVING 0.83 !) INCHES EFFECTIVE DEPTH - ,
Use. 5 �IFiLTftATOR t11GH CAPACITY H 20 U (1 ) ;:" ;.
: NOT To SCALE. _ . : _ :- ,. �..>� � _ R N Y: �CES ATE. OCTOBER 15 2004
,.: .,. ,.;, �. , . N . . SCALE: 1 , 20 , ,., ... D AW 8 , , ,
TO USED 1MTH 4.0 OF WASHED STONE ON THE SIDE. AND 3.5 OF'WASHED STONE '
e , .-•..
, �„ . ,� ..: ;. ... . ,. ,: .. PR J CT SD643� FILENAME:: `S0643PP,DWG SHEET '1 : OF 1
ON T'HE,ENDS. 'NO STONE UNDER. ., .,, x,. . O E n
,
.,. r .. ., ., vx, tie v ... ... ;. , :.e .' :: g, -: '• ,•t -
,..
a