HomeMy WebLinkAbout0022 LAURA ROAD - Health 22 Laura Road
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evalu ion by the Local Approving Authority
1-14-13
Inspector's 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.
t5ins-11/10 Tide 5 Official Inspection bsurface Sewage Disposal System-Page 1 of 17
f
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with'a'complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound; not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
c
TOWN OF BARNSTABLE
LOCATION a L 4[mac r'ct SEWAGE
VILLAGE �� f�✓c> �l le ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO_
SEPTIC TANK CAPACITY 15 6 v ?
LEACHING FACILITY: (typa) C e.,I�,er_s (size) J
NO.OF B EDROOMS / _
$ITILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility - -- Feet
private Water Supply Well and Leaching Facility (If any wells exist
on site or within 2tm feet of leashing facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by — (,`AI-1 . ��l'°
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville . MA 02632 1-14-12
page. City[Town State Zip Code Date of Inspection
B. Certification (cont.)
B), System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken,or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection- Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Laura Rd
M
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
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 se system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or
Y P
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 m provided that no other failure criteria are triggered.A co of the analysis must
pp � p g9 copy Y
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
.❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply:
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system.passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection .Form
"s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recent) art of
9 y
❑ ® y or as P this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 31.0 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I�
f
,
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
m a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? El Yes ® No
Last date of occupancy: 12-2012
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?j ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5.122 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)`
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
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: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
4 Title 5 official Inspection Form
,ak o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 22"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 14"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: 1500 gal
Sludge depth: 12'
t5ins-11/10 Title 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
22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
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
20"
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
15"
How were dimensions determined? 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.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
l Title 5 Official Inspection Form
Subsur
face Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
M 22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448),
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened).(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from chambers.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 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
22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3-500's
❑ 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.):
Leach chambers in good condition and holding 3"of water with stain line at 12" off bottom of
chamber.
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
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.):
Privylocate on site plan):
( P )
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
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
141
A c
D E F
0-F .23 �
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
n, 22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how 9
you established the high round water elevation:
Y 9
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
L
Commonwealth of Massachusetts
s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 22 Laura Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 1-14-12
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Ap
TITLE 5 h _
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 22 Laura Road
entervi e C-„
Owner's Name: Larry Sinclair =X
Owner's Address: „
Date of Inspection: _
Name of Inspector:(please print) Wi 11 i am E_ •Robinson Sr.
Company Name: William E. Robinson Septic Service i
Mailing Address: P O Box 1089 w
rn
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant t�ction 1S.340 of Title 5(310 CMR 1S.000). The system:
Passes
Conditionally Passes
Needs Farther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: zo t, Dote: U S
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr
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 approxing
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 22 Laura Road
Centerville
Owner: Larry Sinclair
Date of lnspectiont —& JYA
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System asses:
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:
On�or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The s ptic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exM;bits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the -
existing tank�s 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 th1t the tank is less than 20 years old is available.
ND explain:
Obs rvation of sewage backup or break out or high static water level in the distribution box due to-broken or _
obstructedhpe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval f Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND lain:
e system required pumping more than 4 times a year due to broken or obstnxted pipe(s).The system will
pass in ection if(with approval ofthe Board of Health):
broken pipe(s)are replaced
obswcdw is removed
ND expl n: V L
I
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 22 Laura Road
Centerville
Owner: Larr .Sinclair
Dale of Inspection: .
C Further,417valuation is Required by the Board of Health:
Condit ons exist which require further evaluation by the Board of Health in order to determine if the system
is failing to pr tect 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 i not functioning in a manner which will protect public health,safety,and the environment:
Cesl ool or privy is within 50 feet of a P �'Y surface water
_ Cess ool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System t ill fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is fu'hclioning 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
surfa c water supply or tributary to a surface water supply.
e 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 front a
private water supply well— Method used to determine distance
*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
b teria and volatile organic compounds indicates that the well is free from pollution from that facility and -
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fail a criteria are triggered.A copy of the analysis must be attached to this form.
3. Othe
3
n
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 22 Laura Road
Centerville
Owner: Larry Sinclair
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You m st indicate'). res"or"no"to each of the following for all inspections:
Yes N
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
esspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow
Required pumping more Qtan 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
ny portion of the SAS,cesspool or privy is below high ground water elevation.
A y portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface
ater supply.
All y portion of a cesspool or.privy is within a Zone I of a public well.
_ y portion of a cesspool or privy is within 50 feet of a private water supply well.
y portion of a cesspool or privy is less than 100 feet but greater than 50 f et from a private%%atcr
upply well with no acceptable water quality analysis.IThis system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free.from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
(Yes/No)The system fails. 1 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. La ge Systems:To be c sidered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd•
You must dicate either"yes"or"no"to each of the following:
(11te follow g criteria apply to large systems in addition to the criteria above)
yes no
_ the s stem 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 stem is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped
Zon 11 of a public water supply well
If you have an ered"yes"to any question in Section E ilz system is cousidered a significant threat,or answered
"yes"in Sectio D above the large system has fatted.The(mmer ar operator of wry large system considered a
significant thre t under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The s), tem ommer should contact the appropriate regional office of the Department.
4
I
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 22 Laura .Road
Centerville
Owner: Larry Sinclair
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No l
Pumping information was provided by the owner,occupant,or Board of Health
Zwcre 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?
V — 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 thebaf/fles 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:
Yes .no -
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)(310 CMR 15.302(3)(b))
5
Page 6 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address•• 22 Laura Road
Centerville
Owner: Larry Sinclair s
Date of Inspection:,,2:—_`/
FLOW CONDITIONS ,
RESIDENTIAL f6
Number of bedrooms(design):., Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms):
Number of current residents:_
Does residence have a garbage grinder(yes or no):`4, �
Is laundry on a separate sewage system(yes or no): r✓�[ifyes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 4 = 36, 000
Sump pump(yes or no): A-40 2003 — r
Last date of occupancy:
COMMERC L/INDUSTRIAL
Type of estab o shment:
Design flow(baced on 310 CMR 15.203): gpd
Basis of des gn flow(seats/persons/sgft,etc.):
Grease tra present(yes or no):_
Industrial aste holding tank present(yes or no):_
Non-san' waste discharged to the Title 5 system(yes or no):_
Water eter readings,if available:
Last to of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as par1rof the inspection(yes or no):_
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP F SYSTEM
eptic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP,approval
_Other(describe):
Approxi ate a� of 1 compo nt , ate installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):/v
6
Pagc 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 22 Laura Road
en ervi e
Owner: Larry Sinclair
Dale of Inspection: —G�lS �_
BUILDING SEWER locate on site plan)
Dcptlt below grade:
Materials of cons ction:—cast iron _40 PVC_other(explain):
Distance front nvate waler supply well or suction lute:
Comments(o condition ofjuunls,venling,evidence of leakage,etc.):
SEPTIC TANK:✓(locate on site plan)
Depth below n
p grade: C) t
Material of construction: ✓concrete metal fiberglass�ol)•cdiylene
_othcr(explain) — —
If tank is metal list age:— Is age conftnned•by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) / �C �
Dimensions: �t
Sludge depth: /—,j
Distance from top of sludge to buitonn of outlet Ice or baffle: _
Scunt thickness:
Distance front top of scum to top of outlet Ice or battle:
Distance Gorn bottom of scull,to bottom of uptict ice or battle: �"
l low were dimensions dctcrniincd: 0 ! if,D LL;
Comments(on pumping rcconunendations, inlet and outict tec or battle condition,structwal integrity,liquid levels
as related to outlet invert,evidf ice of IIkage,etc.): ,
GREASE TRAI':_(local on site plan) —
Depth below grade:_
Material of construction- concrete metal fiberglass—polyctln}Iene__other
(explain):_ — —
Dimensions:
Scum thickness:
Distance front lopff of scum to top of outict ice or battle:
Distance front bdttom of scum to bottom of outlet tee or baffle:
Date of last p )ping:
Conunents n pumping recommendations,inlet and uullct ice or baffle condilio:i,structural integrity, liquid levels
as related outict invcrl,ct•idcnce of leakage,etc.):
7
'agc 8 of 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFO101ATION(continued)
hopertyAddress: 22 Laura Road
Centerville —
Owner: Larry Sinclair
Date or lospectlon:
TIGIIT or ll LDING TANK:_(tank must be pumped at time of inspection)(locate on site plan)
Depth bdoq grade: -
Material of onstruction:—concrete_metal_fiberglass_polyethylene other(explaur):
Uimcnsio s:
Capacity: gallons
Dcsign Flow.- gallons/day
Alarnt Ocscnt(yes or no):
Alarm evel: Alarm in working order(yes or no):_
Datc last pumping:
Co ants(condition of alarm and float switches,etc.):
DISTIUB UTION BOX: (if
( present must be opcncd)(locatc on site plan)
Depth of liquid level above outlet invert: L
Conunents(note if box is level and distribution to outlets equal,any evidence of solids carr),over,any evidence of -
leakage into or out of box,cic.):
PUMP CRAMDER: (locate on site plan)
Pumps in working o cr(yes or no):
Alarms in workin rdcr(yes or no):—
Comments(note ondition of pump chamber,condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 22 Laura Road
Centerville
Owner: Larry Si ncl_ai r
Date of Inspection: ,!�'"`z—43
SOIL ABSORPTION SYSTEM(SAS): /(locate on site plan,excavation not required)
If SAS not located explain why:
Type r
aching pits,number:_
leaching chambers,number: 3
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): _
5.
6 PA
CESSPOOLS: /�hdto
pool must be pumped as part of inspection)(locate on site plan)
Number and conDepth—top of liet invert:
Depth of solids)
Depth of scu ayer:
Dimensions f cesspool:
Materials construction:
Indicatio of groundwater inflow(yes or no):
Comme,is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
i
PRIVY: (lo ate on site plan)
Materials of nstruction:
Dimension .
Depth of olids:
Comm is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 22 Laura Road
Centerville
Owner: Larry Sinclair
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
G
� / ,
f
1
10
Page I I of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 22 Laura Road
Centerville
Owner: Larry Sinclair
Date.of Inspection: _ia
SITE EXAM
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within ISO 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 establish d the high ground water elevation:
11
TOWN OF BARNSTABLE N
OC ATION C` i�/�'�2��'IIC� SEWAGE #
VIL.AGEa,J� LAt42 A (24d) ASSESSOR'S MAP & LOT r
INSTALLER'S NAME&PHONE NO. (AIM. E. exx✓ ifAohC 775
SEPTIC TANK CAPACITY 1 S d O
LEACHING FACILITY: (type) T)" (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTT DATE: COMPLIANCE DATE: /: 92 ('
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
6
�.,No. 1`� , Fee $50
THE COMMONWEALTH OFMASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Migpogal *p5tem Construction Permit
Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
L c Von Address or Lot No. Owner's Name,Address and Tel.No.
�Z Laura Rd.. , Centerville Larry Sinclair
Assessor's Map/Parcel -�-S— ) ]
Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
PO Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S and.
Nature of Repairs or Alterations(Answer when applicable) new Title-5 septic system.
Tank, D—hnx and 3 leach nhamher'S .
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 t
jiis,poard of HAth.oe
n
Signed zr4e � ✓ems— Date djell 2�
'
Application Approved by . Date
Application Disapproved for the following reasons
Permit No. Z9 Date Issued 7,a
No. 9.. S 7`y l 1 1 Fee $50
THE COMMONWlMalf&MASSACHUSETTS Entered in computer:
IL Yes
- PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS
2ppricatiou for Dizpool *pgtem Cottgtructiou Permit
u Application for a Permit to Construct'( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
L c Lion Address or Lot No. Owner's Name,Address and Tel.No.
Laura Rd. , Centerville Larry Sinclair
Assessor's Map/Parcel
Installer's Name�,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
PO Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
-Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets IRevision Date
-_.
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand,
Nature of Repairs or Alterations(Answer when applicable) new Title-5 septic system.
Tank, n-box and 3 1Path chambt-ra
Date last inspected: t
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 t is and of Hy Ith. �' n
Signed t ✓ Date '7
Application Approved by 7. • `" Date ?.!i
Application Disapproved for the following reasons
Permit No. t7 Date Issued Z�
THE COMMONWEALTH OF MASSACHUSETTS
Sinclair BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System,Constructed( )Repaired(X )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service
at 2Z Laura Rd.. , Uenlerville has been construe�, 30;��
ind ce
with the provisions of Title 5 and the for Disposal System Construction Permit No. Z dated O
Installer Wm. E.. Robinson S r. Designer I r
The issuance of thus p t shall not be construed as a guarantee that the sy t will functi n as designed�
Date rl Inspectors O /
— — J � --------------------------Fee .J F
7- S /-/i/ THE COMMONWEALTH OF MASSACHUSETTS
Sinclair PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS '? 11
lwigogat *proem Cow5truction Permit
Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) 30 ,
System located at 22 Laura Rd. , Centerville
L
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.
Provided:Constructlo must b completed within three years of the date of this it.
Date: // Approved by •
r
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERnRCATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, W i l l iarn E . Robinson,S,rhereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 22 Laura Rd . C e n t e r v i l l e meets all of the
following criteria:
The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
a The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system _
4 There are no private wells within 150 feet of the proposed septic system
V There is no increase in flow and/or change in use proposed
O There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. (AdjAdjust the groundwater table using the Frimptor
method when applicable)
® If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(1.1) feet above the maximum adjusted
groundwater table elevation,
Please complete the following: J
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation T the MAX. High G.W. Adjustment
DIFFERENCE BETWEEN A and B �r I
SIGNED > i�C L� DATE: �'�"Z O
[Sketch proposed plan of system on back].
y:health folder:cen
GIB
1
t T
OWN OF BARNSTABLE J
LOCATION SEWAGE #d 9" Sv�
VILLAGE Ae� LAW A fZG� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. J�on c 7 7 5- 7 7.6
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) DPLQ (size) 3 x Z
i
NO.OF BEDROOMS L/
BUILDER OR OWNER
PERMITDATE: 6115 _COMPLIANCE DATE:
Separation Distance Between the: '
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
0 I
h