HomeMy WebLinkAbout0044 MAUREEN ROAD - Health 441VMureen Road
Centerville
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Commonwealth of Massachusetts
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(o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd. ~'
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26119
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 SY 13�-93
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
4/26/19
Inspector' ig ature 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
�- Title 5 Official Inspection Form
I° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner s Name
information is
required for every Centerville MA 02632 4/26/19
page. Cityrrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
New system 2013
2) System S Conditional) Passes:
Y
❑
One or mores stem components as described in the"Conditional Pass"section need to be Y P
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
(o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner s Name
information is
required for every Centerville MA 02632 4/26/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
�11. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
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
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal.
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
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 Y2 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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner s Name
information is
required for every Centerville MA 02632 4/26/19
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
® ❑ 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
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4126/19
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: 0
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: vacant 4 months
per owner
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owners Name
information is
required for every Centerville MA 02632 4/26/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): , Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Pumped October 2018 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 118
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
1° Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
page. Cityfrown 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:
2013 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
>10'
Distance from private water supply well or suction line: 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
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owners Name
information is
required for every Centerville MA 02632 4/26/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 18"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank in very good condition
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
1,
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
>12"
Scum thickness
trace-2"
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.7/26/2018 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
44 Maureen Rd.
Property Address
McNamara
Owner Owner s Name
information is
required for every Centerville MA 02632 4/26/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
page. CityrTown 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.):
D-box is 3' below grade, cover raised to 12", very good condition
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
11. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
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.):
Leach chambes are dry at this time, bottom at 6' below grade, cover raised to 2' of grade, sidewalls
are clean, in very good condition
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
r: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
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
y s ce"L-e
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
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: >120"feet
i
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: 2013 NGW 120"
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
>5.5' seperation per BOH record
❑ 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
t� - �9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered incompuer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
' 2pplication for Misposal 6pstem Construction permit
Application for a Permit to Construct Repair ���// .0 Upgrade,( Abandon( ) [eCom lete System ❑Individual Components
PP ( ) P �P'�) Pg ( ) P P
Location Address or Lot No.qy N"neon Owner's Name,Address,and Tel.No.SoS- 771` f7$7
(2en4ed-Uii1e_. Pk; II"P Ac(1lu.M0_rv-ASll°Iaume.n Pj•
Assessor's Map/Parcel 443 .?/ 09G D
I taller's Name,Address,and Tel.No. 501-6-1? D signer's Name,Address,and Tel.No.uolR—369,VSV/
t o�of�i 'an C �STncicr��f/y ill• aUk-)ea.�e tne�-inS�+c q3q Ma,ih -
S s �
Type of Building:
,o-
Dwelling No.of Bedrooms J Lot Size //, 083 sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) -i3o gpd Design flow provided 33(o gpd
Plan Date�p[P_m o?y,na01'X Number of sheets
� I / Revision Date
Title ;i� S Si I�n o.k y f �/�it�9/2t�1n d tJl• rC2f U i rrP YVI lht
Size of Septic Tank a t4 lU Type of S.A.S. hoe.le( u) JC 30(. X .1
Description of Soil <&.e
Nature of Repairs or Alterations(Answer when applicable) Iw d.
& 1 a � a ,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and mainte of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Enviro a 'Code o place the system in operation until a Certificate of
Compliance has been issued by this Board�14
i ed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. y Date Issued
y ` i•y
�e Fee V
uter:
THE COMMONWEALTH OF MASSACHUSETTS P
Yes
Entered in com
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplicatioii for Disposal 6pstrm Construction Permit
Application for a Permit to Construct( ) Repair `:,]Upgrad ( ) Abandon( ) [Complete System ❑Individual Components
Location Address or Lot No.q q Mabneen M, r/ Owner's Name,Address,and Tel.No..5c)8-
--- -- G�C�hJzf Ut +� Phi I�e(� )LICf lair7ctY'Gt ,'d�iY'14u��en
- Assessor's Map/Parcel q/ ,9_n 4emu, crlr Oae-,3�
I taller's Name,Address,and Tel.No. 508•'2? 3 T9 Designer's Name,Address,and Tel.No._ofs--36P-V51/
tz{ro�o � G + icn LnC 452nclusf��F 1. ,� elwh(2atae &)9 ineei I Main,Sf•'
r Oa(D
Type of Building:
DwellingNo.of Bedrooms Lot Size �/, 093
,.,3 , sq.ft. Garbage Grinder
i
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) .330 gpd Design flow provided 3.3(o gpd ,
Plan Date i'1�5 (- o?G� 201a- Number of sheets Revision Date
Title I`,}jam'S Sid i r� cs� yt/ l'll4l �r�ra t,� AS• (I,n , (,)r (
Size of Septic Tank , 1 L4 Type of S.A.S. 1—ie_lej C( R3'Lo X 3h X
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) `J z 4J S e�c �� ,_�/,'c r , Y-
alJ�4�r�/a ky) A6X a (0I0) .Si�r�J�0 1—e-aa 6211421 �r, c� Q-�S� rc� i X 317�f_ sc Q
Date last inspected:
- Agreement:
The undersigned agrees to ensure the construction and mainten_a ce of the afore described on-site sewage disposal system in
Zm g ��. g P Y
accordance with the provisions of Title 5 of the Environnrttental Code d not-to place the system in operation until a Certificate'of
i; Compliance has been issued by this Board of Health. •
j�ed
r ./}f,'n DaCtee-:
' v � �
�r
Application Approved by
Date
PP PP
v
Application Disapproved by / / Date
for the following reasons (/
Permit No. G '' Date Issued
TH F COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( )
Abandoned( )by Z2r--� ,-t-t-, (a�j c- ,c k.`t(-Nn A-nC
at (-/q M(,r"Ppr) a, d&n k_ral 1 J'e has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. '� Jated
Installer &r--kl/6# ( Ln 5k le Designer rxv 7 h22 - i' T
U �
#bedrooms �?j Approved design flow gpd
The issuance of this peEL
t shall not be construed as a guarantee that the syste will fu ctio as d igned.
Date ' l� Inspecto!r r`-•--�� �
------------------------------------------------------------------------------------------------------------------------- -------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposat *pstrm Construction Permit
Permission is hereby granted to Construct( ) Repair Upgrade( Abandon( )
System located at `y QUIP.�n \ z7
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:Constru do must b com feted within three ears of the date of this ermit. U
Y P
Date Approved by ,
'JJi fli L"lam
r;• o.
r � � ham as, F. 613eiler 30 TinectaE
* i35A7d5T'AELE)
5. rs >e 4�t e.�t1th > >i,rieron
1 horu ss Mcl!t ean, ']Ili ee to
2700 Main Street,Hymais,P 1�A 02.601
Ou ce: 508-962-4644 Fax: 508-790-6304
Tnstflell & Desrei�Cercti�nea>tno>mForm
Date- / Sewall-e Permit'l 201-3 — 0/ Assessor's Map1Ta cell
]J@esn e>re 0 W ►1 Innstaner..
Add. ess: 93 q /Y4-', LPt7 Address: 0° o-
On was issued a permit to install a
(date) (installer),p
septic system.at � �Gl�rree�, (�0 based on a design drawn by
(address)
.60(of /4- _ a,l k Pr ��' dated
( esiper)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. ST' �'U r n e q0 ° do-Per ?V h o U4't
I certify that the septic system referenced above was stalled with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but 'in accordance with State & Local Regulations_ Flan revision or
certified as-built by designer to _follow.
.�OF"gs y
DANI !
o nJALA
(Installer's Signature) CIVIL
o Iqo.4i 502
P 'pF GO I 5-
\S/ONAL ECG
(Designer's Signalire) (Affix Designer's Stamp I_ere)
PLEASE RETUK. q O ARNSTAALE PUBLIC HEALTI I DIVISION. C`+RTITICA E OF
COMPLIANCE WILL Mini B SSOED fJPi'i H BOTH THIS FORM �J� r.�-B�JILT ��� A Z
RECE ){L BY TBE BARNSTABLE PUBLIC II•ALTH DMSION. TIIfi14a YOU
Q:Health/Septic/Desigaer Certification Foi—in 3-26-04-dac
i^1
Town of Barnstable P 4t
Departineut of Regulatory.Services
u Public Health Division Date 12 /Z -2
J��� 200 Main Street,Hyannis MA 02601
Date Scheduled Time Fee Pd. 6 0
► Oil SuitabiliO ,Assessment for Se
Performed-By:
Witnessed By:
LOCATION& CENERAIL INFORMATION
Location Address
Owner's Name M C�a
Ce4 1 e-1 VI G l e Address
Assessor's Map/Parcel: z2$//7�
Engineer's Name 0— e
NEW CONSTRUCTION REPAIR
T�el�ephon�dk �
Land Use: L-a U/9'7 96 es 51v �— ��/
P ( ) Surface Stones
Distances from: Open Water Body :�(Qr/ ft Possible Wet_Area 7 SOU
ft Drinking Water Well y�lG ft
Drainage Way 7 1GG ft Property Line 1 7 r ft Other
ft
;IME''I'CH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands 3n proximity to holes)
• N � •
`\ �► tip, -.1
zz ^—
t
Parent material(geologic)
Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Iv N,
Weeping from Pit Pnae
Estimated Seasonal High Groundwater
Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE
Depth Observed standing ir.abs.hcic: Alai-e. ia, Deptlt to 5911 lnvttlest
Depth to weeping from side of obs.hole: Gh F ltl.
Index Wetl# bt, (3rvundwaterAdjugtmenk fl.
Reading Index Wellloyal Adj,factor— Atj.GroutidwaterLeval
PERCOLATION TEST bakp)2/2b//� Tim, a,00
[Hole
servation j
# Time at 9"
pth of Pere 7-� Time at G" ��' -
-�--- -
Start Pro-soak Time @
Time(9"-0) -
End Pre-soak
Rate Min./luch 7 r I T h C
Site Suitability Assessment Site Passed 5itq Fallcd:
Addldonal Tasting Needed(YIN)
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 Conse>Fvation Division at least one (1) Week prior to begialning.
Q!\SEPTIC\PERCPORM.DO C
DEEP-OBSERVATION HOLE LOG- Hole#
Depth from Soil Horizon Soil Texture .Shcl Color Soil. Other
Surface(in.) (USDA) (Munsell) Mottling (Structure, Stones;Boulders.
o i tcn=V.%'Gravell
i3-30 -7
30—)�o 10yR /
DEEP OBSERVATION HOLE LOG Hole 4 Z
Depth from Soll Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling
(Structure,Stones,Boulders. .
0 1 ' 3 A L ' ` _Consistency,�Yo G ve
1- 5
11495 G R ?/�
DEEP OBSERV
ATION HOLE LOG Hole�.
Depth from Soil Horizon Soll Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling
(Structure,Stones,Boulders.
Co 1 tc c Gravel)
4 '
i- t ___.._..F-_
t
s DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
Consistency
y
Flood Insurance Irate Map:
Above 503 year flood boundary No_ Yes
Within 500 year boundary No v+ Yes '
Within 100 year flood boundary No.Z Yes
Depth of Naturally Occurring Pervious Material
Does at least four feat of naturally occurring pervious mliterial exist in all areas observed throughout the
area proposed for the soil absorption systeml _I/P S
If not,what is the depth of haturally,occurring pervious matorial?
Certification S/'
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the requited training,expertise and experience described in�10 CMR 15.017.
Signature :��,.. �-. - Datb I &/''f 2—
Q:\S,EPTlaPHRCPORM.D O C
1
V.l t (
AJ �� � �
�
OF BARNSTABLE
LOCATION SEWAGE #
5
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
J
i rvll--�
s r� G �,vim
4 T
f / vt
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7A,
44 Maureen Rd.
zG %% Property Address
McNamara
Owner's Name f
able MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433
Telephone Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/4/12
Inspector' Ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or D.EP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Lz 1-0/�Z)/ If U
44 Maureen Rd.doc-03/08 Title 5 lil?1ecdon Form:Subsurface Sewage Disposal System-Page 1 of 15
zfz ,r,; ( r
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System "Fails" due to hydraulic loading at the pit. System is comprised of a cesspool to an overflow
leach pit.
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 ism eta[ 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:
n/a
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
44 Maureen Rd.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
n/a
❑ 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:
n/a
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.
44 Maureen Rd.doc•03106 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
n/a
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to anoverloaded
or clogged SAS or cesspool
® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100.feet of a surface water supply or
tributary to a surface water supply.
44 Maureen Rd.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System-Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection .
B. Certification (cons.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"Po"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
44 Maureen Rd.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system 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)]
44 Maureen Rd.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): n/a 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 ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes. ® No
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: n/a
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe): n/a
44 Maureen Rd.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
J
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
dty/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Pumped 1 yr ago 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:
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:
Original block cesspool from 1970. Overflow Leach Pit installed 1990 per owner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
44 Maureen Rd.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
>10'
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: n/a
feet i
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No.
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
44 Maureen Rd.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
w u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3 yrs to prolong the life of the system
Grease Trap (locate on site plan):
Depth below grade.: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
n/a
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.):
n/a
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):
n/a
44 Maureen Rd.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM °` 44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No-
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
n/a
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
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 ❑ No
Alarms in working order: ❑ Yes ❑ No
44 Maureen Rd.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
1
® 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.):
Leach Pit is full at this time. The effluent level is level w/the bottom of inlet invert. The pit is in a state
of hydraulic failure
44 Maureen Rd.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth —top of liquid to inlet invert 1/2
Depth of solids layer
12
Depth of scum layer
12"
Dimensions of cesspool 6'x6'
Materials of construction block
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
n/a
44 Maureen Rd.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 44 Maureen Rd.
Property.Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.).
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.
i
44 Maureen Rd.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
` Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 44 Maureen Rd.
Property Address
McNamara
Owner's Name
Barnstable MA 02632 10/4/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: >12
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Per elevation of home to nearby surface water
44 Maureen Rd.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
TOWN OF B�AsRNSTABLE
LUCATION �f N�� �"� �Y - SEWAGE# X01__3 --oO j
ALLAGE C-6,�� zio LLL-'' ASSESSOR'S MAP&PARCEL ,J�4T— t I
INSTALLER'S NAME&PHONE NO. ��Z���1 cew 777
SEPTIC TANK CAPACITY �V ��-L A,41e
0 P P •
LEACHING FACILITY:(type) (size) �_ 3
NO. OF BEDROOMS 3 .S� i� ✓�
OWNER L
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -4— 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) d Feet
FURNISHED BY 'Aly✓4et Lsjt�/�srrr�'!S
�`yy
361,v
31 & 0
yy '
Etl
IOCATIO SEWAG. PERMIT N0.
VILLAGE
c�
INSTA,. LER'S NAME i ADD ESS
BUILDER OR OWNER
DA T E P.ERMIT ISSUED
DATE CoOMPLIANCE ISSUED �, � '�
c Jr
-M o
O o e
o
Fim
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
Application is hereby made for a Permit to Construct or Repair ( A-)r`an Individual Sewage Disposal
System at: &4
L7A.:. ....%pd.
Installer Address
PQ
Z Other Distribution box ( ) Dosing tank ( )
U Nature of Repairs or Alterations—Answer when applicable----- ------- . ......
� ''--_-''_---_ ._-_-_-_'_-.-----_
Agreeozcot:
The undersigned agrees to install thexforedescribed Individual System in accordance with
the provisions of THTLE4 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hhas bee issued boy d oft I Ith.
Peb
Date
Date
Date
-~-'^'---'-'--'-'-'--'-''-''''--'--''''-----'--'''-'`''''''''''''''
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
t
Appliratiun for Uiupoii ai orku Tunutrurtion .erutit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
Z.r
a: ily. 11 e✓S l f 6 r ;3
! f Location;Address, or Lot No.
d --Owner, a 4 ,..„ -- ...•-
{) --•-----•---------•--------•-----•-•-•----•.Address
a ... 'A.°_ ✓_ ,..�.:€.C.O s'�9! i ft f'a� .1-._.:._c .:Fl....:�:^s:"�:.'.�:._ ...........................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
al Other fixtures ------------------------•------• .
d ------------------------------
-------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity........____gallons Length---------------- Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by........•••••••-•---•--------••--•-----•••---•----••-------••-•-••-•..... Date---------------------------------------
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................
�•-------------D -------•----•-••-----•------------------------•-------------------.........................................................
Descriptionof Soil----.. ralelk_:!t�i----•-------•------------------------------------•------------------------•--------------------.....----•-••---...........---•-----...-•---
x
U ---•..............•••••••••-----•-•-•-••-----•---------------------------•--•-•-•--
U P --------------------------• ------•-•-•-••-•....-•---_... ..--------•--•..... ... s... ....7. .. `
:?_..
Nature of Repairs or Alterations—Answer when applicable._.._,:: :. < f ..,. f�"`'-
------------------------•-••------•--•---•---•----------------.....----•------•----•----------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL' 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,,the board of health �f
g rr t
I!
Date
6 +'
Application Approved By.. `="==�------ -•-----------------------------------------•-----•- ......................... ---•--•---
Date
Application Disapproved for the following reasons----------------------------------------------------------------•----------------•-----.........................
..............•-----•------.....---•-----...----.....----------------•-................................................................--------------------------•------------------..................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... :...€.w�'.............OF....f.. ...::.............:.::,r:...: t '
�rrtifirair of TontlrfiFattrr
THI$ IS,TO CERTIFY, That the Individual ,Sewage Dispoal System constructed ( ) or Repaired �)-
s.
by :....:.••-•
Installer
at c'r. ,�t'f f�,��k yam ' ..f F v >
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------------------------------------------ dated_-..............................................
THE IS51J NC
pE OF THIS CERTIFICATE SHALT. NOT BE CONSTRII AS A GUARANTEE THAT THE
SYSTEM�I JF TION SATISFACTORY.
DATE--- �YK
! �---------------•--...................•....._--•-•• Inspector ---P
-•-...:•---•------••-----------••.................----------............--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........OF...... f .So=/'�: .......................... .._
No......................... FEE..Z.0...:..--.....
'Biupos a1 Porkg Cho utr=tw antic
Permission is hereby granted--- �' ram' G,�.��; , ......
to Construct ( ) or�Repair 'an Individu v�,age sposal S stems
!�1 l '. ' ' . -------•--•-------------------
at No.
treet
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
--------------------------------------•--------•----------------•--•-------•-------.........-•-•-•..._._
Board of Health
DATE.................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
SYSTEM PROFILE ALL SYSTEM
WIT COMPONENTS
SHALL BE NOTES
MARKEDOR
PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. ASSUMED
ACCESS COVERS TO WITHIN 6" OF FIN. GRADEF CONCRETE COVERS TO WITHIN 3" GRADE 1. DATUM IS
2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING
TOP FOUND. EL. 41.4' s
FILTER FABRIC OVER STONE
2% SLOPE REQUIRED OVER SYSTEM 37 -38' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. o
MINIMUM .75' OF COVER OVER PRECAST �
4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO 0
. � PRECAST H-10 C
RISERS (TYP.) BLOCKS
KST ORISERS H- 10 oJl�� in a
4"0SCH40 PVC PREMORTAR ALL =
,.: PIPES LEVEL 1ST 2' COMPONENTS H-10 5. PIPE JOINTS TO BE MADE WATERTIGHT. °c
4 (TYP.) 2. '
38.7f'* 10" 14 ENDS . SIDES 35.83' S°
• LOCUS
' 1500 GAL H-10 P o
ACCORDANCE WITH
° ° ° °.o ° ° ° ° ° O1PE1
°o°oUo oso _ o - 0000000° CONSTRUCTION DETAILS E IT IN A
° MASS. ENVIRONMENTAL CODE TITLE 5.
TEE TEE o 0 0 0 !E�l
°°°g° o o 0 0 0 0 ,000000°SEPTIC TANK 35.97 0 0 0 o a❑o❑o 0 0 ���� o O❑o❑o�o ° ° ° ° 7• THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
0 0 0 0 0 0 0 0 0 0 0�❑0❑❑❑ o00000 ❑❑�❑�❑❑❑❑❑ ;,o°o°o°o°o°o �o°o°o°o° O O O O O O oo°o°0 0 0 0 O O O O O O o 0 0 0GAS BAFFLE::` o 0 0 0 0_ o o ° o ❑❑❑❑❑❑❑ ° o ❑❑��❑❑❑❑❑❑❑ o o ° o36.22 ° `� ;°0000000 �o�Do Do Do 00� o00000 o o o 0 0 0 0 0°0°000° BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
o 0 o ° o0 0 0 ❑❑❑I���❑❑❑❑❑ °o°o°boo ,.
.': 4' LIQ. LEVEL (ACME OR EQUAL''_ 35.32 35.15 °0000000 °°o°o° °0000000 33.0
8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. G ~...� .r.:..:•:.:.:.s.. :. •. 5 6" MIN. SUMP orsesh00 Ln
°o°°o°°o°°o°o°°o°°o°o o°0000000000000000000°-0000000 12" MIN. INT. DIM.
o,,o�o_n_�_�_o.o 0 0 0 0 - _n_o.o o H-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL.. 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
3/4"-1-1/2" DOUBLE WASHED STONE (2) UNITS REQUIRED WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION _D
} 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 30' X 9.83' OBTAINED FROM BOARD. OF HEALTH. CIC1,90lle Beoch Rd.
COMPACTION. (15.221 (21) io 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
Ui DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION
(13.7y; SLOPE)
( 5 SLOPE) ( 1 SLOPE) OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO
- COMMENCEMENT OF WORK. LOCUS MAP
FOUNDATION 18' SEPTIC TANK 13' D' BOX 17' LEACHING
FACILITY 27.5' BOTTOM TH-2 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND NOT TO SCALE
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL NO GROUNDWATER FOUND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE ASSESSORS MAP 228 PARCEL 71
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM REMOVED 5' BENEATH AND AROUND THE PROPOSED
LEACHING FACILITY.
LEGEND
99 EXISTING CONTOUR
X 99.1 EXIST. SPOT ELEV.
SYSTEM DESIGN:
-[991- PROPOSED CONTOUR
198.41 PROPOSED SPOT EL. GARBAGE DISPOSER IS NOT ALLOWED
TH 1
TEST HOLE . /43.56
DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD
/ USE A 330 GPD DESIGN FLOW
UTILITY POLE
SEPTIC TANK: 330 GPD (2) = 660
_.. W WATER LINE
USE A 1500 GAL. SEPTIC TANK
G GAS LINE 42 9
OHE OVERHEAD ELECTRIC LEACHING:
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING 6q1.72 QO / 1.90 99 BENCH MARK 4� SIDES: 2 (30 + 9.83) 2 (.74) = 118 GPD
- TOP OF
�'o / FOUNDATION HERE. EL. 41.4 BOTTOM 30 x 9.83 (.74) = 218 GPD
TEST HOLE LOGS
\ 05 41.43 PAVEDDRIV TOTAL: 454 S.F. 336 GPD
41.26
ENGINEER: DANIEL E. GONSALVES, SE #13587 o0 84 USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
40.45 0 41.17 WITH 2.5' STONE AT SIDES, 4' AT ENDS AND 5'
WITNESS: DON DESMARAIS, RS �� o o
12 26 12 / \ Ap'OR ° �p x 7.71 BETWEEN UNITS
DATE: / / J °'�\ 'bb
1.25 G
INCH 2 MIN ° �s ,qR S
PERC. RATE _ < / � / y �w \ �q 4 .37
I 13829 Fyo _ 9 113
CLASS SOILS P# / 3 MA
�N 4 Q2 APP OVE E BOARD OF HEALTH
ELEV. ELEV. �� EXc,TING
�] \ .P DWI=LUNG
V ' 4 TOP FNDN. _ .90
0" 38.0 0" 37.5 NOTE: N LOT
BOUND ) 41.4' x 1o1
A A (NOT ON LOT CORNER LOT 28 \ � J
�8' 39.0 `b G
Ls LS /37.55 0°.61 11,083fSF o TITLE 5 SITE PLAN
12 37.0 12
1OYR 3/2 „ 37.5 1OYR 3/2 O OF
� o
40.03
B B PR VIDE LS Ls TH1 44 MAUREEN ROAD
0
1 OYR 4/6 1 OYR 4/6 - 3 �g N CENTERVILLE, MA
30 35.5 30" 35.0'
H2 1�
'21 _ 3g PREPARED FOR
37 ) BORTOLOTTI/MCNAMARA
PERC 36.74 jNOFMAS �
DANIEL q1y* V DANIE, ti � DATE: DECEMBER 26, 2012
T.
F �o JA,A
MS MS A
r
�I> " CIVIL
OJALq It
No.116502 off 508-362-4541
5.67 No.40980 ' �'
k
oF P � }� qfox 508-362-9880
1OYR 7/4 1OYR 7/4 �� - downcope.com
o , ; ; �y � down cope engineerift Inc.
A. C11.IL 4 I civil engineers
120" 28.0' 120" 27.5' Scale: 1"= 20' � N0' � P rho. 465024 land Surveyors
\ �.
Fss °�, '`F IS -r\�;1 939 Main Street ( Rte 6A)
sUgvE °;« o YARMOUTHPORT MA 02675
NO GROUNDWATER ENCOUNTERED / ,. ., ifs
0 10 20 30 40 50 FEET
DCE #12-323 DATE DANIEL A. OJALA, P.E., P.L.S. 12-323 BORTOLOTTI-MCNAMARA.DWG