HomeMy WebLinkAbout0177 MAIN STREET (CENT.) - Health (2) 177 Win Street (Cent.)
Centerville P---
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Commonwealth of Massachusetts
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner Owner's Name _
information is
required for every Centerville MA 02632 4/29/19
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.
A. Inspector Information 5i*.. 13:4-g1-
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
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
4/29/19
Inspect s Signatu 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
Commonwealth of Massachusetts
{9 Title 5 Official Inspection Form
ir Subsurface Sewage Disposal System Form Not for Voluntary Assessments
e ts
177 Main St.
Property Address
Singer
Owner Owner's Name
information is
required for every Centerville MA 02632 4/29/19
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:
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
r� ,9 Title 5 Official Inspection Form
li° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner information is Owner's Name
required for every Centerville MA 02632 4/29/19
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
c� Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
f
System Form -Not for Voluntary
Subsurface Sewage Disposal Sy Assessments
177 Main St.
Property Address
Singer
Owner Owner's Name
information is
required for every Centerville MA 02632 4/29/19
page. Cityfrown 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
r= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner information is Owners Name
required for every Centerville MA 02632 4/29/19
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 Y 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
{@ Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner Owner's Name
information is
required for every Centerville MA 02632 4/29/19
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?
❑ ® 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
177 Main St.
Property Address
Singer
Owner information is Owner's Name
required for every Centerville MA 02632 4/29/19
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): 330
Description:
Number of current residents: 5
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
l5insp.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
177 Main St.
Property Address
Singer
Owner information is Owner's Flame
required for every Centerville MA 02632 4/29/19
page. Cityfrown 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: Pumped August 2017 per owner
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.1126/2018 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
177 Main St.
Property Address
Singer
Owner information is Owner's Name
required for every Centerville MA 02632 4/29/19
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:
D-box and SAS 2010, septic tank 2014 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 12"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
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
w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner information is Owner's Name
required for every Centerville MA 02632 4/29/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
6"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle >2
Distance from bottom of scum to bottom of outlet tee or baffle
>2"
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.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc-rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�n (P Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
177 Main St.
Property Address
Singer
inform
Owneration is Owner's Name
required for every Centerville MA 02632 4/29/19
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
�n ►F Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner information is Owner's Name
required for every Centerville MA 02632 4/29/19
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):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-10 D-box is 3'6" below grade, cover raised to 18", it is on the very edge of a the driveway, carryover
in box, no indication 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
�n i-11P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner information is Owner's Name
required for every Centerville MA 02632 4/29/19
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:
® leaching chambers number: 20
❑ 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 113 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
177 Main St.
Property Address
Singer
Owner information is Owner's Name
required for every Centerville MA 02632 4/29/19
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.):
Chambers were video inspected and are damp at this time, bottom is approximately 4' below grade,
no indication of past hydraulic 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
r: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner information is Owner's Name
required for every Centerville MA 02632 4/29/19
page. Cityrrown 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
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner Owner's Name
information is
required for every Centerville MA 02632 4/29/19
page. Cityrrown 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
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l 1 �
f \
y Q41 ZU
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
,9 Title 5 Official Inspection Form
jn Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner Owner's Name
information is
required for every Centerville MA 02632 4/29/19
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: >11'
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: 2010
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
4'seperation per 2010 Installer and Designer Certification
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping
You must describe how you established the high ground water elevation:
See above
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
(n io Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
177 Main St.
Property Address
Singer
Owner information is Owner's Name
required for every Centerville MA 02632 4/29/19
page. Cityrrown 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
Lt5,,Ispdoc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
, /I�LO��CL -f��e. �4H 4 Gml
TOWN OF BARNSTABLI
LOCATION ' a�C SEWAGE# I
ViILLAGE eEFU L.C.CASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. z�
SEPTIC TANK CAPACITY J 5 r b 4,4:t_ ea' 1 ��d
LEACHING FACILITY.(type) (size) i,S�K old
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NO.OF BEDROOMS 3 (orG
OWNER lV t--`—
PERMIT DATE: Qa -I L- COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -+I— 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
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No. —�� Fee O
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4plifation for Bisposar *pstem Construction permit
Application for a Permit to Construct( ) Repair(;Upgrade( ) Abandon( ) ❑Complete System PIndividual Components
Location Address or Lot No. i 7 ri Ma rN St Owner's Name,Addr ss,and Tel.No. �-'YX-X31
e�,�u Mte
l I e- ay ��nel & ��f�iceac M
Assessor's Map/Parcel c?O$ Zoo/
02,43
nI�nstaller's Name, ddress,and Tel.No. Srq y2$-got ado Designer's Name,Address,and Tel.No.
f2)Dr4c,Ivff i '0' y 1Y�C r o/A i QJV�(L on
rs6-ors i/s 03ke-0
Type of Building: Z
Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable).`vtiS 1 StY� 00 ter °
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Enviro a Code d not to place the system in operation until a Certificate of
Compliance has been issued by this Board of He j
Signed Date J_Z /",1511f
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. ®/ — 0 Date Issued
-- e -- ------ - - ,��
N. Fee /O
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYication for Disposal .6pstem Construction 3permit
Application for a Permit to Construct( ) Repair(wUpgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. I r)rl 0.t h �• Owner's Name,Addree,ss,and Tel.N ..
ru, 1 I e Nta'CJ (�v zc,gel (c, (NC�a�AiJa
Assessor's.Map/Parcel o?O� 099 00 00 i f lei A 0-C)43$
�nstaller's Name,tddress,.and Tel No. q 1, ' �f a L Designer's Name,Address,and Tel.No.
t—��(v�C,OpC''!��?S+1�vGLL.--�-ia►�,.l.n� ,•c�/i�- l 4.�»(G. Qv>C�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)�',Sfr_u neu-, Mb 15cx> ce.Q., uk-kr
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 Environmerifal Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health
Signed Date
A Application Approved by 1 Date /1 .3
Application Disapproved by Date
for the following reasons
Permit No. t' _ So Date Issued /
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Ceftificate of Complianre
THIS IS TO ERTIF,�(Y,that the On-site Sewage Disposal system Constructed( ) Repaired C k) Upgraded( )
Abandoned( )by ! (U 16q` cff t_Qr_S1✓��G/�/rn�, —.1410
at �� �/(id7 ST ("&/7 k rul 1h has been constructed in accordance try
with the provisions of__Title
..5 and the for Dispos%%1 System Construction Permit N�"���dated o��
Installer &r 1v f v Gt.i L`�S ✓c.�t/ov� 2 rL Designer r.111 /e Al f�� 5 /L/
#bedrooms —3 1 Approved desi pw , of c. gpd P
The issuance of this permit sha b/ cons as a g ar e that the system wi ct -asp des e,
Date / InspectorIV
r -
� 11
-------------------------------------------:----------------------------------------------------- - ---------
K '^�
No. J L) _ �G�7+� . Fee `�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *psteut Construction permit
Permission is hereby granted to Construct( ) Repair(11 Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction m t be c let d within three years of the-date of this permit.
n.
Date ` r Approved by
Assessing As-Built Cards Page 1 of 1
TOWN OF BARNSTABLE
LOCATION 1�� MA�n S 1 SEWAGE a
VILLAGE Ccn trv,l�J. ASSESSOR'S MAP&LOT O$ oq
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) Gn1 J (size)
NO.OF BEDROOMS
BUILDER 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 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachipg facility) Feet
Furnished by2/1S Q Jbn
116 31 -
-
3 19 2LO
o y ' 7 97
http://www.town.barnstable.ma.us/Assessing/HMdisplay.asp?mappar=208099001&seq=1 12/29/2014
TOWN OF BARNSTABLE
TION y11 4�� s} SEWAGE# of 0 P 1 Q q
VILLAGE ¢��vt —ASSESSOR'S MAP&PARCEL AO
INSTALLER'S NAME&PHONE NO.
0
SEPTIC TANK CAPACITY 1500 1-� t
LEACHING FACILITY:(type) �o?c2� ACC 3(01la (size) IS Z O
NO.OF BEDROOMS 3
OWNER �� V2a ZQ n C' \ r
PERMIT DATE: -LDS- 7.r'�� COMPLIANCE DATE: `�1 1 2 0 1�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility v60 1/ Feet
Private Water Supply Well and Leaching Facility Of 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
FURNIS D BY
A9� / 4
l �Z
BIZ �3,� 32 o�4�co � .
R3 s-S.� �3 s8, y
. � s
No. P O t o_N q r Fee /CV, /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
9pplicatiou for ;DigPo9;a1 *pgtem Cougtructiou Vertu
Application for a Permit to Construct( ) Repair( ) /Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. I )') /Ylt�in ST Cep w vl Owner's Name,Address,and Tel.No. /-1 4LGt 4, YZ®Z Ain,�,
Assessor's Map/Parcel 2�5$ (:peel m,& iz&gg e�
Installer's Name,Address,and Tel.No. C '1_"__ cL " r,ve, Designer's Name,Address and Tel.No.
�
l7 �vxZco 3 2&s crrs�.
6, --w,.'L( .• a73 -Q 3 1 ��car ✓'
Type of Building:
Dwelling No.of Bedrooms ff Lot Size � 1 (3(s sq. ft. Garbage Grinder ( )
Other Type of Building t t�A2 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) J C2 gpd Design flow provided 3 5 S ZQ gpd
Plan Date Number of sheets I Revision Date
Title
Size of Septic Tank l CK5a P-Aj1> Type of S.A.S. sfxn � �
Description of Soil
Nature iRepa�lter atioQ n�Angwer�yhen applicable)
Date last inspected: o I.6
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of lth. p GG
Signed Date 28 —ZO 1-Z>
Application Approved by Date d �� —.)-ol d
Application Disapproved by: Date
for the following reasons
Permit No. C900 l Date Issued (O ` l e)
— ------------------. ---�-- ——————--
No. � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ..Yes
t
ZIppYication for Migogar *pgtemc Cowaructiort Permit
Application for a Permit to Construct( ,)' Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No. M A' x6c
(o Gs 1
5h�o`-C rz 2
Assessor's Map/Parcel ���
l'
►lit K'
Installer's Name,Address,and Tel.No. e,v.�2�.1.c�¢ �n�'C�� �y Designer's Name,Address and Tel.No.
�-(Zf -�-loZ..�, P-' �`"`7c•3 a z 1< Ste{ c_r a.,.,c-,.�,��r►.�,�,
Type of Building:
Dwelling No.of Bedrooms Lot Size 2c� f �Ql) sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 p gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 a--)C7 &n Type of S.A.S.
Description of Soil
Nature of Repair or Alterations(Answer hen applicable) K T)A1At-- 1--e A,y -t3Q5�
Date last inspected: Zo I0
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Pqlth. f y
Signed Date 2 0 -ZO t
Application Approved by ` Date ",�O/
Application Disapproved by: Date
for the following reasons
Permit No. ��y (r�'j x Date Issued �e -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( �) Upgraded ( )
Abandoned( )by
at 1 �I'� 4", CT has been constructed in accordance
with the provisions of Titlenn5 and the jor Disposal System Construction Permit No. 9010" �`-f dated g' d
Installer Designer�t 0 n-CA�t.i
#bedrooms 7 Approved de ign o ' U gpd
The issuance of thi pe. it shall not be construed as a guarantee that the system w 1 fu ett�oh as des ed.
Date I p Inspector �
sr
----- --•---�---- ----— -------- —--———---` - --
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
Iigpogar 6pgtem Congtruction Permit
Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( )
System located at f-7 7 ,/11 T'
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: Construction must be completed within three years of the date of this p�t.
Date V� ��' �� Approved by c5
-e
Town of Barnstable
Regulatory Services
Thomns F.Geiler,Director
BARN A LE, . Public Health Division
16 Chomas McKean,Director
200 Main Street, Hyannis,MA 02601
Otfire: 509-862-4644 Fax: Kf;:;•
IL Sewage Permit# `ZOto @ l'tq Assessor's Map/Parcel
Installer &. I)esigner Certification Form
Dcsi ncr; C e) ftee;idlc
• �� � �_��._._.r,_,.. Installer; C.ct����; d�, L:v�tec�•ciS t:_� ,. .
Addres+: 2 ,.5"/ CC<'N1iY�_l'lf �\Wc? ! Address; �O �Ja� �(�3 C-
Oil 6_21�-Zoto C44 �o(�Q ��'��®n�tZ wits issued a permit to install a
(date) (installer)
septic s�~tern at _..— t. 7 ._._Main S rre.e,t _._based on a design drawn by
T(: F �cl�ecirlC G_ _-------
(designer) dat`d . ,:junL�I�, xp1-0---
` ._
I certify that the septic systern rctl�reneed above was installed Substantially accordin:;
the design, which may include minor approved changes such as lateral relocation ofillr
distribution box and/or septic tank, Stripout (if required) was inspected and the S.Iik
\\cre found satisfactory.
_,. ._ I certify that the septic systern referenced above was installed with major changc,, 6-v
greater than 10' lateral relocation of the SAS or any vertical relocation of any com Poll k,n:
of the Septic systern) but. in accordance with State & Local Regulations. Alan revision .\r
certified as-built by designer to Billow, Stripout(if req ill nspected and the: sail,
\kere found satisfactory. �OFAj
y
(IntiC @I''S Sign "C)-...___ CIVIL, I•
N 1$c7
esigner-s Signatur:, -- (Affix estg rlcrtj-
PLEASE RETURN `I.0 §ARNSTABLE PjjBLIC HEetLTH DIVISION C`)TRTIFI 'A 1:1,,,
OF COMPLIANCI". W><LI. NOT BE ISSUED UNTIL BATH 'HlSrll'�pItI1%I AND AS-
BUIC.T CARD ARE IZEC YVEJ) By THE BARNSTABLE PUBLI"EALTI[
THANK: YOU.
. „la:(, .:...:;..I�!acrt,.itil•i..ai,a'.Burn J,i�
7Ga J ocC4 CJ7 620IC ''1NT?I-4-4NT'IN-q—i WH CC APi P111G17-1R--1n.r
N41WIW5'1ti791- ':°:tl47�wf�l w nc n 4#rtr ,.,ve 1 5i .1&t %�f4 �trsfti� JAitaEw w�14 Ytw 7:",
Town of Barnst
able F'd � Z
Doplowdo gar 260AAW7 EIrtbu -16 -j 0
Publlc' ie�tit3>t Divla�on nw
We Mauom,Ibu* A 0201
iao,vo
SOU S &abimy Assessmen.t for Sewage DIVOea l
t'+efior lbr lt;Vlo¢�I Qi cv�i'l 0 � E-I,CS6' Witom d� you i� w.s kn la�,., 2 5 _
• I�C��iaN�CiBL INF(7RMA�'T't01�1 .
y�,Won Aaae.s �1 �a� s�,ek �wer'rNwr Marcy A, (�o z���-;
1
Cz-)keruille riPt 'o2632 Adeuer+ � c;yskl �td5e(td, catvi} rtA
gC en5oeecI45, oc. ,
Ateera'sYrpAtiaet H'oQ 20 8 (�orc�l 9 tOplhal'rNrrq ,
. Icy 1IL'1'�i RBPA�t •
FoenilY rest enklai i slow 1..._._.. 10 �utEMnelknorr
1 �A "r��- __ -w� t�llit���,�ee •c�rt�rraarwru A «
um
!6raeetntm�►a+ uia�.diat wKtle�raar etautlowl�pur 1 .4rMrWa+Yaf, i}orsei411
See aWW-CL eicn
F*W modd(00*10) �ukw c s� • b llwifeelt 7 I Z+-....ter-•""„"^.,�' .
pro6wGiarn�NeR 61eedlyWrwlrUidr� b oy,NrlyAbr�bletMa
-7 12 6"b -s .
D&md WWIt1i0b 0ea• ter ------ --
MMMMATION POR SUSOMAL HIGH WATBRTA►"
(1 OW Vid D U@ G� d�SetUcklGrl 00 dWXW 7 f 2 Co 71 Z 6
eWtditltia eee.ao>� - —I!, aplb IOrtd1 rtoRzErt
7, =�,,._.61� wOrs
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a.prretreA 30"-y 8. 'tirore ...-•,�
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r►et�iabit�y As■.r�n.�t ae I�,..ea._..Yet... . u�d;�....•.. d'l�.d'��iruNa r�M..r..Al .
o trleea'wane Obo�w>aan Y;ota Uft TO 8c Carp %md on 7l 4....__._
«"t 0imistiou bet u to be 6ndustud within 100'It Nrdtpnd,7W wit eQlt�/qh
$e yU C�On Dtrtrton at IoW one(1)Wok pry'
to bISAMIMID
. 4:�BPI'1C�t�BIIt�DRL•IIOC .
u�:aa.a.cueiosa^:ri.rip .. •.,a�niy�,;,W:ar{� ��.<1+ �.'..,._. +Tt
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river
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c 30
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50-yS 6 LS /o` t s/6:
DBE'0IMIMAMON BrO AIM
bobw own'' Sear. "Own w otr.r
ub a (ia� Ono �wp YedUws NAM
DUP YA7TON HOB I JG ]me#,,..._,,,
�bam Sou Itotlam e v obu m Sd dotot . 1op oftr
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i •
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• �iRaleS00ywtM� q► lra_,!. 'Ys.,;w,,�, .
'N�1ti!>oyiierrnod?perd�ry 110 _..
Dap at leW het od at lly . p�mix mota w spirt tt►allow obwvw dtwvAabwt d&o
itc�a bsr die�aU abrorptiba q�temt7 Y.,,..,,,=,t,,,,..
If mt,ghat it*v dopib 0 O'du ally owaft �,parviqu mtsert�►1...,.,......r� '
_(")Y bay paned ft loll trirduar afoidon appmvw by.tbe
D olBnvlio�u�aardollrtotaetioa aid dial du above inafytN N�palhraed by uo emabwot� , ,
do halted ale&aspowso dworW io$tOCMR isaM
6 A io
�.roaeUM
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL
,AP
PARCEL, _� �� � _. AUG 0 9 2004
LOT - — = TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 177 Main Street
Centerville, MA 02632
Owner's Name: Michael Natale
Owner's Address:
Date of Inspection: July 30, 2004 i
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford -3
Mailing Address: P.O. Box 49 I r
Chi C 3
Osterville,MA 02655-0049 < o
Telephone Number: (508) 862-9400 i✓ `�
o
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the in ormation-repor-W
below is true,accurate and complete as of the time of the inspection. The inspection was perform Id based�11 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 syst m:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: )7j Date: August 2, 2004
The system inspector shall submi 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.
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 1
, 4
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
Inspection Summary: Check A B C D or E/ALWAYS complete all of Section D
P ry � � P
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CM
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.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/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 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 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
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone II of a public water supply well
If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
f
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period? .
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ _ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
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 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: I
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown-No information available
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 6"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
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: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level and clean. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
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:
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.):
The galleys were dry and clean. There did not appear to be any signs of failure or backup.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
• Page 10 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
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.
a 3 Q
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3 o y
10
• Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 177 Main Street
Centerville, MA
Owner: Michael Natale
Date of Inspection: July 30, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20 +/- 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 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic maps and water contours maps, the maps were showing approximately 20'+/-to ground water
at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
i
COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
,
o,M�'Syev�
350 MAIN STREET
WEST YARMOUTII,MA
® 508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 177 MAIN STREET
CENTERVI.LLE,MA 02632
Owner's Name: JAMI.E POP.ILLO
Owner's Address: 177MAIN STREET RECEIVED
CENIERVILLI ,MA 02632
Dale of Inspection MARCtl 81 2001
Name of Inspector:(please print) JAMES D.SEARS APR 13 2001
Company Name: A&B Canco TOWN OF BARNSTABLE
Mailing Address: 350 Main Street HEALTH DEPT.
West Yannouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection. The inspection was
performed based on my training and experience in the proper function and maintenance of on site sewage
disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310
CM 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 3-13-01
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 tot
he buyer, if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at.the time of inspection and under the conditions of use at
that time. This inspection does not address how the system will perform in the future under the same
or different conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 177 MAIN STREET
CENTERVILLE,MA 02632
Owner: POPILLO,JAMMIE
Date of Inspection: MARCH 8,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:X
_ I have not found any information which indicates that any of the failure criteria described in 310 CUR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 177 MAIN STREET
CENTERVILLE,MA 02632
Owner: POPILLO,JAMIE
Date of Inspection: MARCH 8,2001
C. Further Evaluation is Required by the Board of Health: N/A
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(i)(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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 177 MAIN STREET
CENTERVILLE,MA 02632
Owner: POPILLO,JAMIE
Date of Inspection: MARCH 8,2001
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in leaching is less than 6"below invert or available volume is less than Y2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone H 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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 177 MAIN STREET
CENTERVU,LE,MA 02632
Owner: POPILLO,JAMIE
Date of Inspection: MARCH 8,2001
Check if the following have been done. You must indicate"yes" or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
X Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 177 MAIN STREET
CENTERVILLE,MA 02632
Owner: POPILLO,JAMIE
Date of Inspection: MARCH 8,2001
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 2
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 1999 69,000/2000 72,000
Sump pump(yes or no) NO
Last date of occupancy: N/A
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A—NOTE MAINTENANCE PUMPING AFTER INSPECTION
Was system pumped as part of the inspection(yes or no): AFTER
If yes,volume pumped: 1000 gallons—How was quantity pumped determined?
Reason for pumping: MAINTENANCE
TYPE OF SYSTEM
X 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)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 177 MAIN STREET
CENTERVILLE,MA 02632
Owner: POPILLO,JAMIE
Date of Inspection: MARCH 8,2001
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 6"
Material of construction: X concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 101,
Distance from top of sludge to the bottom of outlet tee or baffle: 21"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How were dimensions determined: ASBUILT AND 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.):
MAIN TANK AT WORKING LEVEL.INLET AND OUTLET TEES.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence'of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 177 MAIN STREET
CENTERVILLE,MA 02632
Owner: POPILLO,JAMIE
Date of Inspection: MARCH 8,2001
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
f 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.,):
D-BOX IS CLEAN AND SOLID.NO SIGN OF OVERLOADING AT D-BOX.BOX IS 20"BELOW GRADE.
BOX IS 16"X16".
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 177 MAIN STREET
CENTERVILLE,MA 02632
Owner: POPILLO,JAMIE
Date of Inspection: MARCH 8,2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
X leaching galleries,number 3
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.)
THREE GALLEYS,GALLEYS ARE 16"BELOW GRADE.6"WATER IN GALLEYS.NO HIGH STAIN LINE.
NO SIGN OF OVERLOADING.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
J
Title 5 Inspection Form 6/15/2000 9
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 177 MAIN STREET
CEN'TEIZVILLE,MA 02632
Owner: POPLLLO,JAMII
Date of Inspection: MAIZCII 8,2001
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.
t
a�
q 7+ `1
o' Z
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 177 MAIN STREET
CENTERVILLE,MA 02632
Owner: POPILLO,JAMIE
Date of Inspection: MARCH 8,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to adjusted groundwater 18 feet
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation 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:
ADJUSTED GROUND WATER TAKEN OFF ASBUILT. BARNSTABLE HEALTH DEPARTMENT
18'.
Title 5 Inspection Form 6/15/2000 11
7
aog- cm--00(
No. 1 F$a ��«
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL H
.............1 6.l.A1Jq.......OF...�.�- ..)A` _jt j 46...-. .......
Appliratinn for Disposal Marks (ffonshvdion Frrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( f-)—a—n( Individual Sewage Disposal
System at:
««. .«..b .- -..._.. •••...................... ..........•••••••••• ...........- ...---.. .........................
....
...«.........
/� y, y C� Loecatiofnv-Address or Lot No.
................................. ................:Ca u�.. .......:.. ..............
.............«......«.«.....
Owner �7A_ p
...........N__Y. :.C�........;S~F z.............................. .......... �.lf. .. .�t.... ..7YJ.ddress.- •dF�C .i_-�•�• .............
Installer Address
Type of Building Size Lot................ Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixt s
WW Design Flow.......-�. ...................gallons per person day. Total daily flow___• �3.a- ........................gallons.
A4 Septic Tank 4 Liquid capaci y 1. gallons Length......_:_ Width....`.e........ Diameter................ Depth................
Disposal TrenchS No.f rS__. Width----2........... Total Length.._. ....... Total leaching area...................sq. ft.
3 Seepage Pit No..................... 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........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ••••••••--••....•--•-•••••....•--••••••---•••••••.....-••-•-......••••-•••••----------------•••••--•.........................................................
0 Description of Soil........................................................................................................................................................................
z
U ..........
---------
• -•-----... ------
-----------------
-......
.-------------
•-----------
•--------•----..---------------------------------
--------------------.----------
W
U Nature of Repairs or Alterations—Answer when applicable-��. ........ .n.�-'?✓��Z T ...........
----•---•--------------------------•.......-••--•-•...---..._-•-•••••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'1'!L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ed by the board of health.
_
Signed........... ,,
��� !. ••---
�ate
Application Approved By.....---- -- •-.-•--• ----�--- - '•
Date
Application Disapproved for the following reasons:... ..................................................•....__._....._........._.------------
..............•--...----•----•-------•------.....-----------------------------------------•--•-----------•-••-•••-•-•..........•--•------••-••••••••••••--••••-•--••.....••••-••••••••••........._•••---
Date
Permit No..---.40--- -:'"✓ ' --« Issued.•..-. _. Dry......«...........«
No. '.'.: ..� F$s..j�f',.An
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appl ration for Disposal Works Tonstrnrtiun rtrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( L.)-ann Individual Sewage Disposal
System at:
Location-Address or Lot No.
........ !1�4Np1-+1� ........................ ......................................................1 1 ...._........... ._.._..........._..
Owner ddress
O, 2ti xCra,� u�( t/�. C,. .......-- - ..... .............. ..... ........ .. ------ -•-.............;--......,....1................
Installer
Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Ga4 Type of Building g ------•-•------------------- No. of ersons._......----------...._.---- Showers — - ( )
p ( ) Cafeteria
Q Other fixtures
Design Flow.......:. ...................gallons per person peter day. Total daily flow---- .........................gallons.
Septic Tank Liquid capacity(Mgallons Length....k"....... Width....Yl ........ Diameter................ Depth................
W Disposal Trench,;, No.na.017,:,', Length _. Total leaching area....................sq. ft.
x � �------. Width-----�{-...--•----- Total Len h----/�(��---•---
1,.... _
3 Seepage Pit No--------------------- Diameter...................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution boxy( ) Dosing tank;( )
`.•1 Percolation Test Result" Performed by........-•----•-••...................••...._...--•--.........-•----.----.. Date........................................
Test Pit No. 1"s...............minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a :.....................................................................................................=................................................
ODescription of Soil...w._..----•-.....-•--•..............••---•-•--•........_........-----••-----•-•----•---•------------•---.......--•--.........................---------•••-••-••••....
................................................
x ......................................
---------------------•------------------------------•--------------------------• -----------..... --------------•---•------....... --------•----
Nature of Repairs or Alterations—Answer when a licable-:1: _.(� t r 1.,C.,.__:- ! ............
U eP PP -- -
- ------------------------- ---
Agreement:
N The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA I 5 of the State Sanitary Code—The undersigned further agrees not to place the system in,
operation until a Certificate of Compliance has beengtssued by;the board of health. '"
(7
a
te
Application Approved ..........
Date
Application Disapproved for the following reasons: ----------------•--•-•------...--------........--•---•----•-----•-•---•-------•---...--•------••...__.
-------------------------•-•..-••••••---••----••---•-----------•-•--------•-----....----..........------.•--•----•------•-----------------•-----.....-------......-----..._.....--------••-•••-••.•-•-•-
ate
Permit No..... ��'-a ....... -•••-••---.....:.......D
Date
THE COMMONWEALTH OF MASSACHUSETTS ' t
f'
BOARD OF HEALTH
........OF... A-KZ wS .�A - ................................
CIrrtif iratr of Toutpl am
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by......................... e i��=..2..- t /� .�,�.�C,--------------r------ --...---------------.........------------------.......---•---•---•-----------
A Installer
at........................J.7.��-f•........N,^!! A RIB..:!�K...................-Z. ........•...........................
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code s described in the
application for Disposal Works Construction Permit No........ ,.�-.._.^n*-................. dated.... e0 1rte7-7 .__.__...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU CTION ATISFACTORY. ��-'"" � 51
DATE.........._i/.. � *...................... Inspecto '... .... ............
t .. rr
THE COMMONWEALTH OF MASSACHUSETTS
s BOARD OF HEALTH--
'a.�. !`-!.......oF\, ..................Y� . ...............................
No.....��.... FEEYlv•l/�
................
Disposal Works Tunstriirtiun jhrmit
Permission is hereby granted....... ..............................................................
to Construct ( ) or Repair (man Individual Sewage Disposal System 4
atNo.:-•-...--••--....lr' ........� ._��:. •••-�................. -;�,�.�------------------------------••-•......................---..............................
Street ,✓
as shown on the application for Disposal Works Construction Permit No.��'' Dated... ....... .........................
Boardyof Health
DATE ......... ...... ����------•----------------......
TOWN OF BARNSTABLE
'LOCATION 1 MAID S� SEWAGE #
VILLAGE C1 n e/v t�� ASSESSOR'S MAP & LOTLA03 ag 9
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Gnil��,s (size)
NO.OF BEDROOMS
BUILDER OR OWNER 6AT13 It
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 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leach�g facility) Feet
Furnished by J n!4q—tU )Dn
� a 3
0
a
/(o 31
1 S aS
3 1 ao
a y 41-7 y-7
TOWN OF BARNSTABLE
LOCATION 17 7 /M#1 S 7 . SEWAGE #
VILLAGE C £N7T ASSESSOR'S MAP & LOT
�A1S,�Fc!ps
` IAST*L-E� NAME St PHONE NO. A & B CANCO 775-6264
-SEPTIC TANK CAPACITY S
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER OaO L� ✓ ���
DATE PERMIT ISSUED:
DATE 3 E"
VARIANCE GRANTED: Yes No
_ 1 I� £� � '
e
�� 3� �.� _
o r9°
��� �,17
TOWN OF BARNSTABLE
'LOCATION �77�CJff7J� SEWAGE #
�J 0�8'
VILLAGE 0&1,9 �erud/� A/S/SESWR'S MAP &LOT6 y9.CJ0/
NAME&PHONE NO ar 10/D 3 -1 C.&S/
SEPTIC TANK CAPACITY /000 4fi/1iJ
LEACHING FACILITY: (type)�S K3 J (size)
NO. OF BEDROOMS u�
BUILDER O OWNER ShQ.(112 a/'i 12' 4-1
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
i
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �d 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
AI
within 300 feet of leaching fac'jty) Feet
Furnished by 7�/ i Gn X ruz/001), .Z�e. 6 -ate— ..
,<��'
ti
°
�a
y`
TOWN OF BARNSTABLE
r° w
LOCATION + -7 SEWAGE #
V&LAGE �°� �1�d. 'ti ASSESSOR'S MAP 6z LOT
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) Q>,-4
NO. OF BEDROOMS PRIVATE WELL ORIIU:[BLIC WATE�� .
BUILDER OR OWNERh
DATE PERMIT ISSUED:
—DATE COUPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
b
T.O.F. EL.= 97.7'±' INISH GRADE OVER D-BOX= 8.7.2'± 4"SCHEDULE 40 PVC MIN. SLOPE 1 % PROPOSED PVC VENT FINISHED GRADE OVER BIODIFFUSERS= 85•5' - 87•0' GENERAL NOTES
PROVIDE EXTENSION RISER SLOPE @ 2% MIN.
WITH COVER OVER INLET& REMOVABLE WATER-TIGHT COVER OVER INSPECTION PORT WITH 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION
FINISH GRADE
OUTLET TO WITHIN 6"OF F.G. RISER TO WITHIN 6"OF FINISHED GRADE ACCESS BOX TO WITHIN METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
@ FND. EL.= 90•9'+ F.G. OVER TANK EL. = 90.7'±' 5"DIA. OUTLET(S) 3"OF F.G. (ONE PER ROW)
_ CODE AND ANY APPLICABLE LOCAL RULES.
2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
--EXISTING 4"
PROPOSED 4" 36"MIN. SEE
48 MAX21 TOP OF SAS/B.O. = 83,00 3. 4 SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
SEWER PIPE ��� PVC SEWER PIPE " " '
� � SYSTEM UNLESS OTHERWISE NOTED.
6" 3" 3" DROP MAX " �+ PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
_-= - 2"DROP MIN 3 9 MIN.SLOPE ,% L - 47_ JOINTS (TYP.) ELEVATION =83.00' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
10" 4" PVC IN FROM 1.33' Q 16„ 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF
14" \-*88•7'± SEPTIC TANK O 4" PVC OUT TO o 90, (Ty 10.75ff"(n'P) THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
LEACHING FACILITY
5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
82.57 81 .67 laid flat 2.875'(34.5")-�-I 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
EIH
CONTRACTOR CONTRACTOR SHALL 12" 6"
SHALL VERIFY SIZE 48" VERIFY CONDITION OF OUTLET TEE 85.00 MIN. $4.83' (TYP.) 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
AND CONDITION OF EXISTING TEES GAS BAFFLE 6"CRUSHED STONE
(TYP.) MIN.
5.0' FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
5'
EXISTING SEPTIC AND REPLACE AS OVER MECHANICALLY 14.375'
REQ'D NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
TANK NECESSARY COMPACTED BASE
20.0' AND DESIGN ENGINEER.
L 5 OUTLET DISTRIBUTION BOX (TYP.) 8. ELEVATIONS BASED ON ASSUMED DATUM DATUM OF 87.35' ESTABLISHED
TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV.= < 76.50' BIODIFFUSERS END VIEW) ON A NAIL SET IN FENCE AS SHOWN ON PLAN.
BASE. FIRST TWO FEET OF OUTLET
EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. 20 - BIODIFFUSERS (PROFILE) 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
CROSS SECTION VIEW (BY ADVANCED DRAINAGE SYSTEMS, INC.) 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
t.CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL 20 - ARC 36HC (#3616 B D) H-20 BIODIFFUSERS TO THE DESIGN ENGINEER.
TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE
10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT.
- • • 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
' �` • `,� TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
j • • 4 + . •• +•+' �( PERC NO. 12972 APPROPRIATE AUTHORITY.
•. ' � • o • �►•. ,�' '� If INSPECTOR: David W. Stanton, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
yi +• EVALUATOR: Michael Pimentel, E.I.T. LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE
• ~ • ''�■ ' C.S.E. APPROVAL DATE: Oct. 1999 THEY SHALL WITHSTAND H-20 LOADING.
° r• 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
•: • •• �„ t DATE: June 10, 2010
\� oy� 1 •�.'�` • • „ TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
�\ r ` •� 1V '�� (I'III+ ELEV TOP= 87.50' MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
ELEV WATER= <77.00' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
!�
M �'� �y y� o��^ ch t __ PERC RATE _ <2 min./inch 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
\ - • SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
aI F�C� 9 =yo�tA� o „ •' ! ` • • DEPTH OF PERC = 30"-48" 16. PROPOSED PROJECT IS LOCATED WITHIN:
' • -1! • • ' • TEXTURAL CLASS: 1 ASSESSOR'S MAP 208 PARCEL 99-01
ch I 0\ h 1� �� • . • ./ • • •
o MAP 209 ��s J` \ + f/ .: . I OWNER OF RECORD: MARCY A. ROZANEI
10
.ki I �,+ c, O • •
m PARCEL 42 �/ l_ y • • , •' ADDRESS: 6 CRYSTAL RIDGE ROAD
°,�g �, �\ ' �s r� `9� . . . LOCUS +, . 0" 87.50'
J O \ S\�j 0�,� + • • " • '� • COTUIT, MA 02635
a. �`� I \ O� / p ( • ,��� ' Fill
I ' FEMA FLOOD ZONE C
\ �Ps '�/I # •� .- ` I 30" 85.00'
CD
\ • moo ♦ O . • B Perc = Loamy Sand COMMUNITY PANEL# 250001 0005 C
� #177 Ps `�g � � i � • • '�-= / • . �,,, 48„ �;-- 10Yr 5/6 83 50' 17. DEED REFERENCE: DEED BOOK 19224, PAGE 284
EXIST. 1,000 GAL. SEPTIC /� EXISTING c �k.� I • `i U
} \ / ` • • •
TANK TO BE UTILIZED AS 3-BEDROOM+/ a DWELLING �� � • ' . p • 11 � �,- . 18. PLAN REFERENCE: PLAN BOOK 376, PAGE 33
PART OF THIS DESIGN-�
TOF_97.7,+ 9g �� �,` \ j o 0¢ . ' 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
EXIST. SAS (i.e. GALLEYS) }/+ BFE - 91.0_
/� TO BE ABANDONED }/ y� ��Q �t� Q. . . �` • 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
C Medium Sand FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
AA``
`SSO° Benchmark / a O °�� �G� �° FQ �V_�P-1 ' 4 2.5Y 6/6 FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
O
Nail Set in Fence cO \ ��
Epp, SF Elev. =87.35' �/ �` / /`� ;Ca dJ \JP w� • ! • • 21. IN ACCORDANCE WITH 310 CMR 15.401 -15.405,THE FOLLOWING LOCAL UPGRADE
QQ` APPROVAL IS REQUESTED FROM 310 CMR 15.221 (7):
Assumed Datum o°
MAP 208 (1.) A 1.0'WAIVER(4.0-3.0') FOR THE MAXIMUM COVER OVER THE LEACHING FACILITY.
PARCEL 101
,�' ' �.� ��O °` LOCUS PLAN
A14��
1
//z 9 - f
SCALE: 1"= 1000'
o�\��'� �--EXIS(. DISTRIBUTION BOX TO BE ABANDONED 126" 77.00'
PROP. PVC VENT; EXACT SHED
f No Mottling, Standing or Weeping Observed
LOCATION PER OWNER
TP
87.2 E / / DESIGN DATA TEST PIT DATA LEGEND
84x6'
85x2' �' PERC NO. 12972 MAP 208 8;;� 8 PROPOSED DISTRIBUTION BOX INSPECTOR: David W.Stanton, R.S.
PARCEL 99-01 I 85x4'
// I, EVALUATOR: Michael Pimentel, E.I.T. x EXISTING SPOT GRADE
20,100 S.F.t 00 A 84x2 S NUMBER OF BEDROOMS (DESIGN) 3 - - 50 EXISTING CONTOUR
.�, C.S.E. APPROVAL DATE: Oct. 1999
\ 85x5' ' 4 PROPOSED TOTAL 20 ARC 36HC (#3616BD) H-20 DESIGN FLOW 110 GAUDAY/BEDROOM DATE: June 10, 2010 50 PROPOSED CONTOUR
/ BIODIFFUSERS IN A FIELD CONFIGURATION TOTAL DESIGN FLOW 330 GAUDAY
84x4' / �Z TEST PIT o = 660 I : ❑/H/W - EXISTING OVERHEAD UTILITIES
PROPOSED INSPECTION PORT WITH I ELEV TOP 87.00'
DESIGN FLOW X 200 /o GAUDAY
ACCESS BOX TO GRADE (TYP OF 5) SWING
� USE EXISTING 1,000 GALLON SEPTIC TANK
GAS - EXISTING GAS LINE
-TIES SCALE: 1"=20' ELEV WATER= <76.50'
DESCRIPTION HC-1 HC-2 PERC RATE = W W- EXISTING WATER LINE
° / BIODIFFUSER CORNER(1) -9.5- 60.5' DEPTH OF PERC = TEST PIT LOCATION
07, / D° BIODIFFUSER CORNER(2) E4.2' 59.5' i INSTALL 20 - ARC 36HC (#3616BD) H-20 BIODIFFUSERS TEXTURAL CLASS: 1
° 0 r - -
'V BIODIFFUSER CORNER(3) 82.7' 79.5' EXISTING 1,000 GALLON SEPTIC TANK
SYSTEM CAPACITY
MAP 208 BIODIFFUSER CORNER(4) 79.1' 80.2' (TOTAL L.F. OF BIOS)(4.8 SF/LF)(0.74 GPD/SQ.FT.)=GPD 0" 87.00' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE
PARCEL 99-02 (100.0')(4.8 SF/LF)(0.74 GAUSQ.FT.)= 355.2 GAL. LEACHING/DAY
--#177 Fill D PROPOSED DISTRIBUTION BOX
/ EXISTING TOTALS:3-BEDROOM TOTAL NUMBER OF BIODIFFUSERS: 20 B 30" Loamy Sand 84.50' PROPOSED ARC 36HC (#3616BD) H-20 BIODIFFUSER
DWELLING 10Yr 5/6
HC-1 TOF = 97.7'± TOTAL NUMBER OF COUPLINGS: 0 48" 83.00'
BFE = 91.0'±
TOTAL LEACHING AREA: 480.0
TOTAL LEACHING CAPACITY: 355.2 REV. DATE BY APP'D. DESCRIPTION
PROPOSED SEPTIC SYSTEM UPGRADE
NOTE:
EFFECTIVE LEACHING AREA OF 4.80 SF/LF OBTAINED FROM THE C
Medium Sand PREPARED FOR:
HC-2 DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER 2.5Y 6/6 CAPEWIDE ENTERPRISES
"MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO ADVANCED
DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003(LAST MODIFIED LOCATED AT
FEBRUARY 18, 2010). TRANSMITTAL NUMBER=W000052.
NOTES: 177 MAIN STREET
SHED CENTERVILLE, MA 02632
1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF -- - --- - - -
1 SCALE: 1 INCH = 20 FT. DATE: JUNE 18, 2010
EACH SEPTIC SYSTEM COMPONENT. � 126" 76.50' 0 10 20 ao so FEET
�c?p, No Mottling, Standing or Weeping Observed tc.
2. JONN L
CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE
(4 2) -- _ . �A PREPARED BY:
PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST PIT RESERVED FOR BOARD of HEALTH USE U dii. JC ENGINEERING, INC.
DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL BOARD OF 6
HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. Q ° �,' "'� 3 2854 CRANBERRY HIGHWAY
EAST WAREHAM, MA 02538
3.) PROPERTY IS LOCATED WITHIN THE ESTUARINE ZONE WATERSHED. SITE PLAN 3) 508.273.0377
SCALE: 1"=20' Drawn By: MCP L Designed By:MCP Checked By:JLC P JOB No.1835