HomeMy WebLinkAbout0011 MASTHEAD LANE - Health i
11 Masthead Lane ?
Centerville
A= 193 —066
iM E A D
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c Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l
........... 11 Masthead Lane ` 'I
Property Address ,
Susan J.Teixera t. a
Owner Owner's Name `
information is Centerville Ma 02632 9-9-19 rryp,
required for every
page. City/Town State Zip Code Date of Inspection e t t
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information �filling out forms * Q/0
on the computer,
use only the tab Brett Hickey
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
t Company Address
Sandwich Ma 02563
City/Town State Zip Code
rrm (508)477-0653 S113747
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
Brett Hickey 9-9-19
os>.xoiv.o°.io i3.zs:ze oam
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts '
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑■ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
�n IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L 11 Masthead Lane
u
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
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
f Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
V
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town 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
❑ Y P P Y (SAS)
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
❑ Q Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Q 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
�V
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than day flow
❑ El Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ R Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 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.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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-
El ❑ 10,000 gpd.
❑ El 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 16,000 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
c� Commonwealth of Massachusetts
+m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town 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
❑ El Pumping information was provided by the owner, occupant, or Board of Health
❑ El 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?
0 ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
0 ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ 0 Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
El ❑ 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
pr Title 5 Official Inspection Form
lol Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
L�
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 360/GPD
Description:
Number of current residents:
1
Does residence have a garbage grinder? ❑ Yes ff] No
Does residence have a water treatment unit? ❑ Yes ❑. No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes 0 No
Seasonal use? ❑ Yes (E No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
***2018- 255,000gallons 2017- 175,000gallons***
Sump pump? ❑ Yes ❑■ No
Last date of occupancy: currentDate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,V
11 Masthead Lane
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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: Owner- date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ❑N No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
,iq Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El 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:
new SAS added to existing tank in 2011
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
3'6"
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑other(explain):
Distance from private water supply well or suction line: Town waterfeet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
21611
1611
Depth below grade: feet
Material of construction:
❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 000gallons
1511
Sludge depth:
2111
Distance from top of sludge to bottom of outlet tee or baffle
6"
Scum thickness
211
Distance from top of scum to top of outlet tee or baffle
1419
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
11 Masthead Lane
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
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):
NA
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
L
f Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
Property Address
Susan J.Teixera
Owner Owners Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town 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):
0°
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
10 HiCap infiltrators
El leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
c Commonwealth of Massachusetts
+s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
v
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Leaching was dry when viewed.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
11 Masthead Lane
v
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: NA
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
141-1 Commonwealth of Massachusetts
�n ,lp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Masthead Lane
�V
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
vrI I A ;" -�--r;cz _� ✓:{ .. sssri€ s 1I -:.PARCEL 3 ..
SEPTIC"i"AWK.CAPACCT"Y "• l
._ ._._......__....__.._�.__.._._
LtA.CHING FACILITYY (type)
NO.O P1F,T R,66M5
OWNER,,
PFFLN[IT;I?AZE __ �-¢ - 1`i CCtC92PLIANCF IJtIYE `
Srcparadrrn Distiarcc-Ti'�crween Lli+c: _
Maxinturxt`flaljjisstrnt-GroT.vxiava�aer Takla to tickiottgnw��of Lca?iaing°FuxiiixY' �_.: .. ._........._.......__..
Pttivale Watcr Supply.,W_ell And.L.eachintL Faci;I,ity£I€n'4!Y welL9.CRisi on
site rar.Wit]ifta:200,&2-A, axihing facility,)
Edge of Wetittndand Lemtching'1°axAl'ity flf-any wetlands rxiia within,
300 feet of'leaclaing faciiityt # [�e� E"ect
/J.
41
i
i.
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t5insp.doc-rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.......... 11 Masthead Lane
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
■❑ Check Slope
■❑ Surface water
■❑ Check cellar
■❑ Shallow wells
Estimated depth to high ground water: No GW @ 120"feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
If checked, date of design plan reviewed: Sept 8 2011Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain: .
You must describe how you established the high ground water elevation:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
11 Masthead Lane
V
Property Address
Susan J.Teixera
Owner Owner's Name
information is Centerville Ma 02632 9-9-19
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑E A. Inspector Information: Complete all fields in this section.
Q■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
❑■ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation
of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
-.MW F BARNS
TABLE
LOCATION j j t/t; l —I.C�1 Ll�t_ _' SEWAGE# i i - 30-3
`VILLAGE Coy; Z-L/i t_�ASSESSOR'S MAP&PARCEL 1 3 -
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY C=�r��S-, 4 I0i0- tA-C.
LEACHING FACILITY: (type) (size) i•��ic �.
NO.OF BEDROOMS Q ",� d- S CA 4+1-C A i>
OWNER t=
PERMIT DATE: 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 leaching facility) Feet
, k
FURNISHED BY
1.
i-
f/
�? ���-
3;
� ;
No. �.�.� � Fee
t
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
01ppYtcatiou for Mioa t *pgtem (faivaructiou Perron'
Application for a Permit to Construct( ) Repair Vupgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. /; �<�� — Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel �+
308 /- 9359
Installer's Name,A dress,and Tel No. D signer's Name,Address and Tel.No.
�1 off to i l�»S1�i7Je��cvJ rLr�G t g7��cYrJ Y)1 Y"Mnc'
44 A14 oa,-7.S'
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) 33c) gpd Design flow provided .3(00 gpd
Plan Date p,�_ �( � V'')Al i Number of sheets Revision Date
Title TT r
Size of Septic Tank e—y— Type of S.A.S. /O
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1 [R.W 0 Bei-j( 4— AQ 14e- ,(S 10 C11-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boa rf Health.
Signed Date /
Application Approved by Date 9 /
Application Disapproved by: Date
for the following reasons
Permit No. �0�� J9 Date Issued �� ��
No. / t, c t
Q�/ � .J '��'"��.� _"R�a�• Fee
_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: #
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
91i _ ZIppricatiou for Migoal &p!5tem Conttruction Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. j� G�< ' Owner's Name,Address,and Tel.No. T e l yla(p
0e /ems j �sq &AA G.�44 /�
Assessor's Map/Parcel / n ('� 0�6Z-
sv�5
Installer's Name,Address,and Tel.No. _ Designer's Name,Address and Tel.No. 31"X
�6f�n�O�i• �UnSfrcJ��iCv') �1.v�G ��1�1e Jam'c.Y t��inf,i!?e•
�STrt� 0/;, 1114151r,,rK lVilli NZ U,'�lo f
Type of Building:
Dwelling No.of Bedrooms _ Lot Size /rl ley / sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330 gpd Design flow provided 36 U gpd
Plan Date �`a0A.01M pA X.:20 f 1 Number of sheets Revision Date
Title
F�en1..�
Size of Septic Tank e_),jca�; �r!�,r, Type of S.A.S. /0 ,/�,'�� 4,10,
Description of Soil h
Nature of Repairs or Alterations(Answer when applicable) l ,@ W r)Ax. 1` 10 14e y} t,(S I,-1 n-
LIS 7 se
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar Hof Health.
Signed (., �- Date ,y /
Application Approved by L, ��--'� Date
Application Disapproved by: Date
for the following reasons
i
.Permit No. o0011 ' 7� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that
thheec.On-site
'Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( )
Abandoned( )by &r t/r�/d ff, I �"7 I, /,,no -
at // 11,14<• cad /,z /gyp rj/,.6E has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. clb 3-3 dated 9 h ph/
Installer jy j" { �' /� Desi ner
1/ g �r,�celo �/4/n5 1 C'
#bedrooms 13 Approved design flow gpd
The issuance of this permits Tall not e``construed as a guarantee that the system ill func on .s esigned.
Date 1 1 L4 1 Inspector 1
-
No. cr`l��/ �1."V) -------- Fee --- -
✓THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
Miopogal 6p.5tem Corigtruction Permit
Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( )
System located at ar� i ,� (1.n raz
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 condition
Provided: Construction st be ompleted within three years of the date o,this pe
Date � �' �� Approved by
SEP-15-2011 08:21 From:BORTOLOTTI CONST 5064289399 To-15087906304 P.1/1 T
{ Town of Barnstable
Regulatory Services
$ $ Thomas F.Gellcr,Director
`"� Public Health Division
Thomas McKean,Director
2001Main Street,Hyaanis,MA 02601
Cica: 508.862-4644
Fax: 508-7"4304
der&Design_ a rtifiggt wro
Dane: 1 9►t1 Skwsge perry w 070/l-30 3Asseseor'b MaplParcel 93 raG
Designer. 11 �. ry '�
i � lttstaller:
Address: Address:
p-/on
ate � was issued a permit to install a
ms er)
septic system tit tl H*,6T`irkt*;k, p A_ based on a design drawn by
(a ames
sapp a424
. ? dated q ��
ccttif' that the septic system referenced above
the deaf which m vyas installed substantially according to
1 ay include minor approved chn of the
i distribution box audle r septic tank.
1 certify that the Septic syystem referenced above was installed with major changes {i.e
greater than 10' lateral relocation of the SAS or any verlical relocation of an c
Of the septic system but in accordance Y dm}�onanl
certied with State& Local Regulations, flan revision or
it by designer to follow,
,r' 81'�Figd CFI
i
�nStilllBr S Ig�78t'!�'IC)
1 Ns,atia8l }
esigner s gnature) ix p ere)
T `rADL 1� 1B L $ N. 'E TIVI f4 A TE
� a
Q;19ep1""'Pf r L:ulif W1*n FOnn R Mscd.doc
t
i
Town of Barnstable P#
gyp'' Department of Regulatory Services J
MAB& Public Health Division Date J
� >u�
A i639• �� 200 Main Street,Hyannis MA 02601
rFo„fit"
Date Scheduled Time t Fee Pd.
Soil Suitability Assessment for Sewage Disposal
Performed By: S/69#6, 3 A . Witnessed By:
LOCATI N& GENERAL INFORMATION
Location Address `\ M A-S�-4V e �—AtA-P_ Owner's Name Q C ill Al, J Address ' k l./} ��• }a Q'�
Assesson's Map/Parcel: / / ,3 Engineer's Name S\e_vL Arks 'FA,\e S'�a vr,U NEW CONSTRUCTION REPAIR Telephone# !E�Og,—
Land Use Slopes(90) L-'-- Surface Stones
Distances from: Open Water Body ft Possible Wet Area — ft Drinking Water Well ft
Drainage Way ft Property Line U'` ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
AO
l�
� 132
Parent material(geologic) Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater ��� , -
`J
DETERMINATION FOR SEASONAL HIGH WATER TABLE -
Method Used: ��� �-c�-e��
Depth Observed standing in obs.hole: in, Depth to soil mottles:
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level— Adj.factor Adj.Oro undwa ter Level,,n
Observation PERCOLATION TEST Date & ,/ 'rime limy
Hole# 1 Time at 9"
Depth of Perc SZ ,r Time at 6"
Start Pre-soak Time @ Time(9"-6"
End Pre-soak
Rate MinJInch GZ
Site Suitability Assessment: Site Passed Site Failed: Additional Testing'Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on'Back----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one (1) week prior to beginning.
Q:ISEPTICU'ERCFORM.DOC
DEEP-OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consisten LX,%Graven
of 4,L
14
DEEP OBSERVATION HOLE LOG Hole# �-
Deptli from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,% rave
JX 41
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistencv.%Gravel)
e
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Co si to 1
,t
Flood Insurance Rate Map:
Above 500 year flood boundary No— Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No..i/ Yes
Depth of Naturally occurring Pervious Material
Does at least four feet of naturally occurring pervio,jis material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material? ._
Certification
I certify that on ( T (date)I have passed the soil evaluator examination approved by the .
Department of Enviro ntal Protection and that the above analysis was performed by me consistent.with .
the required Ing x ertise and experience described in 310 CMR 15.017.
Signature Date I/ok 1,1
Q:\,S.EPTICIPERCFORM.DOC
OF T
Town of Barnstable Barnstable
THE
MAM
I ° Regulatory Services Department "�M
sn�rrsrnB t
69. Public Health Division
s'OrFnMa�A* 200 Main Street, Hyai4nis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70081830000205009724
1/26/2010
Sean &Mamie McCabe
11 Masthead Lane
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 11 Masthead Lane Centerville, MA was last inspected on
January 21, 2010,by David B. Mason, a certified septic inspector for the Statebf
Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS.
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
ZPERRDER OF THE "OARD OF HEALTH
c dean, R.S.,
Agent of the Board of Health
COMMONWEALTH OF MASSACHUSETTS 01UGEM
F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
� r
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
F
yQ
�V
5�. David B.Mason,R.S,Certified Title V Inspector,508-833-2177
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe I
Owner's Address: 11 Masthead Lane,Centerville,MA
Date of Inspection:January 21,2010
Name of Inspector: (please print)David B.Mason
Company Name: N.A.
Mailing Address: 4 Glacier Path a ' =
East Sandwich,MA 02537
Telephone Number: 508-833-2177 t
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 CMR 15.000). The system:
_ Passes
_Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
X Fails
[4 Inspector's Signa Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments: System as inspected has-failed.The information as identified represents only the condition of
the system on January 21,2010 at 10:30 AM. Maintenance pumping of septic tank is required.
****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
r
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection: January 21,2010
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303
or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
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 exfiltraion 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
COMPLETED) distribution box is leveled or replaced (THIS IS REQUIRED TO BE
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
I
ND explain:
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles S Tnenartinn Fnrm All 1;/1)fl(Ul 2
I
Page 3 of 11
PART A
CERTIFICATION(continued)
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection: January 21,2010
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:
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles S IncnPotinn Fnrm A/1 1;i)000 3
I
Page 4 of 11
PART A
CERTIFICATION(continued)
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection: January 21,2010
D. System Failure Criteria applicable to all systems:
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 cesspool is less than 6"below invert or available volume is less than''/z 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.
_X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X 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 form.]
_YES_(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:
To be considered a large system the system
g y y tem 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.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles S Tnenartinn Rnrm A/11;IM 0 4
Page 5 of 11
PART B
CHECKLIST
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection: January 21,2010
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)on the site 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(3)(b)]
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles 5 Tnenartinn Fnr 6/1 si')nnn 5
Page 6 of 11
PART C
SYSTEM INFORMATION
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection: January 21,2010
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 (per assessors records Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (330 gpd capacity)
Number of current residents:_2_
Does residence have a garbage grinder(yes or no):NO(Not Allowed)
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Per owner
Laundry system inspected(yes or no):NA
Seasonal use: (yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): 2007: 104,000 gal. 2006: 122,000ga1.
Sump pump(yes or no):No
Last date of occupancy: (current)
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: Barnstable Health Department
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: Requires maintenance pumping
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system(1000 gal pit with overflow 1000 gal.pit)
_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: Overflow pit installed
10/4/85
Were sewage odors detected when arriving at the site(yes or no):NO
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles 5 Inenartinn Pr% r An ;/1000 6
Page 7 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection: January 21,2010
BUILDING SEWER(locate on site plan)
Depth below grade: Approximate;30 Inches
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:_NA
Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident
leakage.
SEPTIC TANK: N.A.(locate on site plan)
Depth below grade: cover at grade.Tank approx.24 inches below grade
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: Typical 1000 gallon tank
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 14"
Scum thickness: 2.5 inches
Distance from top of scum to top of outlet tee or baffle: 15"
Distance from bottom of scum to bottom of outlet tee or baffle: 12.5"
How were dimensions determined: Actual measurements with tape and scour stick.
Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid
levels as related to outlet invert, evidence of leakage,etc.) Pre-cast outlet tee in good condition,PVC inlet tee in
good condition,Effluent level with outlet pipe.
GREASE TRAP: 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.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles G TnenPrtinn Rnr 611 5/')00() 7
I
Page 8 of l l
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection: January 21,2010
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:_Not Present_(if present must be opened)(locate on site plan)
Depth of liquid level even with outlet invert: liquid level even with outlet pipe
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.):
PUMP CHAMBER:_(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.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles 5 Tncnarfinn Fnrm i1;/1'qi70n0 8
Page 9 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection: January 21,2010
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: 2- 1000 gal pits with approx. 2' stone
_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,
etch Probed stone area. Signs of hydraulic failure. No excessive vegetation growth.Probing soil around SAS
indicates ponding or saturated soil.
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 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.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Tifla 5 TnCnP!`tlnn Fnr F/1';1'MW1 9
Page 10 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection:January 21,2010
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.
W
[fB
❑ REAR
DECK
IC
0
AC 26'
[D BC 16'
AD 38'
BD 34'
AE 22'
BE 66'
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title C TnQnP!`tlnn Fnr A/1 5l')OW) 10
r
Page 11 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Masthead Lane,Centerville,MA
Owner's:McCabe
Date of Inspection: January 21,2010
SITE EXAM
Slope
Surface water
Check cellar (crawl space)
Shallow wells
Estimated depth to ground water_20 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:
_X_Observed site(abutting property/observation hole within 150 feet of SAS)
_X_Checked with local Board of Health-explain: Recent Test Holes, Existing engineer records with BOH
_X_Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized existing site design information on file with the Board of Health. Additionally, existing site and abutting
site topography does not indicate ground water to be within 5 feet of bottom of leaching facility. Utilized
groundwater contour map.
Titles S Tnenartinn Pnrm A/1 5/')000 11
' ij-t-4TION SEWAGE PERMIT NO.
MILL GE
INSTA'CL•ER'S NAME i • ADDRESS . ..
III U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
f
J
V'
�t
t�
�y
THE COMMONWEALTH OF MASSACHUSETTS
BOAR.D F HEA. T&. . . .......................
.....OF.
Appliration for Diapmal Works Tonstrurtion 11amit
Application is hereb made for a P rmit to Construct or Re air (�an Individual Sewage Disposal
System at- 7
dzt�...... -.. j......................................................................
cati. -Ad r or Lot No.
--------------1 ..................... . ..................................................................................................
-0 er :47 Address
..................................................................................................
/.... .... .... e,
Installer Address
Type of Building/ Size Lot............................Sq. feet
Dwelling;; No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
Otherfixtures ......................................................................................................................................................
< Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter__._.___.._..... Depth................
Disposal Trench—No. .................... Width.................... Total Length.._................. Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.............__..._. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..__..__._.._........_..
Li, Test Pit No. 2................minutes per inch Dept of Test Pit...._............._. Depth to ground water.....................___
9 ...... .........................................................................................
0
Description of Soil......... .. ...... ..........................................................................................
---------------------------*----------------------------------------------------------------------------**-----------------------------------------*-------------------*----------- -----------
............................................................................................................. ' __ _---------
__*........................
U Nature of Repairs or Alterations—Answer when applicable__.-. .........a4f 14.W?....40......................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL 1 TL 1Zj 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued b the o r f heal
Sig ................... . n......... ...... ...............
Date
ApplicationApproved By................. ................. .. ............................... .........................................
Date
Application Disapproved for the fol wing reasons:..............................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
---------- �j
——-------——---------------------------------- - =j
THE COMMONWEALTH OF MASSACHUSETTS 1
BOARD CF HEA�J,
✓1 - .....OF.... ......
Appliratiun fur Disposal Works Tons#rur#iun rani#
Application is hereby. made for:a Permit to Construct ( ) or Re ( *an Individual Sewage Disposal
System at,
.. !�F 4� .SX- .a:.._.r�.�................ ... ...... .. .�..................
c6 -Ad ror Lot No.
....'..1�__ _.f --.._..`.._.O rer .M ... ...... �- ••................ ............ ......Address........._... ............--....--
14
a ...�.....- � ... .... .. . ......................•--.............._.........................._:... ................
Installer Address
Type of Building Size Lot............... ..Sq. feet
�. Dwelling `"No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T e of Building No. of
YP g ----•-•---•----•--...._..... persons............................ Showers ( ) — Cafeteria ( )
0 Other fixtures -----••-•----------•----------------•-••---•----•--•---•---•-••••••----•----....---•--•---•-------••••---••••...._:................---•......---.....
W Design Flow.... gallons per person per day. Total daily flow..............:......_........._...-....._..gallons.
WSeptic Tank—Liquid capacity.._.........gallons Length................. Width................ Diameter................ Depth..:::...........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft.
Seepage Pit No----------------_--- Diameter.................... Depth below inlet.-:................. Total leaching area..........._....isq.fv
Z Other Distribution box ( ) Dosing tank ( ) �,� -• .
Percolation Test Results Performed bY........................................................................... Date............................
= ......
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..:......................
fN Test Pit No. 2................minutes per inch . Depth.of Test Pit.................... Depth to ground water........................
x ....=? '......... ....
...-----------•------•••------.........................................................
Descriptionof Soil.......... .......---•-------•-•---••--•.............................•--••---......----........-•---•
x
c, --........-••-•--••-•-........•-•.............................••-•-•---•-•--.............---------•••---•--•-•--•-•---•---•••-----•-•-•••---••-•----•---......_.....•••---.....----_...............••---
W ....------•------------•----•--------------•---•--•-----••-•----•--••---•---•---•---•••.._..••---•-----••--•---- rr -----.
U Nature of Repairs or Alterations—Answer when applicable_.... -e<....................................................- r�✓ �
----•-----------------------------------------•--...---.....-•------•-•--•-----•--•---••--•-----=------....--••-----------------•-------------••-- .........._..._.:---•--.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA LE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by)theiVoard f health y
Sign " n1 s �e'� ' " ` . .�", i
�.� =
Date
ApplicationApproved By................. ... ---•--. ... ........................... .......................................
Date
Application Disapproved for the f oll ing reasons-....................................:........ ...........................................................-.
...---...•----•.... ;. ........- •. -----•-•----•••----------•------------------•--...-----
Date
-
r
Permit NO..................................................._.._ I ss u ed:--.:..:•--------------•-------.._.:.....__ ..._..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH r =
......... .......0F...... e J. r° ...................
f�rrtifirtt#le larf faunt�littnrr
TH Sr 0 m TIFY, That t e Individual Sew:>ge'0isposal Sl�eonstructed ( ) or Repaired
( ° ."
l
" jr/f'' eg•y� yf�` �,,/ ,�.�+ Installer ��
at---., ....._..^ r '!'�.F.'..........." ' ------- ............................................
has been installed in accordance with the provisions of TIT LEE 5 of The State Sanitary Code as described in the
9J;H s, apphcation for Disposal Works Construction Permit No......................................... dated.......................................
t THE ISSUANCE OF THIS .CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
a DATE ' ...�-.
......................................... Inspector........... --•eo4&...............................
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH/-
0
�� � /1 :........:'':.f s ..'........' . F...... �.:.....:.' :r.5.... :jfnf ..................................." r
iVro...... ............ .. Fn .....' °z ......
Disposal Works Tons#r iun Vrr t
Permission is hereby granted...--: '....%_ =- ...r..:._...:......1' �
to Construct ( )eor Repa><r/ an Individual Sewage Disposal Systems
at No.....Z01.....-.._ '''. �.�.. sly .r% -�
Street
as shown on the application for Disposal Works Construction Permit No.. r '`;.' Dated...... _ "'_I " - •
..... br'1 ......................
DATE................`' `. .��"5 ....................................
.,� FORM 1255r A. M. SULKIN, INC., BOSTON
1�r
US
L OtwrrION SEWAGE PERMIT NO.
oT* I we�
VIt-LAGE
r
INSTA LLER'S NAME & ADDRESS
` B UILDE R OR OWNER
DATE PERMIT ISSUED'
DAT E COMPLIANCE ISSUED
��-h
+4
' �,
111333 r-
..
��
!t
ec��>ti-�
a,v
�7/.��i�f/is7 n�'�t
�;.:,
0....'Yli?...... OR ..............................
• THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HE LT
'To��_ oF_ ...........................
10 _'6bOAppliration -for M_qpooat Works Towitrurtiou Vamit
Application is hereby made for a Permit to Construct ��/ or Repair an Individual Sewage Disposal
System :
3;
f.
...........................
----- ------_-_---_---(.01----
cation-Add or Lot
A
............... . ............. ..... .. ........................... ....................... ..... ..............................................................
07n Address
.......... . .
.........
Installer . .................................. Address
U Type Building Size LotZX1_Z!KY-------Sq. feet
Dwelling—No. of Bedrooms-------3---------------------------z....Expansion Attic Garbage Grinder
a4 Other—Type of Building ---------------------------- No. of persons.________-__________._--_.__ Showers, Cafeteria
Otherfixtures ---------- ....... --------------------------------- ------------------------------------------------------------------------------------
Design Flow...........5. .......................gallons per person per day. Total daily flow............3_0---Q....................gallons.
9 Septic Tank—Liquid capacit/0-421fill—ons Length------------_- Width................ Diameter________________ Depth-_--_---_----
Disposal Trench—No..................... NV1*dt1Lo,1---------------- Length-_-_____-_-_-_-___--Y 11 11� '�ta I Ching area....................sq. f t.
lq�_L ��_j �c
Pit No ............ n _D4 et area-
la-'la
by ----------
Seepage 0-0 -' T, ea
--------/ la _t .... e ling, -----sq. ft.
_2
-2
Other Distribution box Dosing tank /- 7-7
C
Percolation Test Results ............ Date....(--=---- ----------
.....................
Test Pit No. I................minutes per inch Depth of Test Pit ------------------ Depth to -round water-_.___..-__-...._.......
Pit No. 2-----------------minutes per inch Depth of Test Pit.................... Depth to ground water_.._.______-_.______....
...........IX.... - ......................... .......
0 1 10- -
Description of Soil-------------4:0----------- ............;1'----------I. -------- - --......I------
U .................................................................................................................................................................................................
W
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U
Z Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------- ---------------_-------- -----------------
-----------------------------------------------------------------------------------------------------------------!;Z-------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the boa of hea i.
Signed.-- . . .......... ... .......t-- ---- --- --------------- .........71 a
Application Approved By........... . .. ............... ------ -------
Date
Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------
-------------------------------------------------------*-----------------------------*------------------------------------------------------------------------------------------------------------------
Date
PermitNo........................................................ Issued..... d 7.......-..........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
', BOARD OF HEALTH
Trrttf traU of f�n�utphattrr
"J
THIS IS 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by--._....._ R -------------------------------
stiller !�
------------------------------------------------------------
at................. �.... �'.. - " ' -- -- ------------------------•--•••-
has been installed ii' ccor�ance with th provisions of Article f The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......... ____ dated__-_-________
THE ISSUANCE OF THIS CERTIFICATE SHALL. N E 4 NSTRUED AS A GUAR NTEE THAT TI P'
`
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... �__._ � _
` *� ...................................... Inspector_--:''il' L �
i+
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
\,,% ,
t �
No..... FEE........................
Permission: is hereby granted_.............. «* ^ f�'- ! �`'�%'-=�'��- .........
to Construct .(. ) qr Repair ( ) an Individua�&age Di posal; seer .P v
yy � Street
as shown on th ap l catio for Disposal Works Construction Permit No _______________ Dated------------
---------------------------- e;�;Y., .2
�
DATE............ ,.,,----• /_.Z_..._..._...•--•••••-•--•-
Board offalt
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS *''�
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
Fas............................
THE COMMONWEALTH OF MASSACHUSETTS
v.
BOARD OF HEALTH
,� .._..f.. _ .. . _.........OF...................... o f.._ . - ......................
Appliration -filar :431li illittl Worku C omitrurtion Prruld
Application,is--hereby'made for a Permit to Construct;O or Repair ( ) an Individual Sewage Disposal
System at: ,
- = ---_----_------- ------------•-•--
oca Ltion'-Addr
r ess �
i ,/ % —
---f�/'�*'/,L<.�+ �+ Owner"'_t,tl J/ {
W ess
.......•../..............................................................� .... .+' fi .e?-___.__ t/i!:C 1..........ar4/"'✓.. ...
.r• P ✓Installer ` Address
U 'type of B ding !` Size Lot,_-f _.�__.__-___-Sq. feet
Dwelling—No. of Bedrooms_-__'=___________________________________Expansion Attic ( ) Garbage Grinder ( )
per-, Ni Other—Type of Building _--__--'�--------------- No. of persons..-------------------------- Showers ( ) — Cafeteria ( )
a
d Other fixtures o.. ._.... --------------------------------------------------------------•---------------------------------•--------------..------
W Design Flow......... .... ..........................-.gallons per person per day.. Total daily flow.........c ._.__...____..._......gallons.
R: Septic T uk—Linuidapacity. .. ____g�gallons Length______________ _ Width----_I.---.......... Diameter-----_--------- Depth----------
Disposal Trench—No ,
..__..Width.................... Total Length ---. __----oTotal,16ching area_._...____ . sq. ft.
See a e"Pit No.._....... iameter p g F �De� }�elow-inlet __. t! q��'ta1 eaching are: sq. it.
r i ( r; Miry .•••'2 0i • 7�
Z Other Distribution box,(" �) ,1,' ` Dosing tank ( ) Q�e,
�� < _� Cr'�
a Percolation Test Results ;Performed by........ .....__.._.__._______ .; _ "; .� ate.._..__. - ----- ------ 1Test Pit No. 1__-___----_•-_-_minutes per inch Depth of Test --- ------------- Depth to ground water.__.__-----------------
,G14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth-toground
Description of Soil
�t
water r_----.--__-_._--_--.
---- ----- ----------•---•- - ----------------
---- -
r
---------- --- � -�U 0 ,3 ............................................,
W -
UNature of Repairs or Alterations—Answer when applicable-----------------r.. __..____.___....__.._.__'_._...__..__...______..._.________.._..___... .
-------------------•---.---- --- - -- -.---------..---- -`•-------------------- ----•----------- - ----------•------- •------
----------------
Agre,ement:
The`"'undersigned agrees to install"the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until-a Certificate of Compliance has been issued by the board of health. �t�<e
Sign d _� '' -----.� r_.y
Y.~r _
Date
Application Approved By------------ ---- ........
+�
.............. /
----------------------
Application Disapproved for the following reasons:.......................... r----------------------------------.`"°'��
----•----------------------------------------- -----------------------------------------------------•---------------------------------------------------------- --•-•---------------
- - Date
G 7
Permit No............................... •--••=-•--•-••-••-••... Issued... . •�---�-••-• -----------••----
Date
--�.�_---
t SI k- LL- P Am I L-- 'FSCnxrJaM
1.10 <'�At�'I3laG �tZ1 t�lLat iG /o !�
rjdl t_�( t`Low :. Ito 4 ?. :
`!"l.�"V_ = 3 O. tSC o
USA lo4C--s GAL-.
- y &AIM
SPcxAt. PIT t?sG 1pcx�
tC�lvt3tl A2f=�. = l�jU ��. a' ;r t� i
:�;-7S
TOT,&L -LTA G-StGQ = •42S G.P.D. TA�►K �jr `
Pt�t'GOLMOt.J Cc'ATE: I l"tom+ itJ� 02 �.5{s.
VIC
1] f1141 4AFtV 9 1`
n Mk-
vs.u
s Q PPS 7 IW. c�,a�. qc,.g
yGJy I t Wv 'TA W W-
l�A✓. az-r 9z IOc-)o
FIT a
W I'rLA
WAS,�lED p
CC--IZTIT- tr ID F't_C,7-
,tr---
� cw4TcsrL„
! Gt�1Z'itt= j Tt-(Ai- TOC:. � )t1►.Ivb'notl 51.1owk) .t,J S? t=�!�.�a►.iGG
,,c- %rt_v a
nun L,nCIG �'trCJUtQC-AAA." OP TI-AU� ,/ LOT �
'Tovt� c�� A .ayT.�3t.E V-tJO'TTy V1 L LAC.G
z�F�
C1A.�'C__ � ' �d� t"�..,..._._.. 1� 't�1L 4Y. 4J1r(= 1�_IG_
CA-4 P.e,..1
1t�StZ�tJrJlt .l.t i `)iJt_�It_`t 'r t!�(' tit C ��{-rri il•1p4Jt r� ! F71•1rt...l 6,1-1'\
t�..F:it" C',:._ {J�,I�_l.• ii,, i>t;l-i=.c:M,i �.;1 ., 1_oY' t_tt-t�_';� - __ � ____ .... _ Capp `;t �.T. E �1:..
Yu J
ACCESS COVERS MUST BE WITHIN INSPECTION 6' OF FINISH GRAD 9' MINIMUM. INVERT EL E VA T I DNS : DES / GN CR I TER / A GENERAL NO TES .
E \ PORT 3 • MAXIMUM COVER
FIRST 2 ' TO r INVERT OUT SEPTIC TANK: 94.5
DESIGN FLOW:
i BE LEVEL INVERT /N DIST. BOX: 94. 17 3 BEDROOMS AT 1 /0 G. P.D. PER 1 . TH1S PLAN IS FOR THE DESIGN AND CONSTRUCT-CN
f INVERT OUT D I ST. BOX: 94. 0 BEDROOM EQUAL S 330 G. P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY.
4' DIAM Pip CLEAN SAND BACKFILL INVERT IN LEACH CHAMBER: 93.92
o� 11 AROUND AND 2- OVER CHAMBERS BOTTOM OF LEACH CHAMBER: 93. 0 NO GARBAGE GRINDER 2. VERTICAL DATUM /S ASSUMED. FOR BENCH MARKS
a GAs 1 94. l7; 94, 0 93 O ADJUSTED GROUND WATER: N/A SET. SEE SITE PLAN
BAFFLE SEP T/C TANK REQUIRED:
0 HIGH CAPACITY INF/TRATOR OBSERVED GROUND WATER: N/A
EXISTING 3 OUTLET CHAMBERS /N TRENCH FORMATION O 330 G. P.D. X 200% - 660 GAL. 3. ALL CONSTRUCTION METHODS AND MATERIALS AND
D-BOX BOTTOM F TEST HOLE sl . BB. O 1000 GAL SEPTIC TANK PROVIDED: I000 GAL . EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL
SEPTIC TANK 6- CRUSHED STONE OR CONFORM TO MASS. D.E. P. TITLE 5 AND LOCAL
COMPACTED BASE SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS.
DESIGN PERC RATE ( 5 MIN/INCH
PROF/ L E NOT TO SCALE SOIL TEXTURAL CLASS - / 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
EFFLUENT LOADING RATE - 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
330 GPD / 0. 74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH-
STANDING H-20 WHEEL LOADS.
------_ PROVIDED: 10 HIGH CAPACITY INFILTRATOR
CHAMBERS. 62.5 'x 7. 79 SF/FT 487 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR
(\! 487 S.F. x 0. 74 - 360 GPD APPROVED EQUAL .
E REINFORCED
6. SEPTIC T\ S O I L T L S T P / T DA T A PRECAST CONCRETE ANK AND DORO X SHALL B APPROVED POLYETHYLENE.
INDICATES INDICATES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER
PERCOLATION OBSERVED TESTED FOR LEVEL WHEN THERE lS MORE THAN ONE
�F JI BM. CATCH BASIN TEST - GROUNDWATER
OUTLET.
4 TP rl P+13277 TP #2 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE
HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR 1-888-DIG-SAFE AND THE LOCAL WATER DEPT.
0" 98. 0 0' 98. 0 oa YEWq y FOR LOCATION OF UNDERGROUND UTILITIES.
�
�� BL UE S TDN� DR f w
FILL FILL
/ a5 `\/ 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE!3' 96. 9 /2' -- 97. 0 LOAMY DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
SAND 3/122 SAND 3/2
A OF THE SYSTEM TO ALLOW FOR SCHEDUL ING OF THE
� LOAMY IOYR
l0 H10H CAPACIrr 18 .• • 96. 5 l8 96.5 CONSTRUCTION INSPECTIONS.
1 I NIA I L TRA TOR CHAMBERS �/ p L OAMY 10 YR B L OM(Y 10 YR
D SAND 5/8 SAND 5/8 9. EXISTING LEACH PIT TO BE PUMPED DRY AND
32' _. 95. 3 30" _ 95.5 BACKF/LLED.
s2 �' MED!UM /0 YR MEDIUM /0 YR
\ TP+ l� l SAND 6/6 4 SAND 6/6 l0, VERIFY INVERT AT SEPTIC TANK PRIOR TO
52"
`. CONSTRUCTION, ADJUST INVERTS AS NECESSARY.
TO
SHED
ya : D-Box '�o;o f NO WATER 88. 0 120' NO WA TER
120" 88. 0
�y9�F
AQ_ ° oc^ �y DATE: JUNE 7• 201 i
c
EXISTING TEST BY: STEPHEN HAAS Of
PIT WITNESSED BY: DONALD DESMA,RA I S '. ��SN �
PERC RATE: f 2 MIN/INCH Kul EA-EN ,
HAAS
NIL
>�464
EXISTING
y s9- SEPTIC TANK L D T 39 U
�sv8 15. 1441 S . F. tj
I ��v
S E p 7r S Y S T EM LD E S i G/V
M4STfir'E�4D L GIVE . "AP / 93 . P,1RCEL 66
Q
L7 N -A46L. E ' CE/VTERV / LLE ) "A
'�j PREP,4 RED FOR
E A /V S T,4 A/ L E Y
� �U�� LEGEND
LOCUS--, T c� 3S9 0,4 P T _ L / .J,4 A-/ R 0,4 L�) CEA/ TER V / L L E . M,4 026 32
W CB CONCRETE BOUND
NEDWWJET
1 e
-w WATER LINE SCAL E : / - 20 SEP TEMBER 8 . 20
HYDRANT / EAGLE U R Y
� UE I NG I NC
` -G ,�GAS LINE
OHW- OVER HEAD WIRES
LIGHT POST „ � l 923 Route 6A
Ya rmou t hpor t NAA 02675
-E- UNDERGROUND EL EC TP 1 C L I,NE
f/1 11~ ( 508 ) 362-8 1 32
-T- UNDERGROUND TEL EPNONE L I NE �'`'"' �1�`/I 5 O 8 4-3 2-5.3 3 3
CTV- UNDERGROUND CABL E V I S ION L /NE �7V
t 40.4 SPOT ELEVATION
EXISTING CONTOUR
I n I7 1 1 n 40 PROPOSED CONTOUR -�-
!- -' MAP 2Q 4Q JOB NO: 1 1 -045 F 1 EL D:CANAL CAL C: Skl-ICFW CHECK: CFW DRN: S�H