HomeMy WebLinkAbout0061 JACKSON AVENUE - Health FF61JACKSON AVENUE
eterville
A.= 226 - 128- 005
No. ' Fee m
— o
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
4plication for 30isposal *pstem Construction permit
Application for a Permit to Construct( ) Repair(�j" Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel Vfg,IA �,�yo� �y� o118e' Gl7- 5/1/zP—S'1727
Installer's Name,Address,and Tel.No./is Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 414 gpd Design flow provided A.)Ilry gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: �,Ze/i f
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.
ed i' �� �� Date 9/9-/6 y
Application Approved by Date 'Y" 20I
Application Disapproved Date
for the following reasons -
Permit No.'o I I �� T Date Issued Ozy IZ0)y
No. '"I ? Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppliLatlon for Misposal 6pstem ConstCuttion Permit
Application for a Permit to Construct( ) Repair(6) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or.Lot No. _4'�e Owner's Name,Address,and Tel.No.
Cc��Prvi//C (7 V7
Assessor's Map/Parcel 0 b `l ����or �� 01�6'� 6 i T- yy8 b'Tz7
Installer's Name,Address,and Tel.No./o v/ adf i'�r Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided /y it gpd
Plan Date Number of sheets Revision Date
P �
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /7--roar ,� �'f 4 s7 .r�
12z 7-
Date last inspected:
Agreement:
r •'
,. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
adcordanc&with the p of Title 5 of the Environmental Code and not to pla``e the system in operation until a Certificate of
�, .. X
Compliance has been issued by this Board of Health.
Signed '" - ��.. �.r—y Date 9 X,yam/y
Application Approved by Date I A/ zv)
0
Application Disapproved � Date
for the following reasons -
Permit No. ZO l'i - 3J T Date Issued Z y 2-0 1 y
N. ________________________________________.___--_-----_________________.----_-________._____--------______________-____________________
I
TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(a) Upgraded )
Abandoned( )by
at / i o r-6 r o,� �f� v , has been constructed in accordance
with the provisions off Title 5 and the for Disposal System Construction Permit No.7A t4 dated 1-m ly—► '
Installer /-4.1 p Designer
r
#bedrooms A Approved design flow
flow AM ,�`� /1/. , gpd i
The issuance of this perm' ha n t be cos ed as a guarantee that the system will fi5nncti n as de igned/� l / 1i�
Date l Inspector /
j / ,/ -- cam• �, ... d...�. r �/1 v
----------------------------'-
No D Fee /(/V
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
]Disposal 6pstrm Construction Hermit
Permission is hereby granted to Construct( ) Repair( 94- Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
J\
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit✓
Date 2())J Approved by - =
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is Centerville MA 02632 9/16/2014
required for 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:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin
use the return key. Name of Inspector
�� Neighborhood Waste Water
ICI Company Name
350 Main St
Company Address
W.Yarmouth MA 02673
Cityrrown State Zip Code
508-775-2820 S15016
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: --
El Passes ® Conditionally Passes ❑ Falls nti�
❑ Needs Further Evaluation by the Local Approving Authority
9/19/2014
Inspedofs Signature Date v
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.
t5ins-W13 Title 5 Official I on Fonn Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
. Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is Centerville MA 02632 9/16/2014
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
Z 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,•`y 61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is required for every Centerville MA 02632 9/16/2014
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
® Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below):
D-box is in poor condition and 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 ❑ 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•3113 TiUe 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 3 of 17
L- __
1 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.•�y 61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owners Name
information is required for every Centerville MA 02632 9/16/2014
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
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3/13 Title 5 Official Inspectiori 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
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is required for every Centerville MA 02632 9/16/2014
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is required for every Centerville MA 02632 9/16/2014
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
.® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
• ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 1.5.302(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): 110x3=
330gpd
t5ins•3/13 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
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owners Name
information is Centerville MA 02632 9/16/2014
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 2012=44gpd
9 ( Y 9 (gP ))� 2013=44gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: oU�eknown
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is Centerville MA 02632 9/16/2014
required for every
page. CitylTown 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: BOH 2O08
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is Centerville MA 02632 9/16/2014
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
31 Years per plan on file.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
412"
Depth below grade: feet
Material of construction:
®cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10,
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Line inspected with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan):
317,1
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000Gal H-10
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is required for every Centerville MA 02632 9/16/2014
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
29"
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? Sludge Judge/Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 Gal H-10 tank in good condition. Concrete baffles in place and are clean and solid. Tank at
normal operating level.
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•3/13 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
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is required for every Centerville MA 02632 9/16/2014
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:
El 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•3113 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is required for every Centerville MA 02632 9/16/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
H-10 D13-3 box in poor condition and needs to be replaced.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): '
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�a 61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is Centerville MA 02632 9/16/2014
required for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 3 lines 18'x22'
❑ 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.):
18x22 Leach field with 3 lines. Lines were inspected with sewer camera and were found dry. Lines
are clean with no sign of hydraulic failure or overloading.
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
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is required for every Centerville MA 02632 9/16/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form: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
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is required for every Centerville MA 02632 9/16/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
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PAOLA
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3o kN PQivATE v►J �
LEGEND
EX1STI:Nt� SPOTJ ZVATIO"N +OxO �NOF CERTIFIED PLOT PLAN ... j
EXi STING CONTOUR .0,— L0 T z Z. cJ� cry s Al. .
FINISHED SPOT ELEVATIOAI
FINISHED—'CONTOUR 0.
ISIr I N
1095
APPROVED! BOARD OF HEALTH IN S s`
SS
D'ATE. >. ADENT $CALE� / = 40- DATE 3 `t R 3
C> IENt. lCL t. CERTIF.Y. THAT THE. . PROPOSED
:.
4TER 1ST PLAN
N H
C11iRiL' .; 1AA30. CONFORIrrsS TO THE ZON.INCi LAWS.
DR.ET t
. . -�----� O F. .8 A RN S TA; L E„ 4AS S. '
712' M A 1:1l STREET Ali.AY '
I�YA is N r
SHEET OF 7DATE . _ REO: LAND SURVEYOR. .
20 FT. M/N. /VaTE /F THE SEPTIC rAWAC /S . M_OR4F..
/O FT. M/�/• -rA4-4V /2 l/V CV4=.r Qffl.OAV 4AAOE, A .24
01 INCH 0/AAl6Tjr-R CoNCMJ-70 COVER S/YAL L
4'PVG P/PE dEBRC)U4HT TO GiRAG�,E, ��►N EXTRA N.EAYY
CONCRETE MIA1,p/rey CA37-IRON COEZR s/yr4LL 6E lisjeO lF. IN
— EL- 104.5 COVERS yo PER FT- DR/✓&-Wi4 y
A
?�MJN. 4RADE 4"DOUc�1LE
a.; PERh"i�R,4TE0
PYC P/ALc
L.10VI D LEVEL �— CLEAN 3A V D — • G S •` •C05,
s
4"CA ST '
IRON PIPE "•`. - -
I caoo . . .. ., .
.. .
� M/it/. P/TGN GAL. ••::'.:..,;'. .:.:: ••� • .. •,,,
/4 PER FT. SEPTIC -TANK o/s7- .... , . ..- :... s: :j:=:::•:
' eox CsEE
LEACHING FIELD g C rABalur�oly�
S,t*CT/OIV OF GROUND 1•VATER?A$L£
i} SEWAGE DISPOSAL SYSTEM 7A.60,4A7"/0N
.. LEACHING =lR4D �� o/i►��ivs/Aw o4 .8 F.r.
SCALLr
3 FT. 6.F7: O.C. D/I�IE'NS/ON �. 3. FT
1 D114AMY1ON C` FT.
ale*LrlY.6•R 4"DOuALf n D
OF /1j" 2" E/QFORA TFO . SOIL :TESr. �F: ki- P- Sc]8 SO.?L 1.0�
�1 P
/ SOIL TEST#/ so/L TES•7*;e '
A"SHEOS•7VMAr PYC.P/PLC. PATE Dig' .?OIL TEST 12 2 8
Ez-Aw. 161 14. V.
ME3VJ.T1 WfT/VESSED OY J /lMTb o
3j G•l AM ' Q. !�4TE / / Lass Af 2
LoAM
• :SAND: � PERCOLAT/ N __ fl NCp o- g,
: .• -•�:. PL'RGOLAT/ON R472F Z TrV�N 7aPsolL
ass•• �D� �QigTQI4sLi•.TLr• 0 1N1N�/�VG//
r ,, ; , . ,_:�:;• : DESIGN CRI TE•RIA
PERFORATYp AS.yFD TONS NOOD.STAKES NUM�EA' Of:dEDRDOMS 3 v Q` 12
SET 8 Fr D/AP4 AL 4VNI '. 1.10►.i a vE�
PVC p'/P�F oN CENTER ASTlMATArPI ALAIN 530 .GAL/DAY o G¢WA-re A•o, � �
LEAcNl/VG ..AREA 3qG.
_ S4 ter
%SECT/ON X X R�uRvg 4�EA 59�_ sa FT.
$C.4 LE /Vo GR0U NAD YVATo* ENC01/NTEWED.
INVERT ELEYi4TTONS O ,Gftvu/vv rvATER ATE1.Es.Y
OF y ��N O F M,{s l�� �L 2 - _1;AGI_�.�c�iJ ACE►.I u
* INVERT AT Bu14 PI NO 96 T:-
.5 F
AL RT .- INLET S.E'PrIC TANK Fr
RSE OUTLET SEPTIC TANK 9 . I F7
No.ioesi o H /NtET oi5rR/&UT/ON BOX 95.9 F•T ELDREDGE ENG/NEERlN6 c4q l vC
OUTLET D/STR/Q&/T/ON BOX 95 j F 7 7/Z MAIN S'T., HYAo t4 Sv MASS
hp SU 'cFssippl�,�E% END OF 4RACHING F/ELO 95.5 FT CLIENT ICIf'�13�� DATt�.
T.2;0�Z
JOS No. N2iiA, 9NEE
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owner's Name
information is required for every Centerville MA 02632 9/16/2014
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: +1119"
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: 3/21/1983
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:
Test hole data per plan on file at BOH dated 3/21/1983. Test hole to 11.9'with no groundwater
encountered. 4'to bottom of field. minimum of 7.9'separation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
12
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Jackson Ave.
Property Address
Joan SantaMaria
Owner Owners Name
information is required for every Centerville MA 02632 9/16/2014
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•3/13 Title 5 Official insp
ection Form:Subsurface Sewage Disposal System•Page 17 of 17
it
.... ...--•--•--- -�S-.. �d S Fps.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
................. . ---....---.....OF.......................................
AppliraMon for Eli-quua1 Works Toutitrurtiuu ramit
Application is hereby made for a Permit, q Co struct X) or Repair ( ) an Individual Sewage Disposal
System at: _
. ... .. -- - �- 0.j .. ... 2 - ......
1b
Location.Address
-1• 1.. — . w�A...- !A+ ------ --
... t 4?... 4 .t-1�_ or Lot
�.ST.
-
....I T►! ,n,,
Owner Address
ress
a .... —� p ---... •--..... ,
Installer Address
Type of Building Size Lot...14 f '.Y t.....Sq. feet
v Dwelling—No. of Bedrooms................a.......................Expansion Attic (A) Garbage Grinder ( )
Other—T e of Building No. of persons ................ Showers
a YP g ---•------•---------•-----•• P ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------•-------------------•--••------------------- .............................................................
W Design Flow....................33 ____._____..gallons per person per day. Total daily flow............................................gallons. .
WSeptic Tank—Liquid capacityM.O.ca-gallons Length................ Width................ Diameter--.--........... Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.........I----------- Diameter........(a........ Depth below inlet......4%........ Total leaching area.;? !4-....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by................................................................----..... .Date........................................
Test Pit No. 1...2 ---.minutes per inch Depth of Test Pit------1:;;�--.---- Depth to ground water- ��'�' .........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---................----.
------ ------ ----------------••-----•-•-------•-----•------•--•--...------••---..........................................................
ODescription of Soil.............M�.�.w...... ._�r_'.:Kz�-----------•---•--------------------------------------------------------------------------------------------
x
c,
w
VNature 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 iITLF- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu b the boar f 11 t . L........... II.,
.
Ap oved BY---- ----•- ----• -- -----•-----•••---•••----••••••.............•-•--•----•--•-•..--••-
Date
Application Disapproved for t f owing reasons----------------------------------- -------------------•------------------------•-------------------•-•-•.......
--.......-•---•------•----•-------•------------------------------•---•-•---•-•--•--•-----••••-•.....••--......•-•-•-••-•••-••------•-........----•••---•-----••-•-------- ...............................
Date
PermitNo........................................................ Issued_.......................................................
Date
t
fill
FES..... 0................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..........................................-----------------...................._--------•-
Applirtt#iutt for l iipaa al Marks Cnunarur#ivat Prrutit
Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal
System at: _
................-..... a.. .��. ....� N ...............................
-Address l ( or Lot No M
C?� ��la�Z I fa ,..._ Yi.I Q`2.t�_f!�?T'�7Jtal.._�? .....\�, :�:�?.G�.lv..�A
Owner )� Address
�=, -". ................... .............•• •_l. ( �� e `...
Installer Address
UType of Building Size Lot... _ +t ' .....Sq. feet
I—. Dwelling—No. of Bedrooms................ ___.....................Expansion Attic (A) Garbage Grinder ( )
PL4 Other—Type of Building ............................ No. of persons......-4................ Showers ( ) — Cafeteria ( )
QI Other fixtures -------------------•--.--_--•-._.
W Design Flow.................... 0.............gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid*capacity(�)O.Q.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.........._......... Total leaching area___----_.____-------sq. ft.
Seepage Pit No.........4----------- Diameter........(-------- Depth below inlet.....q.......... Total leaching area. �.Y.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by______________________ ...__......_. Date........................................
,..1 Test Pit No. I... -_-_minutes per inch Depth of Test Pit.....!qN_____... Depth to ground water_V\k>.1- .E....._._ .
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
DDescription of Soil------------- -.:_• ^4._... .N .........-----------•--------------------------------------------------------------•--------•--•-------------
W
U -----•-•-------•---•-------•--------------••---•-----------------•-----------••--•-••----------•--•-----•--•----•--•----•--------------•--------------••---••--•-•--•-•------•--•-••......--•-••---••-•.
W
x ----•-------------------------------------•----••-••---•••-•---------•--------.....-•--...-------•---...----•-•-------------------------------••----••---------------•----••-•------•--•-••••--.........
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued the boar/�,YofZ
.ls _ T.. ''
t i
F .-✓ r Date
2pp ication Approved B . .......... .. ......:..........•--- ------.----.--------------------------
Date
Application Disapproved for t e f .lowing reasons----------------------------------------------------------------------------------------------------------------
-••-....•----------•...............••-••-.....••--•-------•-------•---•-•••-----------.......-----••.....---------------------•-------•------------•---•-•----••••-----•-----•--•-•----•-----•--•-------
Date
PermitNo-------------------------------------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.................................................I...................................
Tatifirtt#r laf Tantpliattrr
T 0 CERTIFY That the Individual Se age Disposal System constructed ( ) or Repaired ( )
Installer
at------, _ � 6• ..--------- .._... ------------
has been installed in ac orda. with the provisions of TITLE 5 f he State Sanitary Co as d cribed in the
application for Disposal orks Construction Permit No.. '._.-_'"_- ___________________ datedS. ._.__�.__a� __................
THE ISSUAN E OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM 1 F NCTION SATISFACTORY.
DATE••...- ......................................................... Inspector--••----....... ................................•................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Q ..............................
.-� OF.............................................._...................................... 410
.............
No._._.._... ' FEE........................
urk� �uttu . imrn .�firrmi#
Permission is__b&6by granted n = ``
to Constr Y' �or 13 pr ( n Indi�y.�dual See Disposal System
at Not& �
------------�---.......,_f_... ..- =--
Street
as shown on the appli on for isposal Works Construction Permit No.....................A d _...._:_.. .._,�°'
B —of Health
DATE.......................................... -•-•-•-........--------....-•----
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
LOCATION SEWAGE' PERMIT NO.
VILLAGE 9
(Alf z4-
INSTA LLER'S NAME & ADDRESS rz
AMA)K Old 7oU)/v I-a h-s Tti
Ct1i�y«�e�2 - Spa n� Q� e,
T
Q �
d UILDE R 00 0*N R
DATE PERMIT ISSUED
® ) AT E COMPLIANCE ISSUED fir.
z x-
J�
I y
6.
1 °
-1 1
JAcksoN A Je .
j!F` i�asi=P� F Tr
rlonn/
TBM e L
lr=-r 12 L'c.c vo.
• I�.�d�s,F 8993 � -�
it,
e
Q M
. L�r. - - _. •�• 9EOTG tMwK MIJ.. . .a`l'
rl
23
IC7,N tF_x
'put eL• Sum
l 7.4{1 1030 `
' lo,coo S..F
-----•- .�,.: d � - pN,� i f 5 tom. ;p 1 CJU W D-f i--j
/a l/E 2d F.
NATE
LEGEt4D ,
' t CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATI-ON OxO OF
EXISTING_ CONTOUR- 0 --1:. 2��,� ��yG Lo T 2�: J� c�< s v n� ,g ✓ ,
FINISHED SPOT ELEVATION,, /YY�- ',�A�S '�� 7'
FINISHED CONTOUR -- 4----- : . _
anoRSE; �, IN
t tiff..10951'.D��
APPROVED`& BOARD OF HEALTH A9�FcsYEP � All MASS*
dISC cYo 1 i o 153.
Y.SCALEt / �4.0 DATE .
OAT
LDREDGE.. NGINEE`R/NG 'CC IN CL,tENT i :rf CERTIFY THAT THE PROPOSED
` EOIS
TERE REGISTL D ,108`NO.g `= BUILDING SHOWN ON THIS PLAN
CIViI .= SAND r CONFORMS . TO THE ZONING LAWS
R ,r DR:BY�..; .. OF BARNSTA�LE, ASS.
712 MAIN STREET 0__- !$ / - ---
s HYANNIS, MASS. DATE t RAG. LAND SURVEYOR
r gHEET..Z.OF ---
20 FT_ MIN. NOTE ; !F THE SFOT/C, TANK /S MoRA
THAN /2 JNCNES dEtDAV. GIlAOE, A 24
/O FT. Al/N /NCH OJA/�lET6R CoNc,rET6 Go1/ER�SYy�4L L
4'PVG P/PE dE BROV4yT TO LAN EXTRA f/EAYY
ColvCRETE /W/N. PITCH «+3T lRoA/ COV&A S/yotZ.L 8E uS•Fo IF. /N
is
EL- 104.S COVERS •PER FT• DR/✓L�1'S/Ay v
M/N. 4RADE 4AOou9LE
A PERF�RATErO
PYC P/PE
L/4t//D LEVEL �--.CLEAN SAND.
4"CAST
IRON PIPE I GAL.
/4 PER FT•
SEPTIC TANK pOX SEE
$ C TA6l/L4T/OI�)
LE.4CNING FIELD
SECTION OF GROUND JVA,TER?A$LE
SEW SE DISPOSAL SYSTEM 7A611LA7101V
" LEACHING FIELD v/ �Ns/o�r.A 8 FT
SCALD �" a_/�_p« o/roEnrsiow $ .3 FT`.
3 FT. . f_iT_ O.C. S/ON;G_
s"'t.4r.� 4"woueLg ,SOIL hTFST Q P 89 8 SOIL LOG
7-1
p� �d 3/d" PEI�FOICATFD SO I L TEST#/ SOIL TEST• 2 '
)VAi / APJMNr PYC P/PL .: OATS OF 10lL T s T
RESUIT.? /V/TNESSED.BY J lbIF
Cl�AN. PERCpLAT/QN i�C4TE /-7--17777-7177
/ toss M/NIJNCIiI �o�I✓1
j+ :SAND- PERCOLo4TlON ATEF JO2 TH_M/XllAICH 7aDsOrZ'
•••=• - - : :, _:-36
DESIGN CRITERIA
,¢"pptl®t 314' I NUMQE� Of.dEDR00/►tS 3 2= {2 '` "�
.. pERFORA-r&p JVA-TNPp.STDNS iY00D.37AXES vE2�W t
SET V P7' G4Ra46E D/ AL IIAICT No w [,QApiNG
PVC plPE ON CENTER ESTJMIITED'FLOh✓ 33o GAL/DAY
•.
L•EACNIA149 AREA ?39[. S4. /e7C r
S9` SQ.FT
92
SECTION X—X MASZRvF AREA o _a9,ti
.. ,. OGROU"D ATER ccNCpr//yT,ERED
SCALE
N YV ;
S 0 GROVIYP WATE/e AT
V T fLEVi477 N
LET 21 _-' J��Sc=+-�.
OF OF
� � H M�ss7 /N✓ERT /+T Bu/LDING 96.5 FT 4`-YA�-4 l'j i S Pct �"T
i AL T INLET SEPTIC TANK 9�.� FT
V SE01M.E.T SEPTIC TANK 9b. I FT.
!la►2i " No.G951 O ti INLET D/SYR/ASZMON ,BOX `1S 9 FT ELOREDGE ENG/.NEE/4IN6.GGt,/IIIG
,Q 0-1 7/2 MAIN STD NYANN/3, MASS_'
4 D�eTt_l��yOQ` A9 FGISTEQ` a�� DonET D/SMI&VTION BOX �.FT Cu-=NT= K13t3EE. DA7-1
h0 SUX'�" OF LEACHING FJELO 55 FT.
b{2 i i A: '•NETT!L.0-w L . ;::
LOCATION SEWAGE' PERMIT NO.
PILLAGE
I N S T A LLER'S NAME 6 ADDRESS
O/d T��Zti �aict�5�afl� ����TTti�
AQ
R I'L D E R OR OWNIER
DATE PEItMIIT ISSUED
OMPLIANCE ISS UER
� Q A t E C
2s-
r$
I �
6
4,bt a2
JgC Sani Je