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TROY WILLIAMS ' v
SEPTIC INSPECTIONS so
Certified try MA Department of Environmental Protection (508) 760-1819
40 Old Bass River Road
South Dennis,MA 02660
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 3 7 M I y L,� C �, 4-e,. ; 1 (
Owner's name& /_y �, Vo <_ e o 1 C,
Mailing address Opp w�da l
Date of Inspection
S�►�l�o� CT. 06 y841
7102 8 /y S PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant and Board of Health.
_ None of the system components have been pumped for at least two weeks and the
system has been receiving normal flow rates during that period. Large volumes of
water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with
N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
y1All system components, excluding the SAS, have been located on the site.
l/ The septic tank manholes were uncovered, opened, and the interior of the septic
tank was inspected for condition of baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge, depth of scum.
t/ The size and location of the SAS on the site has been determined based on existing
information or approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with
information on the proper maintenance of SSDS.
Page 1 of 7
r'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
,_number of bedrooms
_I number of current residents
No garbage grinder, yes or no
%S laundry connected to system, yes or no
N o seasonal use,yes or no
If nonresidential, calculated flow:
Water meter readings, if available: _ 1 o 4
g3
O T p t Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
/\(0 c7J /N A- H4 i e T(,- zt-w4- 1n ex tG I It G.
System pumped as part of inspection, yes or no
If yes,volume pumped
Reason for pumping:
Type f 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)
Other(explain)
Approximate age of all components. Date installed, if known. Source of information:
Sewage odors detected when arriving at the site, yes or no
Page 2 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: _� (locate on site plan)
depth below grade:
material of construction: concrete metal FRP other(explain)
dimensions: S ' x y "xZ /o c o
3 " sludge depth
'/i"distance from top of sludge to bottom of outlet tee or baffle
_,/scum thickness
G " distance from top of scum to top of outlet tee or baffle
I) „ distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation
tlo�outlet invert,structural integrity,evidence of leakage,recommendations/for repairs,etc.)
IOU
V_C G C S J .� o c.. . �n -L Tl a 'k'A U
/�.i)\i� (w�t�✓ �� 1n G OrG� t.r. �c7 C i G N S COY— /L 0. k SAC O 1�
DISTRIBUTION BOX: v1 (locate on site plan)
",-/ " depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,
recommendation for repairs,etc)
L,%>Or kt-1 6"5 n✓'-t c✓. /Va S 1 T o
PUMP CHAMBER: -6�ZA (locate on site plan)
pumps in working order,yes or no
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, recommendations for
maintenance or repairs,etc.)
Page 3 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if poss.;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits and number
leaching chambers and number 02 Flo 4 , r3 09 4-0 h
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of
vegetation,recommendations for maintenance or repairs,etc.) /
o / ova sc."cA te d s yh or
t7 /o►✓ . G
CESSPOOLS (locate on site plan) : �-16,9
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
(cesspool must be pumped as part of inspection)
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of
vegetation,recommendations for maintenance or repairs,etc.)
PRIVY: A1119 (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, recommendations for maintenance or repairs,etc.)
Page 4 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
From W
90
y6'
1Oo0Cf
a �/ew�}��S t✓S
DEPTH TO GROUNDWATER
e. depth to groundwater — adjusted high groundwater level
method of de�termination or approximation:
) `
Page 5 of 7
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no or not determined(Y,N, or ND). Describe basis of determination in all
instances. If"not determined", explain why not)
ABackup of sewage into facility?
A/ Discharge or ponding of effluent to the surface of the ground or surface waters?
Static liquid level in the distribution box above outlet invert?
N�Liquid depth in cesspool<6"below invert or available volume< 1/2 day flow?
N Required pumping 4 times or more in the last year?
Number of times pumped
ASeptic tank is metal? cracked? structurally unsound? substantial infiltration?
substantial exfiltration?tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
Al within 100 feet of a surface water supply or tributary to a surface water supply?
_V within a Zone I of a public well?
IV within 50 feet of a bordering vegetated wetland or salt marsh(cesspools and privies
only, not the SAS)?
within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis? If the well has been analyzed to be acceptable,
attach copy of well water analysis for coliform bacteria,volatile organic
compounds, ammonia nitrogen and nitrate nitrogen.
Page 6 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector: Troy Williams
Company Name: TROY WILLIAMS SEPTIC INSPECTIONS
Company Address: 40 Old Bass River Road, South Dennis, MA 02660
Certification Statement
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported is true, accurate and complete as of the time of inspection.
the inspection was performed and any recommendations regarding upgrade, maintenance
and repair are consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal systems.
Check one:
have not found any information which indicates that the stem sy fails to adequately
protect public health or the environment as defined in 310 CMR 15.303. Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and the environment
as defined in 310 CMR 15.303. The basis for this determination is provided in the
FAILURE CRITERIA section of this form.
Inspector's Signature
Date 1,::,2� / 9S
Original to system owner
Copies to :
Buyer(if applicable)
Approving authority
PROPERTY ADDRESS:
3 7 Al C-
Page 7 of 7 '
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LOCA 10N 27 SEWAGE PERMIT . NO.
a.
Y.I:.:L:L A G E
INSTA LLER'S NA E j ADDRESS
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13
kU.11DER OR OWNER
Alt
o D:ATE PERMIT ISSUED
DATE COMPLIANCE ISSUED - 346 — g
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TOWN OF BARNSTABLE \`
LOCATION 3 -2 /t 4 0- SEWAGE #
VnL iAGE clLti 4% ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. %K f /� L�� C- c. —I—i 9
SEPTIC TANK CAPACITY e y® n
LEACHING FACILITY: (type) �o c.(/ ��v s<. (size) o?NO. OF BEDROOMS .3
BUILDER OR OWNER /
PERMIT DATE: ( ��7 r S.r COMPLIANCE DATE: IR 6 I9
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist '
within 300 feet of leaching faciliv) Feet
Furnished by
ar
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LO. CA ION SEWAGE PERMIT NO.
VILLAGE
li
IN IS� TA�LIER�'S NA �i1E j ADDRESS PQ 8CR I nlVJQ z
I R U I L D E R OR OWNER
Le Aon
i
O DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �_ a6 - ��
� � ,R
,� T',
� o
mow
Board of Health
` Town of
Ba,^uuuammm
� P.O. Box 534
. HyaMnis, MasseohmoftoeMOF MAssAouuecTrs
��K���� ���� ���� HEALTH Yz_ ������~""" ~�~ ==" � "�~" ^�~ " " " ^ ~ �
("OlssXDgw0o
- ------OF---. Hw-3 3-ISVISyAUVII
F [0Q� `
fU0J��T T� AP �� �,°� ��^ ���Q��� Tons
|�-��n�r���,-�t`,'-- �`-~ Disposal ~`-`-~~~~ ~°°°°°t-°° �~~°°°°~~
� k\
~�"herxbv ooule for u Permit to Construct or Repair ( ) an Individual Sewage C&»ouou
System at: '
nf AfJOICA----- Address
Installer Address
Type of Building Size Lot...2.01.16-Z7....Sq. feet
Dwelling
04 Other—Type of Building ............................ No. ofper000u----------.-- Showers ( \ -- Cafeteria ( )
Otherfixtures ----_-----.------------__-------___--_--.----___-__________________.
` Design Flow............... ..................... day. Total 8nvr
BcpticTuok--Iiguidcayacty.l 'gd}000 I.euQth'S�.......... Width--.���---- Diameter.--_-..
DisposalTrench--No. ---��---_' \�idtb-'-.----_- Iot� Length-_-------' Totu leaching aroa..33R
Sceyuge Pit No..................... Diaozetcr--.----- Depth 66mw iolc1--------- Total leaching area.--------'ag. b.
Other Distribution � ~ �� __
box (� ) Dosing� � ,� ��
Percolation 7.eot ]leao8o Pe�oroedbv--����m*' �J�� -. Dotc--���.L.�-' .........
Test P6 No. l''�� ......minutes per inch Depth of Test Pit-���'........ Depth to ground water--q6.----_.-�14 Test Pb No. 2................minutes per inch Depth of Test Pit.................... Depth toground water........................
9 .................................. '__-___-----'_-'_---'---------'-_------------_-_
0 Description uf Soil---_--_ - ...........................-----------_'...................................................................
_-----------------------
---------------------------------------------------
--._---------------
-------------------------------------------
--------------------------
--------
.--------------
--_------------_'--.----'-._-_-._-__-_---_-_---_-.-'-.-'-.--------_--.-__'___'__
U Nature of Repairs or Alterations--Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install theuforedescribed Individual Sewage Disposal System in accordance with
the provisions of]r'I',PIE 5 of the State Code— The unders* ned further agrees not to place the system in
operation until a Certificate of Compliance has been i ed b t e bo of.healtJ4
Signed...........X ... ......
- _ ^ n*"
Application Disapproved for the ____._________.____________________
___-__-'______''-------'___'--- ............................................................................................................................
� __
Peroz�y�o'��=�-_'����'�_-_-----__-- Iueue�.....................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
No.. C?2� F�$...J.............
THE COMMONWEALTH OF MASSACHUSETTS
_
BOARD OF HEALTH
.........,.^... .................OF...........
Y . App irFa#ion for Uhipos al Works T omitratrtion .eratti#
Application is hereby made for a Permit to Construct ( ,K) or Repair ( ) an Individual Sewage Disposal
System at:
_ _
aLpcalion-Address Lot ,f
i
..... C: 1�C.
_ .r 961.............................................. ............ r+ �f3.li�,-•i--t ..) ...-�5=.......P .................
Owner
�j �ji1
a ........... .. ....'�.....f.1�r_���4- y� .......... -t•f-4• �t� � 41_4---------------------------------------------------------------------------
Pq . Installer Address
d Type of Building Size Lot..... ....Sq. feet
aDwelling—No. of Bedrooms.......... ...........Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ............................ No. of'persons............................ Showers ( ) — Cafeteria ( )
Q Other fixtures ..
W Design Flow............................................gallons per person per day. Total daily flow_._......._.......:�.....................gallons.
'1 W Septic Tank—Liquid'capacity.........._gallons Length................ Width........ Diameter---------------- Depth................
x
Disposal Trench—No........:............ Width...................... Total Length.................... Total leaching area................Lsq-ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box O Dosing tank ( )
�4 Percolation Test Results Performed by------------------------- .. !!. '. �!�-�--..._.._..... Date_..:__�___/
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-------z-................
0-4
rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil................... ... _........... ... .......................................r '
x -------------•--•---------•-•--•-••-•--•••••----•---•-••--......-•-••-......_••---
V .....................................-...................................................................................................................................................................
W
V Nature of Repairs or Alterations—Answer when applicable........................................................:..:
...................................
-----------------------------------------------------------------------------------------------------------•--------------------------------------------------------•-----=--------------._.........••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been %ed he bo rd of health.
Signed ...... --17171 Date
Application Approved BY .._... ¢� . -�...............
Date
Application Disapproved for the following asons:------•-----------------•-------------------------...._..-----------------------.._..........••---......._.._._
... ... ..•--•••--•--•••---••---•••-•....................•...._•---•--•-•---•-•-----•--••---•----•--••-••....................................................
Date
Permit No. ..-� -- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1.
..........................................OF.....................................................................................
(Intifirate of Tootp iFanrre.
THIS IS T,p CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at- •IP=-- ----M A -24ft--e ------ ,p __ . ------------------
has been installed in accor ance with the provisions o I 5 y
f"�I L. of The State Sanitary Code as described in the
application for Disposal Works Construction Permit ................. dated--------
- .._.___...______.
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONST UED AS A GUARA EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY,
DATE. ...:.............~'...................- . z-6---....5....... Inspector...-------------- --.----....b.... ....... --••---- ----
THE COMMONWEALTH OF MASSACHUSETTS EMU tNt?'P-k 1NwS
BOARD OF HEALTH
�-- G z
7 w ly�:n] t.E�Zi► �cAt,raaer
No ........: .......... i T
W EE.......................
-
Permiion is hereby grant y��a' ,�-...: .............•----------------•--------------------------•---------------........................
to C nstt, ct ( ) or%Repair ( ) an Individual Sewage Disposal System
at -_ �}��1�� (pe --- - ----- ....
J $�1�...:::..� •l"(.�{„t.�•OC _._Street '= .
,as shown on the application for Disposal Works Construction Permit No...................... Dated........_.................................
`S ,� 1 6Fs ----------- -B a of th- - -- • " -----
°
DATE:._........
� �
FORM 1255 A. M. SULKIN, INC., BOST
. 1
LOW & WELLER, INC.
"Fiddler's Green Plaza"
714 Main Street, P.O. Box 119
Yarmouth Port, Massachusetts 02675
362-6868 362-8131
Registered: George Low, Jr., R.L.S.
Land Surveyors Everett H. Hinckley, P.E., R.L.S.
Professional Engineers William G. Weller, Consultant
September 23, 1985
BOARD OF HEALTH
Town of Barnstable
Town Hall
Hyannis, MA 02601
RE: Lot 26 - May Lane
Centerville
Dear Board:
Please be advised that we have supervised and inspected the in-
stallation and construction of the new sewage systems for the above
referenced location. We find that the system has been installed and
completed in accordance with the approve plan except that a few mature
trees have been retained within the 25' removal area which we find will
not adversely effect the results or the intent of Title V.
If you have any questions, please do not hesitate to contact
US.
Very truly yours,
/ G
f
A. Paul Simard, PE
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