HomeMy WebLinkAbout0061 MERIDETH WAY - Health 61 Merideth Way
Centervilie
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UPC 121"
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'LAM
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms on the
computer,use 61 Merideth Way- Centerville, MA
only the tab key Property Address
to move your Jacob and Ethel Kates, and Leslie Wortzman
cursor-do not
use the return Owner's Name
key. 61 Merideth Way
Owner's Address
t� Centerville MA 02632
City/Town State Zip Code
, Date of Inspection: September 13, 2005Date
2. Inspector:
David D. Coughanowr, R.S.
Name of Inspector r; y
Eco-Tech Environmental -,_ -J
Company Name ! 4
43 Triangle Circle
Company Address '
Sandwich MA 102563 ,v
City/Town State Zip Code- +""3
508 364 0894
Telephone Number
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 ❑ Fails
❑ Needs Further Ev luation by the Local Approving Authority
Q V�S September 13, 2005
Inspector's Signa ure 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.
****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.
t5-2183.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
I
TOWN OF BARNSTABLE
LOCATION l l Akepidd, !A,' w SEWAGE # _
VILLAGE CCiJferV,,,c.A. e. ASSESSOR'S MAP & LOT ✓ `� ��.�
INSTALLER'S NAME&PHONE NO.-1)R V., CQt hQ 4 010r
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type) (size)
NO.OF BEDROOMS .�
BUILDER OR OWNER./ac o6o6Eth v 4, Kates omd A—e5l-w ( ef:ri afa
PERMPTDATE: 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
Furnished by
ICommonwealth of Massachusetts
Title S Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C.System Information(cant.)
61 Mendeth Way
Property Adtlress
• Centerville MA 02632
Gyrrown State Do Code
Jacob and Ethel Kates,and Leslie Wortunan September 13,2005
Owner
's Noma Data o!Inapeedon
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.
LOCATIONS
A B
1 17 ft 10.5 Ft
EXISTING 2 25 f t 22.5 f t
DWELLING 3 36.5 ft 36.5 ft
# 61
SETAM
I
O p0a%
LEACH
(a PIT
MERIDETH WAY NOT TO SCALE i
I t5.21 a5.doo•112004 T ae 5 Ofikial Impeotlon Farm:Subwdeoe$'—a.Disposal System-
page 15 of 16.
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'GSM
A. Certification (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) 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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 2 of 16
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 3of16.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG M
Subsurface Sewage Disposal System Form
A. Certification (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
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:
t5-2183.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
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 an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered.A copy of
the analysis must be attached to this form.]
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.
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 5of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
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"no"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.
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie September 13, 2005
Wortzman Date of Inspection
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, including 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(3)(b)]
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
LM
Subsurface Sewage Disposal System Form
C. System Information
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design): n1a Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan
Number of current residents: 0
Does residence have a garbage grinder? Removal of grinder is recommended ® 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 ears usage d 126 gpd
9 ( Y 9 (gP )):
Sump pump? ❑ Yes ® No
Last date of occupancy: 2 weeks ago
Date
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
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):
t5-2183.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
/GSM
C. System Information (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information:
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Age: 21+years. Certificate of compliance issued 9121182 (Board of Health records)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5-2183.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 2feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer appears structurally sound with no evidence of backup or leakage into dwelling
Septic Tank (locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass El polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of El Yes El No
certificate)
Dimensions:
8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth:
4 inches
Distance from top of sludge to bottom of outlet tee or baffle 30 inches
Scum thickness 2 inch
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 13 inches
How were dimensions determined?
Probe to top of tank
t5-2183.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
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 not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
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.):
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):
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
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.):
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert At 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.):
D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1
❑ 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.):
Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. Leaching pit was uncovered and found to
be empty. No effluent contact staining was observed at cover interface.
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
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.):
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.):
t5-2183.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
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.
LOCATIONS
A B
1 17 Ft 10.5 ft
EXISTING 2 25 f t 22.5 f t
DWELLING 3 36.5 f t 36.5 f t
# 61
W A g
z
J
W I
W
~ I
3 SEPTIC
TANK 10.1
I
2
❑ D-BOX
LEACH
PIT
3
MERIDETH WAY NOT TO SCALE
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 15 of 16
L_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
61 Merideth Way
Property Address
Centerville MA 02632
City/Town State Zip Code
Jacob and Ethel Kates, and Leslie Wortzman September 13, 2005
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to 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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 12 feet above
groundwater table.
t5-2183.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 16 of 16
TO ALL NEW BUSINESS OWNERS
DATE: "
Fill in please:
YOUR NA
APPLICANT'S ' 4lG�D�c�UO �-tOt�
' ♦=:
BUSINESS T
U HOME A 4RESS: C�1 i�11�f1IO�Tl� LATA
/ ;
NTMVi L 1 9 NO, QZ4032 i
TELEPHONE ek Te.le hone Nu, er Home _-- - _
NAME OF NEW BUSINESS ' AT ;vTtN�q ' ES191 W' RU hnev% . TYPE OF BUSINES N17 N61.
IS THIS A HOME OCCUPATION? YES ®-NO
Have you been given approval from the building division? YES NO
ADDRESS OF BUSINESS G1 N 000h VJV CVVTt_\hUC- Mk 0263 MAP/PARCEL NUMBER
When starting anew business there are several things you must do in order to be in compliance with the rules anl,r@gulations of the Town-
Barnstable. This form is intended to assist you in obtaining the information you may need. Once you have obtained the req iu riu red signs ures, listed
below,you may apply for a business certificate at the Town Clerk's Office (Ist floor-Town Hall). You MUST go to the following office to make sure you
have all the required permits and licenses..
GO TO 200 Main St. _ corner of Yarmouth Rd. & Main Street) and you will find the following offices:
1. BUILD G CAthorized.!iWkatu're
ISSI0 ER'S OFFICE
This indivi ualjasrg o any permit requir ments that pertain to this type of business.
OMMENTS U
i t .&\
al; - I A l 2. BOARD OF HEALTH
This individual h een info e uir men
ed �thpermit ets that pertain to this type of business.
Authorized. gnat
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
Business certificates [cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L.
-it does not give you permission to operate -you must get that through completion of the processes from the various departments involved.
**SIGNIFIES APPROVAL FORA BUSINESS CERTIFICATE ONLY.
._ . Date: Qf
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: CSJPAN\"
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: 0 IOTAL AMOUNT:
TELEPHONE NUMBER:
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER: 7`7 � � �t`P � MSDS ON SITE?
TYPEOF BUSINESS:
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous.waste:
Name of Hauler* Destination:
Waste Product: Licensed? Ye No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division
i%t/Z� -G-�-
LIST OF TOXIC AND HAZARDOUS MATERIALS ��/Yn ,
The Board of Health and the Public Health Division have determined that the followin 4cts exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) 'D _ Misc. Corrosive
!!NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes _ Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
-- Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
—0 Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
—0 — Diesel Fuel, kerosene, #2 heating oil NEW USED
—D Misc. petroleum products: grease, ra~ Photochemicals (Developer)
lubricants, gear oil NEW USED
�D Degreasers for engines and metal Printing ink
Degreasers for driveways &garages " b Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
` D — Battery acid (electrolyte)/Batteries —o Lye or caustic soda
Rustproofers —0 Misc. Combustible
—O Car wash detergents 0Leather dyes
— Car waxes and polishes —0 Fertilizers
o Asphalt & roofing tar —0 PCB's
Paints, varnishes, stains, dyes D Other chlorinated hydrocarbons,
Aq Lacquer thinners (inc. carbon tetrachloride)
NEW USED -' D'_ Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
_p Floor & furniture strippers — Other products not listed which you feel
— O Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers ` _
(including bleach)
Spot removers & cleaning fluids
(dry cleaners)
--� Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
1;7
l0C�ll/ 1 �A SEWAGE PERMIT NO.
VILLAGE
Cie
INSTA LLER'S NAME & ADDRESS .
JOH,N A. AALTO .BACKHOE SERVICE
West ,Barnstable, Mass. 02668
B U I L D E R OR OWNER
®b
DA T E P ERMIT ISSUA 0
DAT E COIMPLIA.NCE ISSUED
/�1j ,4
_ __
a�q},
Sa'� 1 . .
a
� \ — ��
\ 1
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No. '�tf �... Fss.: . ..-........... j
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
+.�..nl.................OF............BAR .-N..k.- t 1�.�-- ...........
Appliration for Uhipuiittl Morks Tiantitrurtiurt Frratit
41-11
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
q System at: , . I
�{.......KJ d hl1'�R�1 Lt_i ....••--•----...---•-•-•-•-••---•-----••••••
_..._ -L
Location-Address or Lota o.
1..K-S c_14.........-•••................................ ClITL LO.-D----MA�.IO__...._ y.,4.N.!v .........................
Owner Address
................................................ wild_cols.r•-ST'fi i� �zYl� .....................
Installer Address
d Type of Building Size Lot...
ZC_9_(.a.42....___ . fee
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grin er
Other—Type of Building No. of persons............................ Showers
a YP g P ( ) Cafet a
04 Oth fix�r�o........................ •---..-...-------••---------.___.--------•_...-..-_-._..-------._-.______--------•-•----...----.....__...-------•- ...
w Design Flow...... ... ___________________ gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity/. r gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length............../.... Total leaching area....................sq. ft.
Seepage Pit No..__./--- -----. Diameter_...1:_�--_.. Depth below inlet.___.......... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No.-I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
r14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-............................. ---------
x� Description of Soil......................:........................•-•-----•-----........._....---••-------------•-------•--•••----•-•••---•---•••----•••---•----_____------••-----------_..
w
U 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 LITL% 5 of the State Sanitary Code Oe unders-gned further agrees not to place the system in
operation until a Certificate of Compliance has been issu 'e bo rd i lth.
gned...... -•-_••.....
=- --••-•----------- - -/� -te
Application Approved By... __-_._-�:_ ,/-----•- •-----• ••-----•------.-.*.................••-••_•-••• �....
Application Disapprov for a following reasons:.••-•--•--...•-•---•-•-•••-----•----......•-•---••••••-...-•------------•••---•-.._-•---_-....................
-
,� . . .. .._...---•.......................•-----•-_.....------.._......_..-•------•----•----•----- ...............................................
Date_
PermitNo.....................r Issued........................................................
/ Date
FEs.,...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
nJ.......... - ..oF......-... . : -N. `F Jq--t3..'c...........................
Appliration for Biipoiittl Workii Tonitrurtion thrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
14 (. .!Tt.S ft. k. 4 r a~c --------------------•--•••............._..
-_...- - ---CL T
Location Address
�u _......k .1.R.S,_C m-••••............................................. :Yd MAW...
Owner Address'"*' .......................
a or ti-------A Aq -c- .. -----•---•-------------------------------- WAkNU.r_.S-rfi....CsmM-4V 1.>w r........
Installer Address
d Type of Building Size Lot... feet•
Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grin er
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafete -a
Other-fix rqo...............•-----..._.....---••---•-•-••---•---...-•------------......---------------------•---•-•-••-•-------•-••••--.........---...............
Design Flow....... ,"i.:......... ............... gallons per person per day. Total daily flow......................___._.._.__...........gallons.
W /
WSeptic Tank—Liquid capacityL..'��gallons Length................ Width..............._ Diameter...__...___..... Depth................
x Disposal Trench—No. .................... Width.................... Total Length....... ._.f.... Total leaching area....................sq. ft.
Seepage Pit No....../..._------- Diameter._._S._° .._. Depth below inlet.... ......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by............................................................. ............ Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •----------------------------•-•-••••--••••••••--••---..._........-••---............---.....__•-•••-..........................................................
0 Description of Soil........................................................................................................................................................................
x
W
Z --------------- -----------------------------------------------------------------------•---•--••--------•-•----•--------.-•------ •-•--•-•.....•--•-•-••-----••-••••--••••---••--••......--•---••-•----
U 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 TITLE 5 of the State Sanitary Code— e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu �yy`
e bo rd r lth.
Jr
Application Approved By ............ ........ ...... .................................................. ---• /__
ate •---........
Application Disapprov for a following reasons:.................. ••--••--•----•---------------------••---•----------------•----------.._...._..•----....---•--
V�
............................... ----------------••------------•-••--------..........--•----.......-•--•------•-•------...-----••---------------•-•------------•-----•--------....------•-•--.
Date
PermitNo......................................................... Issued.......................................................
Date
t THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..........................................................:..........................
Tnrtifirair of Tontplianrr
IS I ERTIFY, That the Indivi al Sewage Disposal System constructed (,-- or Repaired ( )
h-U
by.. ...•••••-....•-••-••-•• •- -------------------------------------------•-----
�� Installer
at.................. ........•--- ....•_......-- -•----•
has been installed in accordance with the provisions. T�f T F 5 +�he State Sanitary Cod s c bed in the
application for Disposal Works Construction Permit No. _.�... r................ ated__,. ._l _.. ....
THE ISSU CE F THIS CERTIFICATE SHALL NOT BE CON AS A GU ANTEE THAT THE
SYSTEM WIL F, ION SATISFACTORY.
DATE..... ... 1. .. ...........••---•---•-------•--•-•----•--•-•--...... Inspect .
R
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c .......OF.....................................................................................
7
No. ............. FEE
iottl � .
onotrnrtion proof
0 .............
Permission is e y granted --------- -- ---
to Construct ( or R ~ it ( an I •�w' sal S t
atNo.................. __,1 ._.......•---- .. - ------------------- -•----
Street
as shown on the application for Disposal Works Construction Permit ----------------- ..................................
0 of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
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�✓ �� �$y . ;�e. z
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100 .0
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101
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101
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LEGEND ,
EXISTING SPOT ELEVATION Ox0 OF CERTIFIED PLOT PLAN. ,
EXISTING CONTOUR --- 0 -- 3`���tN M�ss�
FINISHED SPOT ELEVATION Qs _ ems'. ALBERT ° °yc � �T � � �� � 'vG' f�
C'EiVT�/�
FINISHED CONTOUR 0 A. -
r' MORSE y IN
Al ?ROVED j BOARD OF HEALTH 0.1os5P�0 Q° ,�Q �1 .` $, g
DATE AGENT SCALE] / �r=3v DATE (7/�61E3
rrL DREDGE ENGINEERING CO. IN
------- -- CLIENT ' I CERTIFY THAT THE PROPOSED
EGISTERE REGISTERED ' �OQ :NO- S BUILDING SHOWN ON THIS PLAN 1
CIVIL LAND CONFORMS TO THE ZONING LAWS
DR.BY ' . '.
ENGINEER SURVEYO OF BARNSTA LE , MASS. A
• Jac ,
712 MAIN STREET CH. BYE
HYANNIS, MASS.. . Z.
SHEET-/- OF . ^DA E3 R G. LAND SURVEYOR a
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