HomeMy WebLinkAbout0006 LONG POND CIRCLE - Health 6 Long Pond Circle
Centerville
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UPC 10259 4
No. H� 163OR NIII.cQe6
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Commonwealth of Massachusetts 0?0?— D3 -
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Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is
required for every Centerville Ma 02632 9/6/2019
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. Inspector n Information !/y
filling out forms c,7F /��/�
on the computer, -
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return -
key.
Company Name
74 Beldan Lane
Company Address
Centerville Ma .02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com, S14522
sean@smjonestitle5.com 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
1. 9/6/2019
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 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 Form:Subsurface Sewage Disposal System•Page 1 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
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:
The property located at 6 Long Pond Circle Centerville is served by a Title V septic system consisting
of a 1500 gallon poly septic tank, distribution box and 31'x10' leach tench with infiltrators. The system
was found to be in proper working condition at the time of inspection.
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
i
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
page. City/Town 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
r
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is Centerville Ma 02632 9/6/2019
required for every
page. Cityrrown 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
El ® 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
LV 6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
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 '/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 groundwater 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
i
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is Centerville Ma 02632 9/6/2019
required for every
page. Cityrrown 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?
El
® 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is Centerville Ma 02632 9/6/2019
required for every
page. City/Town 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). 330 gpd
Description:
Number of current residents:
3
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 ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No.
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sum um
p pump? El Yes ® No
Last date of occupancy: currentDate
t5insp.doc•rev.7/26/2018 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
�� ...
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information i e
required for every Centerville Ma 02632 9/6/2019
page. Cityrrown 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)
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:
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
L 6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is Centerville Ma 02632 9/6/2019
required for every
page. Cityrrown 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 I/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:
8/25/2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2 -
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
i_
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints in good condition, no leakage, vented through roof.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gallons
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
10.1
How were dimensions determined? Opened covers and took
measurements
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 does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form: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
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is Centerville Ma 02632 9/6/2019
required for every
page. CitylTown 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments
� 6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
page. Cityrrown 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):
Oil
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.):
Distribution box was level and in good condition with no rot. Water level was even with outlet invert
with no signs of past backup.
t5insp.doc•rev.7/26/2018 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
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
page. City/Town 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:
® leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
Teaching 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
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
page. City/Town 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.):
Leaching facility consists of a 31'x10' row of Infiltrators. Chambers were video inspected and found
with 2"of standing water and no signs of past overloading.
i
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 pond ing, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 18
40>1, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
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.):
l5insp.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
C ,e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Long Pond Circle
Property Address
John & Nancy Taylor -
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
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
❑ drawing attached separately
I
I_
� l 2-0 �
AZ- 50
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is required for every Centerville Ma 02632 9/6/2019
page. City/Town 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: 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 you established the high ground water elevation:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 6 Long Pond Circle
Property Address
John & Nancy Taylor
Owner Owner's Name
information is Centerville Ma 02632 9/6/2019
required for every
page. City/Town 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 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
I
No. O L-7 FEE /
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
APPLICATION FOP, DISPOSAL SYSHM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) Complete System El Individual Components
Location 1�� Owner's Name '—k:? {�
Map/Parcel# Address J
Lot# i Telephone#
Installer's Name M Designer's Name �3t�Una
Address M4,4 L Address��®
Telephone# — _3 5 1 A Telephone#
Type of Building Lot Size !mac (-0 sq.ft.
Dwelling-No.of Bedrooms ^�1C`esi C.3� Garbage grinder (/)IA-
Other-Type of Building No.of persons e—Showers (t,<`Cafeteria (i.)-/
Other Fixtures LAyA.-fl K+6-,o-r 5cA-. �iAt)"OW
Design Flow (min.required) '�O gpd Calculated design flow Design flow provided �J�u� gpd
Plan: Date ® Number of sheets Revision Date
Title s
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator C�MtZ,.{ ► A-`bate of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further auees to not to ce a system i�operationuntfiil of ompliAnce has been issued by the Board of Health.
Signed AIJI Date J /®
Inspections
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COMMONWEALTH OF MASSACHUSETTS
' Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repa��4 Upgrade( ) Abandon( ) ;,;<Complete System ❑Individual Components
Location e, �C7^`� \ 4+Nk�f�t�'R Owner's Name
Map/Parcel# Address
Lot# "A;r,` i Telephone#
Installer's Name Designer's Name c� s
� ��M� ��ccz��J S g
Address MAer-� �� �� Address,®" �2.ar �ec1U
Telephone# 5;L4 91 _ 3 9 S b Telephone# 15 -0 � A Q;ts
Type of Building Lot Size c � �o ' sq.ft.
Dwelling-No.of Bedrooms .- C`�SZ cjj) Garbage grinder (/)/A-
Other-Type of Building No.of persons i- _Showers (V)%Cafeteria (L)"'
Other Fixtures
Design Flow (min.required) �JO gpd Calculated design flow .1)30 d . Design flow provided �,, gpd
H t(9 !Qa l Q 4 Number of sheets Revision Date
Plan: Date
Title �v 1 5rar� C l rC; t
Description of Soil(s) 12:a- "__6 (^
Soil Evaluator Form No. Name of Soil Evaluator.(�,tj Anj S f- Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
e - -
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to vflace(the system in operation until a Certificate of(Compliance has been issued by the Board of Health.
Signed `�.1Y tM..�_X WA AzA Date %Q�+
z I.. 1 �� E� �`
Inspections
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No. �)U oq—lo C®MMONWLAIT14 OF MASSAC14USETTS FEE-�
Board of Health, 9 fnf,14 b� MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) tI4 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded(/),Abandoned ( )
by: / I
at [r, �.)n,e t)„nll r I Tc It _.n�eev,/if
has been installP in accordance with the pr visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. '2 U U H-/a!-7 , dated _%1 i 'J Approved Design Flow (gpd)
Installer
Designer: InspeNttor:.p (NILV �._ �..-- -5 Date: / /.�J Z
-� -- y ....v _ ".:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �� / - 167 7 FEE
C®l�'][[�'1 ONWF ILTU O �'ASSACHUSETTS
Board of Health, IISt.��.s/ �t MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;_Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
ii / �
at p Lo 14 (1sl, C tZ. a r n�+ fL��f e as described in the application for
Disposal System Construction Permit No. a Q 0q-)02,dated �/17/0 y
/
Provided: Construction shall be completed within three years of the date o this per" it. All to"al conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date //J�/ Board of Health h-/
TOWN OF BARNSTABLE EC
SEWAGE # nd I D'7
LOCATION IL ,
VILLAG
:l ASSESSOR'S MAP.& LOT
- INSTALLER'S NAME&PHONE NO. �who a,S SOS1 5� '�a,5
SEPTIC TANK CAPACITY C7
LEACHING FACILITY: (type) 1 ��4 ' (size)3[a�x 1 f
NO. OF BEDROOMS
r
BUILDER OR OWNER
PERMIT DATE:
C • . COMPLIANCE DATE: 3 as
Separation Distance Between the:
Feet_
Maximum Adjusted Groundwater'Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist °
Fe et
on site or within 200 feet of leaching facility) —r
Edge of Wetland and Leaching Facility (If any wetlands exist Feet
within 300 feet of leachin ac' 'ty)
Furnished by sae
I
v
Q � °
- �� T
..
Town of Barnstable
Re ulaf6r Services
°* g F .
Thomas F:Geiler, Director
* 9AMSTABLE,
9 MASS. Public Health Division
i639•
ArEO3,�s Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
' Installer& Designer Certification Form
Date: 3/25/04
II Designer: Shay Env.iron_nnental Services Installer: Mannv Barrows
Address: 34 Thatchers Lane Address: North Falmouth Hwy_
East Falmouth, MA 02536 Falmouth, MA
On 3/22/04 Manny Barrows was issued a permit to install a
(date) (installer)
septic system at 6 Long Pond Circle, Centerville, MA based on a design drawn by
(address)
Shay Environmental Services dated 2/20/04
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
ZIA,. J lfk
: ..
(Insta er's Signature)
S"
\a'
A
V 'H c�
�J1 0 8
esigner's Signature) (A ix si �s Sit re)
Sq �
PLEASE RETURN TO BARNSTABLE PUBLIC HEAL H CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH T IS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BA.RNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
' TOWN OF BARNSTABLE Cc. N
LOCATION F SEWAGE #
VILLAGE /k ASSESSOR'S MAP & LOT 20 '-037
` INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1.500 0,) J
LEACHING FACII,=: (type) P S (size)3 1 ,'21
NO. OF BEDROOMS
r
BUILDER OR OWNER
PERMITDATE:. COMPLIANCE DATE: 3 45 v
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility IN h Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 19 d h,f ' Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leachin ac' 'ty) N tt he, Feet
Furnished by /a' _
t�
D
P
Long
SECTION A -A
*NOTE:.ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. VENT PIPE o Least 24 Inches tolf)
ALL P1PE5 FROM THE
f,
10' min. from Exlstn9 roundotk PROFILE VIEW OF ADDITION TO LEACHING SYSTEM DISTRIBUTION BOX SHALL BE t. ,
r house to septic tank Schedule 4 PVC w Charcoal Odor Filter
Top of Foumdotton = ELEV. t00.00 (Assumed) Septic tank covers must be 3' of 1/8' - 1/2' Washed Peastone SET LEVEL FOR AT LEAST 2 FT. 12 CONCRETE COVER �dyz gxh ap
':..
i within 8 n. of finished grade -
Grade over tic Tank -98.00 Ctode over D-Box- 95.00 over SAS- 95.00 to 94.00 / "
s
� 3 4' to 1 1 Washed Crushed Stone "`�^��- ` - 3 _ 5'OUTLET
1
4'PVC(CAPPED)INSPECTION FORT TO BE KNoacouTs
S =' 0.02 INSTALLED AND TO BE WTHIN lS'OF GRADE S.5' OUTLET + 12• MET .�' t S{{ o r z '";,,a
3 HOLE H-10
DIST. BOX Top taod - Ekrv. =9200
12' NEW S-0 01
NEV PIPE '� mn 1,500 GAL or Greater Top of SAS-Elev. -91.50a
p S- 01 root '♦
FROM EXIST. F0UNIIATEW rn SEPTIC TANK O 18 D� 0"EHecthe Depth 155• 4' - SCH. 40 T
PLAN SECTION CROSS-SECTION
CONCRETE FU L FOUNLI� i A H-10 e..e.�. 6 to
PVC TEE REGurtED t O S UnIt3 a 6.25' a 30'
A DUE To REDUCE N °' 0.83' (10 inches) 3' 3' zz
SYSTEM PROFILE 6 n.of 3/4--1 1/2• a�ncPlD1ETaTD ! '^ 3725' 3 HOLE H-10 DISTRIBUTION BOX
,. .
compacted stone o Effective Length Not to Scale - e o n9 NOT TO SCALE c' 4' 4' n SOIL ABSORPTION SYSTEM (SAS)
L 2.5' ;
8 n.of 3/4--1 1/2- 0 10 INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN GENERAL NOTES
compacted (tone Effective Wldt►, (OR EQUIVALENT) Not to Scale
NOTE ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE w o
„ aD 1. Contractor is responsible for Digsafe notification
Bottom of Test Hole I Elev.-i If'"�-C,Q NOTE OVERALL HEIGHT OF INFILTRATOR IS 18' /EFFECTIVE HEIGHT IS 10' and protection of all underground utilities and pipes.
♦Obs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED 2. The septic tank on j distribution box shall be set
NOTE PLUMBING TO BE COMBINED INSIDE BASEMENT TO NEW LOCATION AS SHOWN. level on 6 of 3/4 -1 1/2" stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size.
Design Calculations 4. This system is subject to inspection during installation
d> by Carmen E. Shay - Environmental Services, Inc.
Number of Bedrooms: 3 Equivalent to 330 Gol./Day (330 Gal./Day Min. per Title V) 5. The contractor shall install this system in accordance
PERCOLATION TEST Garbage Grinder: No t with Title V of the Massachusetts state code, the approved plan
Leaching Capacity Proposed: 330 Gal./Doy Minimum (Min. Per Title V) and Local Regulations.
Date of Percolation Test: FEBRUARY 22, 2004 86 Septic Tank : - 3 x 330 Gal./Day = 660 USE NEW 1.500 GAL Septic Tank. 6. If, during installation the contractor encounters any
Test Performed By CARMEN E. SHAY, R.S., C.S.E. SOIL ABSORPTION AREA: Using percolation rate of <2 min.�nch soil conditions or site conditions that are different
Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) .� Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons from those shown on the soil log or in our design
Excavated By. SHAY ENVIRONMENTAL SVCS., INC. ��� �� Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. 58 gallons installation must halt & immediate notification be
Percolation Rate: Less Than <2 MPI ' _ `� l �s3 Providing: = 331.80 gallons made to Carmen E. Shay - Environmental Services, Inc.
88 \`�� �� 38 7. No vehicle or heavy machinery shall drive over the
>� Use: (5) INFILTRATOR HIGH CAPACITY H-10 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH,
septic system unless noted as H-20 septic components.
Off, TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE 8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
Test Hole ON THE ENDS. NO STONE UNDER.
No. 1 9. All Distribution Lines shall be 4' diameter Schedule 40 NSF PVC pipes.
DEPTH` SOILS ELEV. ---___ � 10. All solid piping, tees & fittings shall be 4" diameter
0 95.00 9$ ��\ Schedule 40 NSF PVC pipes with water tight joints.
Sandy ��` 119 0 20 40 50 11. Municipal Water is Connected to ALL OF The Residence and Abutting
Loam ¢ ``` `` Properties Within 150 Feet.
10 YR 3/2 `NN `N ��
0'-6' A, 94.50 `N `�
THE PROPERTY LINES ARE APPROXIMATE AND
Loamy `�\` ���\ `.\ COMPILED FROM THE SURVEY PLAN GENERATED BY
SCALE: 1 =20 NELSON BEARSE, R.L.S. of HYANNIS, MA
,o YR 5/e ��
� ` �� ENTITLED - 'PLAN OF LAND OF FOLSOM'S POINT IN CENTERVILLE, MA
i 6'- 30' Bw 92.50 \ _ \�` �` ` DATED JULY 23, 1952, PLAN BOOK 105, PAGE 125
Med. �� \�N _ -�``� `\ O AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
Sand ` `� ` `
`2s nd ` ` IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
30`- 144 00 \�`�\ �`�\ �`�\ THE SEPTIC SYSTEM INSTALLATION. `
6; �N ,
`�� \ `.\ 6 EXISTING CESSPOOLS TO BE PUMPED OUT AND
I -
`11 h� FILLED IN PLACE.
\`� \` NOTE: ANY STRIPPED OUT SO!L CONTAINING LEACu.9- _
p FROM THE EXISTING CESSPOOLS TO BE DISPOSED
\N r9 OF AS PER "BOARD OF 14EALTH SPECIFICATIONS.
•�, 0O� NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPECtT{
ASSESSORS MAP 209 PARCEL. 037
Perc Ott `9NS� `N` ` r9�~\�`� a /��,\� LEGEND.
�
Depth to Perc: 30' to 48"
Perc Rate= Less Than 2 MPI �\ .O 0
Observed ESHWT® - NONE OBS.- 144" Assumed
NN\�`.� dy? � "�
ADJUSTED H2O Elev. = NONE OBS. - 144' Assumed 10*� g A �� 104X1 DENOTES PROPOSED
14• 4P H SPOT GRADE
` TEST HOLE #1 `
0'' ELEV.= 95.00 ram7.2s DENOTES EXISTING
__ 104.46
98 ----- _ d 29 2 £ �� --- _ o X SPOT GRADE
`� PROPERTY LINE
PROJECT BENCH MARK 4" PVC �.=:•; o PL
.� Vent Pipe _ .+<.- r
TOP OF FOUNDATION �` �`
ELEV. = 100.00 (Assumed) 0 9�� _ `` � 96P}-- PROPOSED CONTOUR
� NEW 1500 gal. ��� NN `� `�
�, - - - - - -97 EXISTING CONTOUR
Septic Tank -� N
.\`� \ \\`�
3-24'DIAM. ACCESS MANHOLES '- O O O __-__. DEEP TEST HOLE & .
N.NPERCOLATION TEST LOCATIqt4
•`� =� - 1 1 •--• 6 FOOT STOCKADE FENCE
� - Failed %`�
1n 100-__ ��' `�\ PATIO N Cesspool
k, `\
INLET / 11 /_11 �_^ `�� p
1 I
MET a' �`.W , ----------_ \N -94
` THE ACCESS COVERS FOR THE SEPTIC TANK, PLOT P LAN
DISTRIBUTION BOX AND LEACHING COMPONENT \\ Failed � �� h i�
SHALL BE RAISED TO WITHIN 6' OF
\ Cesspool HOUSE //NS �`. `\ co
INSTALTUF-FINISHED E. t p OF PROPOSED SEPTIC SYSTEM UPGRADE
STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EQUALS j \ \ M M
PLAN VIEW ON ALL OUTLET TEE ENDS I EXISTING- \\\ II
3 BEDROOM \ 4 PREPARED FOR
-3_24•�,a�E COVERS
� ` y MR . RONALD J . KIM
m i ROUSE
00 1 ► 1
3'min•cbarance •-i. -{ 4• rs• i PORCH- 1 1AT
minT 2' min. Piet to outlet I I #6 LONG POND CIRCLE
OUTLET O I I 1 ► ,
INLE
u
tar mb.T� t.ii 'Tembi " + i I I /
5' _,- C ENTERVI LLE MA
_; ba �d depth I ASPHALT I �00'
a LOTS #1 & #8 DRIVEWAY i �, , �H OF Mqs
• sqc PREPARED BY:
-10-0' S:_B. 29,68f7 Sq,LO1'¢ Feet +� ; __;-_____ .'Zo/ ; �� E CARffEN E. ,SHA Y
CROSS SECTION END-SECTION i ,� i L _ '
+ , 1 I + (' ENVIRONMENTAL SERVICES, INC.
1 = 29.66 I I $�! 0 1
I L �13.7 9g' F a P.O. BOX 627
TYPICAL 1500 GALLON SEPTIC TANK 1 = » I \
I N .�a-53 40 ,E g I Tr- EAST FALMOUTH MA 02536
(H-10T LOADING) R 25TO SCALE5•70 ; --- --- o, 'IN TEL/FAX : 508-548-0796
LONG Co _Z::>O ND C'IR CL E' SCALE: 1"=20' DRAWN BY: CES DATE: FEB. 22, 2004
(40 FOOT RIGHT OF WAY) PROJECT#SD529 FILENAME: SD529PP.DWG SHEET 'I OF 1