HomeMy WebLinkAbout0578 HUCKINS NECK ROAD - Health 578 Huckins Neck Road
Centerville P
ti
J
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Nam
information is ��-
required for every le MA 02632 5/11/12
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, � � �
use only the tab 1. Inspector. 14
key to move your
cursor-do not Ricky Wright
use the return Name of Inspector
key.
B & B Excavation,lnc.
rffi Company Name
14 Teaberry Lane
Company Address
Forestdale MA 02644
City/Town State Zip Code
508-477-0653 S 14595
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:
21
r�
® Passes ❑ Conditionally Passes ❑ Z`aFIs
R k w s:
El Needs Further Evaluation by the Local Approving AuthorityUll�-^H
cu
M.
5/11/12
Inspector's Signature Date a
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.
LA)
t5ins•11/10 Title 5 Offici#InspctionForm:Subsurface Sewage Disposal System•Page 1 of 17
i
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
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):
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•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
wM 578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•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
°M 578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page.. City/Town 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 ears usage d n/a
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 1 year ago
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:
1/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
t5ins-1 7
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ 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.
i
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3'feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >15'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order- no sign of leakage or blockage.
Septic Tank (locate on site plan):
Depth below grade: 2'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:
1000 gal
Sludge depth: no sludge
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. Cityrrown 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 no sludge
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle no scum
Distance from bottom of scum to bottom of outlet tee or baffle no scum
How were dimensions determined? scour 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.):
At time of inspection septic tank appears to be structurally sound - no sign of back-up
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
578 Huckins Neck Road
M
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
H W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box appears to be in good condition.
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:
l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching was dry and appears to be in good condition. No sign of hydraulic
failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. CityrFown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is Centerville
required for every MA 02632 5/11/12
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
= 13'
J$
= 30t
dam 31
b4 - 3� `
a
3
p.
L15ms10
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
578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >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: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
L Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
578 Huckins Neck Road
Property Address
Andrew& Lisa Smith
Owner Owner's Name
information is required for every Centerville MA 02632 5/11/12
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
`,29 3
COMMONWEALTH OF MASSACHUSETTS �+
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF IRSR-ECE
DEPARTMENT OF ENVIRONMENTAL PROTEc riON
234 .
JUN 17 2004
'vy MAP TOWN OF BARNSTABLE
PARCEL i ® y I HEALTH DEPT.
LOT `
TITLE 5
OFFICIAL INSPECTION FORM 'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 578 Huckins Neck Road
Centerville,MA.02632
Owner's Name: Christopher Kuhn
Owner's Address: Same
Date of Inspection: 5/24/2004
Name of Inspector:(please print) Brad J White
Company Name:Windriver Enviromental
Mailing Address: 107 N.Main Street
Carver,MA 02330
Telephone Number:(508)-866-2576 ;�
CERTIFICATION STATEMENT
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 5/24/2004
The system inspector shall submit a copy of /sinspection 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.
Notes and Comments
System Passes.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
a
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 578 Huckins Neck Road
Centerville,MA. 02632
Owner: Kuhn
Date of Inspection: 5/24/2004
Inspection Summary: Check A,B,C,D or E/`ALWAYS complete all of Section D
A. System Passes:
X 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:
System passes.Recommend regular service.
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
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:
T41. 2
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 578 Huckins Neck Road
Centerville,MA.02632
Owner: Kuhn
Date of Inspection: 5/24/2004
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 15303(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.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the 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:
Title G Tncn *r —P—411 si)nnn 3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 578 Huckins Neck Road
Centerville,MA. 02632
Owner: Kuhn
Date of Inspection: 5/24/2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface 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.
Titles T--t;—P—411 c/wnnn 4
i
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 578 Huckins Neck Road
Centerville,MA.02632
Owner: Kuhn
Date of Inspection: 5/24/2004
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X Pumping information was provided by the owner,occupant,or Board of Health
_X Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X _ Was the facility or dwelling inspected for signs of sewage back up'?
_X_ _ Was the site inspected for signs of break out'?
_X_ _ Were all system components,excluding the SAS,located on site?
_X _ 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?
_X _ 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:
Yes no
_X _ Existing information.For example,a plan at the Board of Health.
_X_ _ 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(3)(b)]
T410 T--f-;—T7—(l1 c01100 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 578 Huckins Neck Road
Centerville,MA.02632
Owner: Kuhn
Date of Inspection: 5/24/2004 a4
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330gpd
Number of current residents: 2
Does residence have a garbage grinder(yes or no):NO
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no):Yes
Seasonal use:(yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no):NO
Last date of occupancy:Current
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the.Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped after inspection.
Was system pumped as part of the inspection(yes or no):Yes
If yes,volume pumped: 1,000_gallons--How was quantity pumped determined?Sight tube on truck
Reason for pumping: check tanks structural integrity.
TYPE OF SYSTEM
_X_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
No 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:
System was installed in 1995 per as built plan.
Were sewage odors detected when arriving at the site(yes or no): NO
T41A G Tnon f;-P—4/1';/')Ml1 6
i
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 578 Huckins Neck Road
Centerville,MA,02632
Owner: Kuhn
Date of Inspection: 5/24/2004
BUILDING SEWER(locate on site plan)
Depth below grade: 36"
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supply well or suction line:N/A
Comments(on condition of joints,venting,evidence of leakage,etc.):Building sewer is in good conditon.
SEPTIC TANK: X (locate on site plan)
Depth below grade: 23"
Material of construction:X concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:8'x 5'-8" x 5'-2"
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:30"
Scum thickness:3"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined:Measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Inlet and Outlet tees are in good condition. Liquid level is normal.No evidence of leakage in or out.
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
T41. G Tnon frt T?n A/1 7
� 1
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 578 Huckins Neck Road
Centerville,MA.02632
Owner: Kuhn
Date of Inspection: 5/24/2004
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/day
Alarm present(yes.or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:X (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.):Distribution box is level.Good condition no evidence of solids carry over
1
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Titl. C Tnen "r P^n 4/1 VIMA 8
� f
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 578 Huckins Neck Road
Centerville,MA.02632
Owner: Kuhn
Date of Inspection: 5/24/2004
SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
—X leaching pits,number: 1 @ 6' x 6' (2' from pipe to water)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): Soil is dry.No evidence of hydraulic failure.Vegetation is normal.No ponding on the surface.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,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.):
. Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 578 Huckins Neck Road
Centerville,MA.02632
Owner: Kuhn
Date of Inspection: 5/24/2004
C.y
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.
I
I
V4
A 2
P4 , wo`
3U
T41.G Tnon—#f—P^n All V100A 10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 578 Huckins Neck Road
Centerville,MA.02632
Owner: Kuhn
Date of Inspection: 5/24/2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 6'+ feet
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed: 2001
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:No indication of groundwater at 6'.
Taken from percolation test result dated 8/9/01
T41n C 'P^—4/1 snnnn 11
5/25/01
NOTICE: This Form Is To Be Used'For the Repair Of Failed
Septic Systems Only.
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION
FORM
hereby certify that the engineered plan-signed by me
dated concerning the property located at
' F
meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no
commercial or business uses associated with the dwelling.
• The soil is classified as.CLASS I and the percolation rate is less than or equal to 5
minutes per inch. The applicant may use historical data to conclude this fact or may
conduct preliminary tests at the site without a health agent present.
• There is no increase in flow and/or change'in use proposed
There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than fourteen
(14) feet above.the maximum..adjusted groundwater table elevation. [Adjust the
groundwater table,using the Frimptor method when applicable]
Please complete.the.following:
A) To of Ground Surface Elevation (using GIS information) V D
p ( g
B G.W. Elevation + adjustment for high G.W. 7.
J g
DIFFERENCE BETWEEN A and B
r; SIGNED /
DATE:
NOTICE
Based upon the above information; a repair perrriic will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered
septic system plans. }
i
q:health folder:percexmp
CO VIMONWEAL,TH OF MASSACHUSETTS
ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORINI — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property address:
Owner's Name:
Owner's address:
Date of Inspection:
Name of inspector: (please print) / llCh4yr t (J/( sic/
Company Name: WIND RIVER ENVIRONMENTAL
Mailing Address: 561 MAIN STREET
HUDSON.`IA. 01749
Telephone Number: 1-978-56:-4500
CERTIFICATION STATE.INJENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and come fete 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:
t/, asses
Conditionally Passes
Needs Further Evaluation by the.Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this i �ection 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 an; 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.
Notes and Comments
*'"This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
{ Paue ? of l 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICAT�IION/ (continued)
Property Address: ° ' `'�j �"L"� ��•
Owner: L vfc
Date of Inspect on:
Inspection Summary: Check" A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
v I have not found any information which indicates that any of the failure criteria described in 310 C1v1R
15.303 or in 310 GLAIR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments: Q 5re--, Aix
B. SyQtern Conditionally Passes:
ne or more system components as described in the "Conditional Pass" section need to be replaced or
rep iced. 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,v,Ni D) 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 30 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken. settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced ".
obstruction is removed
distribution box is leveled or replaced
N-D explain:
The system required pumping more than 4 times a year due to broken or obstructed.pipe(s). The system wilt
pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
\D explain:
4
Pace 3 of 1 I
OFFICIAL INSPECTION FORNI - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: i U(__41
a,T tiwi/
Owner: L C'
Date of Inspection.
Wil
urher 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
ing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CNIR 15.301(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 ly�ater Supplier, if any) determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic.tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has.a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes.if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence.of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
y
` Page 4 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _ 7- /7
Owner: C_
Date of Inspecti n: �
D. System Failure Criteria applicable to all systems:
You must indicate "ves" or-'no' to each of the following for all inspections:
Yes No
e—S. Backup of sewage inte facility or system component due to overloaded or clogged SAS or cesspool
_ Discharge or pondin__:i effluent to the surtace of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
�G Static liquid level in ["e distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1,1, day flow
Required pumping me:e than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
Ss. Any portion of the S. S. cesspool or privy is below high ground water elevation.
j<, Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Se .any portion of a cesspool or pricy is within a Zone 1 of a public well.
Any portion of ai:esspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A coPy of the analysis must be attached to this form.]
a (Yes,!-No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 C'-',1R I i.303. therefore the system fails.The system owner should contact the Board of
Health.to determine v hat will be necessary to correct the failure.
E. Larae Svstems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd,
You must indicate either"Yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of surface drinking water supply
the system is within 20o 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
signitic ant threat under.Section E or failed under Section D shall upgrade the system in accordance with 310 CNIR
15.304. The system owner should contact the appropriate regional office of the Department.
i
Page 5 of 11
OFFICI.aL INSPECTION FORM — NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
n/
Owner:
Date of Inspection: 0
Check if the following have been done. You must indicate "yes" or-no" as to each of the following:
e 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 i%is inspection ?
Were as built plans of the system obtained and examined?(If they were not availaie 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 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:
Ye no
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 CNIR 15.303(3)(b)J.
Pose 6 of 1 l
OFFICLAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE
T E SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 5- / l
01 �i 1
Owner: I Giy
Date of Inspecting: 3 (J
LOW CONDITIONS
RESIDENTIAL
Number of bedrooms.(des ign): Number of bedrooms (actual):
DESIGN flow based on 310 CNL R 1�.203 (for example: 110 gpd x#of bedrooms): 33 o
Number of current residents: �L �1�
Does residence have a garbage grinder(yes or no): 1 1u
is laundry on a separate sewage system (yes or no): rXD [if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): M
Water meter readings, if available(last 2 years usage(gpd)): _
Sump pump (yes or no): r�a
Last date of occupancy: Cvfren
CONINIERCIAL/INDUSTRIAL
Type of establishment:
i Design flow (based on 310 CNIR 15?03): gpd
Basis of design flog (sea ts/person s/sgft.etc:):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non-sanitary waste discharged to the Title : system (yes or no): _
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe): `
GENERAL INFORMATION
Pumping Records t�
Source of information: Y10T m SC,, ,-\%1 ` h e4S
Was system pumped as part of thie inspection (yes or no):
If yes, volume pumped: /Wo Rallons --How was quantity pumped determined? S1Ze-
Reason for pumping: �(etv Sol+dS
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)
_ InnovativerAlternative. 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 comeon�, date installed (if known) and source of information:
Grl
Were sewage odors detected when arriving at the site(yes or no): _
Page 7 of l t
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
t SYSTEM INFORMATION(continued)
t1 Property :address: � p V"" keu( BJ'
CPn� 'l
Owner: Lcr 4 .
Date of Inspecti n: -712 (
BUILDING SEWER (locate on site plan)
Depth below grade: 3
Materials of construction: _cast iron V 40 PVC _other (explain):
Distance from-private water supply well or suction line:
Comments (on condition of joints, venting. evidence of leakage, etc.):
SEPTIC TANK: L/_(locate on site plan)
Depth below grade:
Material of construction: Zconcrete_metal _fiberglass_polyethylene
—other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: el^4
Sludge depth:—I� a111i
Distance liom top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: r�e—ULw-r) L-41 SJTLk
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet�nvert, evidence of leakage, etc.):
r'-C,Gr*e a Pw Plnti fecE�(vtr C-G �'[c"_ o�-Te i� t- tl5 pia o j n o
GREASE-TRAP:. . (locate on site plan)
Depth below grade: _
Material of construction: _concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of l I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSINIENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
(SYSTEM INFORMATION(continued)
Property Address: 5-7 0y
CQrtre r�lk
Owner:
Date of Inspectiorl.
TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
"vIaterial of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: sallons
Design Flow: sallons/day
Alarm present (yes or no)--..
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: U
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.):
or
PUMP CHAMBER:� locate on site plan)
Pumps in working order(yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9oflt
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INAfFORMATION (continued)
Property Address:
�l
Owner: L 1 1u)
Date of Inspectio : '
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
V leaching pits. number:_
leachine chambers. number
leaching galleries, number:
leaching trenches, number. length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type,,name of technology:
Comments (note condition of soil, signs of hydraulic,iailure, level of ponding, damp soil, condition of vegetation,
etc.):
nQ Sl O�— 0— 'il�,` Wa, V �ltG�►1�S�c — U� IT�n�.
CESSPOOLS:t`J P-(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 laver:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hvdraulic 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.):
Page 10 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
0j
Property Address: c-�- a•��
Owner Li,(Orec j�n1�t
Date of Inspection: :0 t
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.
i
'J
y a--
c 3.
� �0
Pace 1 1 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOP-Mi ATION (continued)
Propem. Address: �Ct/cJ�f Iu�� �d,
Owner: L .0 kcj
Date of Inspect on:
SITE EX- k
Slope `(�5
Surface water ✓/�� -
Check cellar 0'7'
Shallow wells no
Estimated depth to ground wate � feet
Please indicate (check) all methods used to determine the high Bound water eievation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site (abutting propem./observation hole within 1=0 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators. installers-(attach documentation)
Accessed USGS database=expiain:
r
You must describe how you e tablisIned the high ground water elevation:
L �T)126 �
11
5/25/01
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.,
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION
FORM
hereby certify that the engineered plan signed by me
dated concerning the property located at
meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There.are no
commercial or business uses associated with the dwelling.
• The soil is classified as.CLASS I and the percolation rate is less than or equal to 5
minutes per inch. The applicant may use historical data to conclude this fact or may
conduct preliminary tests at the"site without a health agent present.
• There is no increase in flow and/of`change in use proposed
• There are no variances requested Or needed.
• The bottom of the proposed leaching facility will not be located less than fourteen
(14) feet above the maximum adjusted groundwater table elevation. [Adjust the
groundwater table using the Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation (usin GIS information V D
g )
B) G.W. Elevation +.adjustment for high G.W.
DIFFERENCE BETWEEN A and B
SIGNED : DATE: v. /
4. 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.
q:health Folder:percexmp
oPa
CERTIFICATE OF ANALYSIS Page. 1
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 03/18/1999
Nickulas Building Company Order Number: G9901333
Andrew Miller
578 Huckins Neckk Road
Centerville MA 02632
Laboratory ID#: 9901333-01 Description: Water-Drinking Water
Sample#: 4F-001 Sampling Location: 578 Huckins Neck Road,Cent Collected: 02/05/1999
ollected by: A.Miller Received: 02/05/1999
Test Parameters
ITEM RESULT UNITS MCL Method# Tested
LAB:Inorganics
Ammonia 0.4 mg/L EPA 350.3 02/18/1999
LAB:Microbiology
Fecal Coliform Present I per 100 mL 0 Colilert 02/05/1999
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB:IC Lab
Nitrate 0.7 mg/L 10 EPA 300.0 02/05/1999
LAB:Metals
Copper <0.1 mg/L 1.3 SM 3111B 02/11/1999
Iron 0.1 mg/L 0.3 SM 3111B 02/11/1999
Sodium 17 mg/L 20 SM 311113 02/11/1999
LAB: Microbiology
Total Coliform Present Colilert Absent Colilert 02/05/1999
LAB: Physical Chemistry
Conductance 158 umohs/cm EPA 120.1 02/08/1999
pH 7.3 pH-units EPA 150.1 02/08/1999
Note: Exceeds the recommended maximum contamination level for drinking water due to the presence of Coliform Bacteria.
Approved By-'
(Lab Director)
3/1�f5�
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph:-509-375-6605
Barnstable County Health Laboratory
ANALYTICAL REPORT FOR
Nickulas, Building Company
Report Recipient:
Nickulas Building Company -7
Andrew Miller
578 Huckins Neckk Road
Centerville MA 02632
Invoice#: G9901340
No.of Samples: 4
Date Received: 02/08/1999
Project ID:
J G� CX.vi n �YJ�-� P`-�_ PW'- �r/dv i' cc.✓ w� . tr Ir
AW
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
02/26/1999
t �pF:Hilj�•.
o s Page: 1
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
tY
Report Prepared For: Report Dated: 2/26/99
Nickulas Building Company Order Number: G9901340
Andrew Miller
578 Huckins Neckk Road
Centerville MA 02632
Laboratory ID#: 9901340-01 Description: Water
Sample#: RF-99-01 Samplina Location: G-Surface Collected 2/7/99
Collected by: AMM- Received 2/8/99
Test Parameters
ITEM RESULT UNITS MDL MCL Method# Tested
LAB:Inorganics
Ammonia 0.9 mg/L 0.1 EPA 350.3 02/18/1999
LAB:Microbiology
Fecal Coliform Present J per 100 mL 0 0 Cotilert 02/08/1999
Routine
ITEM RESULT UNITS MDL MCL Method# Tested
LAB: IC Lab
Nitrate 0.9 mg/L 0.1 10 EPA 300.0 02/09/1999
LAB: Metals
Copper <0.1 mg/L 0.1 1.3 SM 3111B 02/11/1999
Iron <0.1 mg/L 0.1 0.3 SM 3111B 02/11/1999
Sodium 26 mg/L 1.0 20 SM 3111B 02/11/1999
LAB:Microbiology
..---
Total Coliform 'Present P/A 0 Absent P/A 02/08/1999
LAB: Physical Chemistry
Conductance 210 umohs/cm 1 EPA 120.1 02/08/1999
PH 7.3 pH-units 0 EPA 150.1 02/08/1999
Note: Exceeds the recommended maximum contamination level for drinking water due to the presence of Coliform Bacteria High
levels of sodium.
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
Page. 2
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 2/26/99
Nickulas Building Company Order Number: G9901340
Andrew Miller
578 Huckins Neckk Road
Centerville MA 02632
Laboratory ED#: 9901340-02 Description: Water
Sample#: HF-99-02 Sampline Location: C-Wells Collected 2/7/99
Collected by: AMM Received 2/8/99
Test Parameters
ITEM RESULT UNITS MDL MCL Method# Tested
LAB.Inorganics
Ammonia 0.1 mg/L 0.1 EPA 350.3 02/18/1999
LAB:Microbiology
Fecal Coliform Absent CFU/100 mL 0 0 MF 02/08/1999
Routine
ITEM RESULT UNITS MDL MCL Method# Tested
LAB: IC Lab
Nitrate 0.8 mg/L 0.1 10 EPA 300.0 02/09/1999
LAB:Metals
Copper <0.1 mg/L 0.1 1.3 SM 3111B 02/11/1999
Iron <0.1 mg/L 0.1 0.3 SM 3111B 02/11/1999
Sodium 36 mg/L 1.0 20 SM 3111B 02/11/1999
LAB:Microbiology
Total Coliform Absent P/A 0 Absent P/A 02/08/1999
LAB:Physical Chemistry
Conductance 278 umohs/cm I EPA 120.1 02/08/1999
pH 7.1 pH-units 0 EPA 150.1 02/08/1999
Note: Based on the results of the parameters tested,the water is suitable for drinking but has high levels of sodium.Persons on low
sodium diet should consult their doctor.
Superior Court House, PO.Bog 427, Barnstable, MA 02630 Ph: 508-375-6605
Page: 3
CERTIFICATE OF ANALYSIS
$'s, Barnstable County Health Laboratory
Report Prepared For: Report Dated: 2/26/99
Nickulas Building Company Order Number: G9901340
Andrew Miller
578 Huckins Neckk Road
Centerville MA 02632
Laboratory ID#: 9901340-03 Descrintion: Water
Sample#: HF-99-03 Samnline Location: A-Well#3 Collected 2/7/99
collected by: AMM Received 2/8/99
Test Parameters
ITEM RESULT UNITS MDL MCL Method# Tested
LAB:Inorganics
Ammonia 0.2' mg/L 0.1 EPA 350.3 02/18/1999
LAB:Microbiology
Fecal Coliform Absent CFU/100 mL 0 0 MF 02/08/1999
Routine
ITEM RESULT UNITS MDL MCL Method# Tested
LAB:IC Lab
Nitrate 1.2 mg/L 0.1 10 EPA 300.0 02/09/1999
LAB: Metals
Copper <0.1 mg/L 0.1 1.3 SM 3111B 02/11/1999
Iron. <0.1 mg/L 0.1 0.3 SM 3111B 02/11/1999
Sodium 18 mg/L 1.0 20 SM 3111B 02/11/1999
LAB:Microbiology
Total Coliform Absent P/A 0 Absent P/A 02/08/1999
LAB:Physical Chemistry
Conductance 155 umohs/cm I EPA 120.1 02/08/1999
pH 7.5 pH-units 0 EPA 150.1 02/08/1999,
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Superior Court House; PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
OE::U,
CERTIFICATE OF ANALYSIS page: 4
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 2/26/99
Nickulas Building Company Order Number: G9901340
Andrew Miller
578 Huckins Neckk Road
Centerville MA 02632
Laboratory ID#: 9901340-04 Description: Water
Sample#: HF-99-04 Sampline Location: F-Surface Collected 2/7/99
collected by: AMM Received 2/8/99
Test Parameters
ITEM RESULT UNITS MDL MCL Method# Tested
LAB:Inorganics
Ammonia 0.2 mg/L 0.1 EPA 350.3 02/18/1999
LAB: Microbiology
Fecal Coliform Present CFU/100 mL 0 0 MP 02/08/1999
Routine
ITEM RESULT UNITS MDL MCL Method# Tested
LAB:IC Lab
Nitrate 0.8 mg/L 0.1 10 EPA 300.0 02/09/1999
LAB: Metals
Copper <0.1 mg/L 0.1 1.3 SM 3111B 02/11/1999
Iron <0.1 mg/L 0.1 0.3 SM 3111B 02/11/1999
Sodium 12 mg/L 1.0 20 SM 3111B 02/11/1999
LAB: Microbiology
Total Coliform Present P/A 0 Absent P/A 02/08/1999
LAB:Physical Chemistry
Conductance 126 umohs/cm 1 EPA 120.1 02/08/1999
pH 7.4 pH-units 0 EPA 150.1 02/08/1999
Note: Exceeds the recommended maximum contamination level for drinking water due to the presence of Coliform Bacteria.
Approved By:
(Lab Director
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
��7SC� f OtOF� RNSTABLE o
LOCATION SEWAGE #
VILLAGE �V��;;c����. ,I ASSESSOR'S MAP & LOTS M1� 1
INSTALLER'S NAME & PHONE NO.
PSEPTIC TANK CAPACITY
�EACHING FACILITY:(type) 1,2oo (size) ,
NO. OF BEDROOMS PRIVATE WELL PUBLIC WATER
BUILDER OR-0 ., ���% �'
DATE PERMIT ISSUED: S /
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
Gv
d
No.J..,.:. -F2�> FRs.......... ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Alip iratioit for Ali►ipooa1 World, Tontrnrtion ramit
Application is he_reby made for a Permit to Construct (,�) or Repair ( ) an Individual Sewage Disposal
System at: 45 /V
ZNf
.... ..........................•-• ---•-
Loctti n-: idress Lot No.
........_ -- ��
/ / nddress —C{...............
...... ...............•
rla. 11si7 J�
Installer Address
UType of Building Size Lot.. ......Sq. feet
., Dwelling—No. of Bedrooms---------------------------------------Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ____________________________ No. of persons......................------ Showers ( ) — Cafeteria ( )
a' Other fixtures ...................................
W Design Flow.... /lf__. �, /� .........gallons per person per day. Total daily flow....__ .......................gal
r y " y ,�..�.�1._. lons.
WSeptic Tank—Liquid capacityX. M..gallons Length.--.��s_4.. Width_c._ -.:._ Diameter----------------- Depth..S�7."
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....al.vs...... Diameter......IP!...... Depth below inlet.....4.......... Total leaching area..,?4�3�e...sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) p
a Percolation Test Results Performed �r .......... Date__..�"�'.9..7................
7"
a Test Pit No. 1.. ,.Z'..__Ininutes per Inch Depth of Test Pit.-/-3............. Depth to ground watenwo.�Lt---
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94 •-••--••-•---••••---------------• •••••-•-•••-••••_•-•.......................................................................................................
ODescription of Soil.............6.•••..-��--_-... .._L-------•---•--•------------------------------------•-----------------------------------.......----......
W
UNature 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 TITLE 5 of the State Environmental 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 . .�.... ... .... . . .. . . ................ .................................:......
Dare
ApplicationApproved By ......... -^s;................................................................ ......7........ ..... ".:.. e-..°1`�-...
Dar
Application Disapproved for the following reasons: .......................................................................................................................................
...................... . ............................... .............................................................................................. . . . . ... . ........ ..... ........................................
Permit No. ............ ....?'�..-..........���............. Issued ....................................................... Dare......
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate, of Complianre r
THIS IS /TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by ......................_1^(. �e- ---
.-------
..........---
.------
----------------- -- -...... ....------- ....................................................................................................
at .............. - ...t.,-c ... .. -------------- - --------------.---.-------- ..............
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ......._.7,y-.w-),-;i.--- .... dated ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DA
TE ....f..../ '.... ._.` ....... ..- --.._..---._--- Ins ec t _. J ..< .......... `
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
q TOWN OF BARNSTABLE No.....�•>`� ..... FEE....k . .......
Uispnott1 Workii Tunotrurtuan "amit
Permission is hereby granted--------------- aXe-1---------r'------------------- --•---......-................................................
to Construct (>4 or Repair ( ) an Individual Sewage Disposal System .
LiC��S�1.w_ R e� .._._1�.--------....._l'.!? Se-ems.
at No..---..._.._ .. T rl ----- scr«c
as shown on the application for Disposal Works Construction Permit No._A.A.?a Dated......... .�l�.r...� .
..----•--•---------------------------------------- -- -— -------------------------------------
� II� 1 �al�ti
DATE------------------- .'' . ...?. L......... .//
FORM 36508 HOBBS R WARREN.INC..PUBLISHERS -
4'�..'Y'iY^.e-.a�.sKLs4R:ti.J✓'�ity-:'I.s�}'.'�L��J --.7Ny �;/ .�i'- +i. .,�.�.�J�' «{. "Si i'.._ f. ,�L r , �t.` �,.•'.�.�:�:Af�.`'��.�+WV'.wi..r � �L�Yi�'MT ����j'S-ie�
r Fs. �"zC1......No. y=
THE COMMONWEALTH OF 'MASSACHUSETTS
^ a BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphratiou for Di►i,pooal Works Towitrur#iou rrrutit
Application is hereby made for a Permit to Construct ( 1 ) or Repair ( ) an Individual Sewage Disposal
System at:
7�✓' J''
................... •--••-----•-•----•-----•--•...---•------•-----------------------------------••----................
Location-Address Lot
....--•-- 116 y ...
�tiN/+�SSL ...... -
O�'n/eq_ Address J
l/ ......_
Installer Address
Q Type of Building Size Lot..45--.1-_.rz_2q......Sq. feet
Dwelling—No. of Bedrooms------ _ -________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures _______________________________ _ _
-------------•--•----------------••---•--•...............
W Design Flow...I'M...���44?M..........gallons per person per day. Total daily flow------ � . 2--------------------------gallons.
9 Septic Tank—Liquid capacity/5,206..gallons Length_._ Width_7'k:_._. Diameter________________ Depth.....?'.!
Disposal Trench—No. .................... Width.................... .Toth Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.... AIC-____-- Diameter------7,01...... Depth below inlet...... '........ Total leaching area._e;?j4.l...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by..(..4(A)Y.�_ / ?!? L�..1��; ....... 9` 7
Date...------—:.�--------------
a Test Pit No. L:4-2......minutes per inch Depth of Test Pit__ 3............. Depth to ground water.NVt.45C� .-
�T4 `' Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ............................... ....................................................................................................................
0 Description of Soil--------- _............. 1�5a__ ../
V .................................•--.......7_.r.- .�/1�1. -._. , >a /lV -
W
-------------------- ------------------------------------------------------------------•--•-•-•-•-•----•----...------.....--•--.........•---- .........................................................
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been iss-s�ue�d by the board of health.
Signed ... 5;�: �r,,..._. � . .............................................
.........................................
ApplicationApproved By .......... .��..L, t- - ---------- -----------•---------------------.-.-.-..-........................ .......6..r.. e-..f�i....
Application Disapproved for the following reasons: ................... ............................................................ ...........................................
.......... ........................................................................... ......................................................... ...................................................... ........................................
Da.
PermitNo. ...........�'�..�/,......... -----..-.... Issued ................. .................................... .......
Daze
-1
' SOLE 101i
SITE PLAN
NO. 1 N0 7
�a apt
i M
-
4
I
TOP OF FOUNDATION E .: G9-aa ��sE 5
• l G
•;� wig �
o IM5�w ,�isE,�/covEz lill I N
6 ,
4 4 . 2� FINISNEO GRAsr��
e 70 A&P-11nl /2" F/N• 61c• 0 E
•� s9.so - 9
El
. ..Tr ¢ • v t v 6-9,B7 1Z /N A c / �2 O
r'1'� i N t i s8�d MIN. C O AZ
V E R sr 2 s„ /co
1 _ N I t
70 w17y//!V /Z FiN• G
,
Q• +- . 2 COVER 1/8 3./8 WASHED ' STONE
IN Et59.28 f
1. 58,31f ° °
IN EL. o . ; I
EL,¢8,/
• 0 B W/ 6 SUMP • .. o ° 3/4 1 1/2 WASHED STONE � 3 FFF
i
4 L I Q U 10 LEVEL o9 wa ,eo�/niDwAr�=,r� A
° • r b 6 E FF
L
�• o o °, DEPTH •
� ° PERC TEST RESULTS
PRECAST SEPTIC TANK WITH PRECAST LEACHING PITS PERC RATE ■ < 2 M14/11ye�
CAST IN PLAGE INLET aNn 5�.3¢ • • . o i NO SIZE: �.�, X <� oE/ryT� WITNESSED BY
� OUTLET T 'S PER TITLE V - EL, � '
_ 'BOARD OF HEALTH
� {
S I Z E �sUo G A L L O N S �,v - --D I A o
OF STONE DATE : 9-/-�7
f
L O N G x sa., W 10 E x 57" DEEP ) ¢ Pervious DIA ALL AROUND
Material
E L. 4s,
PROFILE OF PROPOSED SEWA- GE SYSTEM
SYSTEM DESIGNED B T T `
Y NE OWN OF REGULATIONS AND EF. 3g l
l STATE TIT1E V FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE 1/4 1 0 �P.�2ar..�wvlYvw� 2 �` /
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1 . ALL ' PIPES SHALL BE SCHEDULE 4O P.V.C . SEWER , PIPE �b f
2. ALL PIPES SHALL BE SLOPED •1/4 PER FOOT EXCEPT FOR
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THE FIRST 2 FEET OUT OF THE 0 /0 WHICHI
' SNAIL BE _ LEVEL
0E51GN FLOW 0 BED
3. ROOMS AT 110 GALOAY PER BR 3= GAUDAY '
30 50/ -- S
SEPTIC -:TAN ',SIZE 3 Xi �.. 49
USE /� GAL W/ GARBAGE
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RBA E DISPOSAL
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Jr E PEf is P EG9v�T LEAC.Y/n/ P /19
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LEACHING ;SYSTEM . USE
N , p`
— p 30
71
2 �lX r ZX X
EFFECTIVE AREA . ClleAk
SIDE rr� 2s 7rxxG 2s 47r ,
2 ,
X �.
, TTR / a 7T k 2SX/ o �g G.a.,d
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� TOTAL . FLOW 7 � '�
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TOTAL `` REQ D FLOW X / / 33o wn W/� OARBAGE , DISPOSAL
54 3 0 ... Z
RESERVE FLOW 9 3 D IN ` RESERVE at
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REFERENCE PLANS .
K 4�0 PAGE Z9
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APPROVED BY .
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BOARD OF HEALTH
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DATE .
PROPERTY N OWNER lures,v�A� Br/i�o�iyG GoSITEow . Ial � D SEW�C, E ' PLAN
w..r za /G�YUL9 5 :BU/GD/n/G CQ.
s� F 0 R
�: m;c�, Y e ifi 7H�� D'E O R O O M : SINGLE FAMILY M 1 Y DWELLING
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l K. 2 71 l0T_,_
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DOYLE ENGINEERING ASSOCIATES, INCORPORATEt�
Box 595 53D Thomas B. Landers Road ' W. Falmouth MA 02574
¢ 5 l
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