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Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56 James Otis Rd
Property Address '.:
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
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:out forms A. Inspector Informationfilling out forms #
on the computer,
use only the tab Chad hathaway
key to move your Name of Inspector
cursor-do not H PS
use the return key. Company Name
Company Address
Forestdale Ma 02644
�I City/Town State Zip Code
774 274 2581 12866
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
4/8/19
Inspectors Sig re Date
The system inspector shall su it a co y of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 d completing this inspection. If the system 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
Septic in good working condition at time of inspection. No failure criteria was encounteredduring
inspection. Recommend pumping tank in 1 year for maintenance.
2) 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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
Ltsin.p.d,c•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
!� Title 5 Official Inspection .Form
Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. Cityffown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�...... 56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth'in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
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)]
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. 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): minium of 3
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No
Information In this report.)
Laundry system inspected? 0 Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: currrent
Date
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
: Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
i
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: owner pumps every 2 years
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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 1/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
tank and 1 pit 1985 2nd pit and Dbox 1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.75'
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line. 2 fe eett
Comments(on condition of joints, venting, evidence of leakage, etc.):
no evidence of leaks or poor venting
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
y% 56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1000 gal H10
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
8'6"x 5'
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
31"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tees in place. pump tank in 1 year under normal usa a then every 2 years after that
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 56-James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
- p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
no major decay or visable leaks
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
v 56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: ?)6'x6'
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
jn = Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I �� -56'James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
pit number 2 opened current level is 4 feet below invert with no staining over current level to indicate
past failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,. � 56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
56-James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
E drawing.attached.separately.
AI
33 a y
� C)
� D
3
`1 S
t5insp.doo-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56-James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 30'
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)
ED Accessed USGS database-explain:
town GIS mapping lot el. 53
You-.must.describe.how you established.the high ground-water elevation:
low in area Lumbert pond at el. 23
Before filing.this Inspection Report,please see.Report Completeness Checklist on next page._
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
v 56 James Otis Rd
Property Address
Aube
Owner Owner's Name
information is required for every Centerville Ma 4/8/19
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a' 56 James Otis Rd.
Property Address
Ruth Kelly
Owner owner's Name
information is required for every Centerville MA 02632 4/27/14
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 A. General Information -
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your ,
cursor-do not Robert Paolini
use the return
key. Name of Inspector
Robert Paolini Septic Service
LACompany Name
17 Playground Lane
Company Address
Yarmouthport MA 02675
City/Town State Zip Code
508 362-3555 S 14454
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and thatAhe
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 jte
sewage disposal systems. I am a DEP approved system inspector pursuant to Section.1.5.340of
Title 5(310 CMR 15.000). The system: r
FX1 Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further alua the Local Approving Authority
10 67�__ 4/27/14
Inspect is Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
LX6 .� I �
t5ins•3113 Title 5 Official Inspection Form: age Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑x 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•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
56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town 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):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official 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
56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
^r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
56 James Otis Rd.
Property Address
Ruth Kelly
Owner owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ 0 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.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Z 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.
❑ N 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ n The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a" 56 James Otis Rd.
Property Address
Ruth Kelly
Owner owner's Name
information is required for every Centerville MA 02632 4/27/14
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
❑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?
❑ 0 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)
❑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?
ED ❑ 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?
0 ❑ 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:
❑ 0 Existing information. For example, a plan at the Board of Health.
❑ 0 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-3113 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
�M 56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
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 0 No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? 0 Yes ❑ No
Seasonal use? ❑ Yes 0 No
Water meter readings, if available(last 2 years usage (gpd)):
na
Detail:
Sump pump? ❑ Yes 0 No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•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
56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27114
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes 0 No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
N 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ❑x No
Building Sewer(locate on site plan):
Depth below grade:
2'
feet
Material of construction:
❑ cast iron 0 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.):
Joints appear tight.No evidence of Ieakage.System vented through the building vents.
Septic Tank(locate on site plan):
Depth below grade:
1'
feet
Material of construction:
0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
I
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gl.
Sludge depth: 211
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
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.):
Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
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
u 56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is level.Box has two outlet lateral.No evidence of solids carryover.No evidence of leakage.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4127/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
leaching pits number: 2
❑ 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.):
Sandy soil.No signs of hydraulic failure. Leaching Pits were dry at time of inspection.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 56 James Otis Rd,
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
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
56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is Centerville MA 02632 4127/14
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
0 a
i
i
i
http:/Mmw.tow-barnstaUe.ma.us/assessing/HMdisplay.asp?rmppar=17122OMeq=1 1/2
tEns-3.'13 Tide 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
56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑x Check Slope
❑x Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 15'
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:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS observation well data.USED:Technical bulletin 92-0001 annual ranges of groundwater
elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 56 James Otis Rd.
Property Address
Ruth Kelly
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
0 Inspection Summary: A, B, C, D, or E checked
❑X 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
i
No. (: Fee $ 40.00
THE COMMONWEALTH OF MASSACHUSETTS !------------�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Migooal 6petem Conotruction 3permit
Application is hereby made for a Permit to Construct( )or RepairXXX)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No. /+2 8—7 8 5 0
56 James Otis Road Thomas Kelly
Centerville,Mass . 02632 56 James Otis Road Centerville,MA
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3.8 Designer's Name,Address and Tel.No. 5 0 8—`]7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 jBox 66 Centerville,Mass . 02632
Type of Building:
Dwelling X)M.of Bedrooms # 3 Garbage Grinder( )
Other Type of Building No.of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil Medium sand to fi na gqnd
Nature of Repairs or Alterations(Answer when applicable)
leaching pit to an existing 1000 gallon tank and leac-hingpi ,,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss d by this Bmo of lth.
Signed t ate 8/15/9 6
Application Approved b
Application Disapproved for the following reasons
Permit No. _ T 0 Date Issued Y /_S__ 9(o
. No. `� - d p; , Fee �t n. 00
THE COMMONWEALTH OF MASSACHUSETTS
l -----
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpprication for Migogal 6p.5t'm Conttruction Permit
Application is hereby made for a Permit to Construct( )or Repair)ZX)0 an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No. 42 8•-78 5 0
56 James Otis Road Thomas Kelly`,
Centerville,Mass . 02632 56 James Otis Road Centerville,MA
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 3 Designer's Name,Address and Tel.No. 5 0 8_7 7 5-�3 3 3 8
J.P.Macomber & Son 'Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,14ass . 02632
Type of Building:
Dwelling XM.of Bedrooms # 13 Garbage Grinder( )
Other Type of Building No. of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil Medium sad to f_inn its, d
Nature of Repairs or Alterations(Answer when applicable) ; �. _1_ _
leaching pit to an existing 1000 Fallon tank and leaching ni ..
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo of e�lth.
Signed C ate 8/1 5/9 6
Application Approved byrz
'
Application Disapproved for the following reasons
0J, ,r
Permit No. Date Issued
i
-- -------------
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(XX)on
by J.P.MAcomber & Son Inc. for Thomas Kelly
j as 56 James Otis Road Centerville.Mass . has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. glo--ZIV0dated cC" 1J_ Q�.
f Use of this system is conditioned on compliance with the provisions set forth below:
No. 9 �oC) Fee$ 40.00
' THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS
Migpoar *pgtem Congtruction Permit
Permission is hereby granted to J.P.Macomber & Son Inc.
to construct( )repair(XXITan On-site Sewage System located at 56 James Otis ROad
Centerville.Mass.
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date: Approved by ! '
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
v
•
I Joseph P. Macomber Jr.hereby certify that the application for disposal works
construction permit signed by me dated 8/ 5/96 , concerning the
property located at 56 Tamps nt; s p ,aca„ Centerville MA meets all of the
following criteria:
There are no wetlands within 300 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
The observed groundwater table is ;4 feet or greater below the bottom of tile leaching facility
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNS R DATE: 8/1 5/96
a
LIC� SEPTIC SYSTEM INSTALLER IN T TO`. OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
p�S1GI.1 pATA
,106L& FAMILY - BEORoOM Gld S� I folS
10 GAa.gAGE —
)AILY Pi-ow -- 110 X 3 =
>EPTI(:, TPtiK = 330x15o% =-495G.P. o
U56- 100o GAL. N i.
Vt M Z0
O PeoP G 17
�15Po5AL PIT V51: 1000 GAL. � I. my
5 I PSWALL Av-Sh-
150 5.F X 2.5 r 37 G.PD '� t FiVVi TPA IsicP —
0,0 G.p o.... . i AI7ESA
-7oTA1- I7ES1W4 = 42-r G.PD. .Q -Z 10,C&3
-TaTAL AA 1 LY FLOW •= 330 G.PO, N
G'E2GoLQTIOf�! RATE] 1'�IN 2M1N o�.L65S
C�I'Z
t1I()F bps;
RICHARD Ts �� PETER
"'� o SULLIVAN A. ...
BAXTER
No.24048 No. -9733 J
OISTS
Gko uIN y FFST IONAI E'w
`TE�iT (� 'r �Imo']) ��- c' To P FI•lD= sgio
N 0 LI:
1wv• 55•0
I-OM�1 1000 INV•
jorL DIoX INS. GAL, °s4B
egPTIG
2 IOVd INY• 'G TANK
P1T INV.. ...INY. i..
WITl1
WAS"QD
6Ta N E
S�N� G1=R.TIFIGO PL07 PI-A-W
PR.UFIL�
- - - L O C A'T I o N
a 13' NO• SCALE SCALE (1= gyp SATE "2'7�'a
1 CE RT1�`! TNAT TNT I`:�UIJ►�TlOt�1 SNoWN REF EQEN GI✓
1.{E,REoN GOMPLYS YJITN-THE. SIOE.L11Jt✓ �-o� : �l� ,
IA1.lD SE�'C�.GK 26QvIcz6Mt=t��'� �Q F -T�-tom
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t.ocp.TE>7 •W1TIAIM TN•E GLoap PL-+.IN C�t�l.!'r�l2a./lLl LG-I LA_l�rjs
REG t S'�F ,Z6•v'L-AN o 5 u P-v E-Yoes
Tull PInN 15 t�lorT E3n5c_r> CM AM os•rEcz.Y1t_L�
I1`1�jTR,UM6NT SV'�V� 'fHE Os=F E-r5 6uou
TOWN OF BARNSTABLE
LOCATIO ' --Ii9ZWLE 07-/5 SEWAGE # 4
VILLAGE �-P, !/Il� ASSESSOR'S MAP & LOTZ7/—ZZe)
INS hLLER'S NAME&PHONE NO. �! �l�A�c��ell SO4I L yt C
SEPTIC TANK CAPACITY ,/on n
LEACHING FACILIT (type (size)(typ (size) l00 0
NO.OF BEDROOMS /
BUILDER OROWNEeY16W11vi
PERMITDATE: ZAf--2'd f! COMPL CE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet..
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet'
Furnished by1` •l �i�
O Nj
;O b�
0
Existing 1000
Gallon pit.
Distribution box, m
Existing 1000 New 1000
gallon tank. 0 Gallon leach pit.
�� ewe � � ,.�-ems�f/C�
No ..�G.. .� Fmc. ?-.-
THE COMMONWEALTH OF MASSACHUSETTS
BOAR F I-IE LTH
�-...........OF.......... .............................
Appliratiou for Uiipmal Workii Tnnitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S stem at: �
. -r.4 .. . ......................................- WOL-4 ....... .........................................................
Location-eAddress (q/� Lot No.
'4---•-----•--••---------------•--•--•------- ........ A"fe.................................................
f
Owner Address
a (3 ........................................... ..........
Installer Address
Type of Building Size Lot.... b j_ ...Sq. feet
Dwelling—No. of Bedrooms........`...................................Expansion Attic Garbage Grinder ( �.}.(9
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ................................. ......
?W Design Flow......... . ...•..................gallons per person per day. Total daily flow.....5........ ....................gallons.
WSeptic Tank—Liquid capacityl&9. .gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x Seepage Pit No.�-_x6._.... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------_.................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•-•-------------------------------------------•------------------------..._.......-•'--•......•---•-................................................---.----
0 Description of Soil.........................................................................................................................----...----•---•-•--••---••---•---•------_-•••-
x
W ---------------- -------- - •-----••...•-•-••-•••-•••---••-•--------•••-•-•••._...•-•---•--•-•••........•--.....•••••••--•••••••••-----••-•-•--••••--•-••-••-•••-•••••-•••••......---••--•----------•---
VNature of Repairs or Alterations—Answer when applicable................................................................................................
--•---------------------------------•-•------------------------•------------------------•-•--•--------......._--•••-•-........__.........--•----••-•-••••••••.................................-•---.....
eement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
th rovisioi o T 5 of the State Sanitary Code— The uncle signed further agrees not to place the system in
era u ti a sate of Compliance has been issued b he b and of health.
ed ---------------------------------•------------------.- .....................l.....
1' a ion Approved B ............................................................y_......... °'� � — �•.. _...... -- ••......
Date
Application Disapproved for the following reasons------------------------•-------•-----------------------•---------------------------------- •---........_
--------•-•---•---.......•---••-•...--•••.............••--•-•-•-----•-••-•••----••••-•-•............._.......................•---•••------•-------•--•-•--•--•----••-••--..------------------•-••---•'---
Date
*4, Permit No......................................................................•-••.._ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
• �__ BOARD OF HEALTH
.gyp;lirttiilan for Diipn, al Workii Tomitrur#ivn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................................................................................................. .....................::...........................................................................
Location-Address or Lot No.
If t .
W -•-•---- ........-•--•-...... --•-••----------------------•-•----•----- --...............:.._-•----........ --- •-•---.............•--•----•-•----•--.....
Owner Address
u
a _..•-•- •.......`----••-----•.......... .................................................... --------•- ;..f....;._,...... .....-----•-•-•-...--••-•-•------•-----•.............---
Installer Address
d Type of Building Size Lot....!.......j._:.__=---Sq. feet
Dwelling—No. of Bedrooms........=` '...............................Expansion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ......................................................••.....--•--......_..............-•-•---•-••----•-----------............------.................
W
Design Flow............... .:.........................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth.........:......
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area----_____-_-__-__-_-sq. ft.
Seepage Pit No.'_____ ________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date.............
---------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W •-----••---••••-•---•--••••--••------•-••--•-•-----••-•-----•-•--•-----•.............•----------•-------...--•.................._...... --------------
0 Description of Soil........................................................................................................................................................................
x
U •••.-•--------•--•----••--•••••------•--•-•-•--•-------------•---•--••-------•-•-•-•------•••------•----••-•--•----•----------•--•--••-•------•----••--••-••---•---------------•-••--•--••---••---•-...
W
------------------ --------------------•--•-•••-•••-•-••------.....•••-•-••••---•••--••--•------••----•••-•-•••-------------...•---•-----•-•-•-•--••-----•-••-•---•.....••••••---•------._...._.........
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-------•----------•-----------------•-----•-- --•-•-----•--•-----------•••-••--•-------------._.....--•-....•---•••••---••••----•••-•-•---•-----•••••-......-•-••-•-•-•-•••••••••---....................
cement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
th rovisiol of I ,1 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
ra u it a ate of Compliance has been issued by the board of Health.
Dat
pl' ion Approved By-------- ,.. =.. ' �-. ' 2�I -
D t-t -......
Application Disapproved for the following reasons:..............................................................................................-.................
..-••-•---••--••••--•--•-•..........................•---•--------••••••••-••---•--•---•........---------•.............----------•-•---••---••-.....;...................................................
Date
Permit No......................................................... Issued..................r:
Date......................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF...........................................I.........................................
_ ,f < �rrtif irtt�le of f�nut�rli�tnrr
Tff.LS IS TO CERTIFY..........
That the Individual Sewage Disposal`System constructed (�a�or Repaired ( )
by :�! ._.......�J.-�-•--•.......................•-------------- -•-----•-•---••-••------...----•--••-•-------......._...•-----•-•.....I..............................._
r,,.,,r Installer
. ~ ._
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... .... dated......... G0 _____________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU ® AS A GUARANTEE THAT THE
SYSTEM WILL FUN .TI SATISFACTORY.
DATE.................... ................................... Inspector....................... ......
......------•---....
THE COMMONWEALTH OF MASSACHUSETT
BOARD OF HEALTH
�]jj `. ...........................................OF................................................................................._...
NOGG. "� •.lt- FEE.....
DisVosal Workii Tunitrurtion amit
Permission is hereby granted.......... �i.. .C).O.�L--------------------------------------------•---•---------•----------..........__.......
to Construct ( .�) or Repair ( ) an Individual Sewage Disko VstQM
Street
as shown on the application for Disposal Works Construction Permit No o..................... Dated............................................
...............................
Board of Health
DATE........... `/ _..--------------------•......---•-•----•-•••....__..
FORM 1255 A. M. SULKIN, INC., BOSTON
DES 1 G► I DATA -
r +' lo(LI S folrj
)IQ6Lc- FAM1�Y - gE02DoM
10 GArZ5AGE 6Q mr>P-
P%-OW z 110 X 3 = 73o6.RR hQ (-74-015
)SPT1G TAtiK = 330x15C>% =.49/G.P. L
USE- 100o GAL. \�
V� M Z o D�
»5Po5At_ P17 y6E soo0 C- AL. ' '� O (--P P . ffj 6I'7
\�.
�50 5•� X 2.7r = 3'I5 G,RD � 3St t i'¢op $� �
BOTTO/4� AREA= 5 5,f=, �'uD' TAtA40
-r0TA 1 C>E516W T 4z2 G.P D. 77
TOTAL *FDA 1 LY F%-DVS! = 330 G,PD.
PE2G0LA7rIO4 RATE: I''IN 2MIN owLLt~55 f
OF
c>� . .,RiCHARD pro PETER
N"+� o SULLIVAiV
A.
t3AXTER90
�,=~
No.24048 No. 29733 :
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. 1-1 C�LF' 12-15-g 3 _ _ ._. �: �,.5��' •�Y�Y
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[3QX .5,CPTiG
2 t o0o INY, StF.G TANK
GAL.
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13 No •SCALE scA1.�
v`.ATim
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-Tawt4 C7F ��I2�.f7'rA t.S QNU IS Nam' /�LOGA.•TED •\NITNIW -r"*G G%.00)-D P4b.1h1 l�L=sl.1'r /�.L✓u -�( (/�l� jr
SAXTsV- NYC tINC.
' REG!5•t>rQGV'LA11�5 u izv EYo�S
-Tull PL:&N 1�5-p KlorT 4NSr_n ptd AN c�s'rEQ.VI�LE - NW55.
INSTRu.MEt,1T 5�2vY -tHE o1=rSETS Suaut,'>a {
LOCATION ' SEWAGE PERMIT NO.
VILLAGE
,
IMST LLER'S /nNAM/E,� & ADDRES
�e UILDE R OR WNER
,)DATE PERMIT ISSUED 3
t;�DAT E COMPLIANCE ISSUED �. � `
�a��-�
4
9
1 -
�� �
e
:�
� �
.+�
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