HomeMy WebLinkAbout0152 MONOMOY CIRCLE - Health 152 Monomoy Circle ,
Centerville
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Town of Barnstable Barnstable
Regulatory Services Department AlFAMerleac j
s =ARNS'rABLE, i
y MASS.
1639. Public Health Division m
A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
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CERTIFIED MAIL#7015 1730 0001 3981
October 11, 2017
ALLEN, DADE L TR& BOGERT, WILLIAM
3797 DRY BROOK ROAD
ARKVILLE,NY 12406
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 152 Monomoy Circle, Centerville, MA was inspected on
10/02/2017 by Brett Hickey, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Septic tank is leaking and distribution box needs replacement.
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF T E BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\l52 Monomoy Circle Centerville.doc
i
Town of Barnstable
Tam,
6 9. ,b� Regulatory Services Department
Public Health Division
200 Main Street,Hyannis MA'02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A McKean,CHO
Feb 6, 2007
Rev. 5111116
DE- ADLINES TO*REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000) _
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑Discharge or ponding of effluent to the surface of the ground
Y
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
. TWO (2)YEAR DEADLINE CRITERIA
• 4 Single Cesspoo • " �'
"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
❑Leaching pit or cesspool with high liquid level, <12"below inlet (per Town Code
§360-9.1)
❑Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
7/mil/
Commonwealth of Massachusetts • i ! /'i // 11FF��
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M
152 Monomoy Circle
w
Property Address p
William Bogert
Owner Owner's Name
information is Centerville ✓ Ma 02632 10-2-17 -
required for every -5
page. 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. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Brett Hickey
use the return Name of Inspector
key.
B&B Excavation
,y Company Name
374 Route 130
Company Address
B Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
Telephone Number License 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
(011
10-2-17
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal Systtemm-Page 1 of 17
V
Commonwealth of Massachusetts s
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is
required for every Centerville Ma 02632 10-2-17
page. 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:
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.
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):
The liquid level in the septic tank was low (at the seam)when inspected showing that the tank was
leaking. D-box was also in poor condition.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
' _ r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is Centerville Ma 02632 10-2-17
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
D-box was in poor condition.
❑ 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):
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts •
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (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 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.
3. Other:
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 '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 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"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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. 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))
D. System Information
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is
required for every Centerville Ma 02632 10-2-17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
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 ears usage d See below
9 ( Y 9 (gp ))�
Detail:
2015- 14,000gallons 2016- 14,000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: 6 months
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
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:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Not known
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):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Monomoy Circle
M
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
8"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
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: To grade
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000gallons
Sludge depth: TANK LEAKING
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
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? Observed
Comments (on pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level in the septic tank was low due to a leak in the tank.
Grease Trap (locate on site plan):
Depth below grade: NA
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
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. CityrTown 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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
NA
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain).-
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.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
11
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 was in poor condition when inspected. D-box will need to be replaced
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3 flow diffusors
❑ 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.):
Leaching was in working order at time of inspection with no sign of hydraulic failure. No high staining
was observed when viewed.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
c Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-.
Privy (locate on site plan):
Materials of construction:
NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title
5 Official n i I 0 c a Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
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
61-15' C1-44'
A2-38' B2-32'
B3-42' C3-88'
C
00
2 0-
3
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. Citylfown 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: 94
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: 6-28-85
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:
Plan on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Monomoy Circle
Property Address
William Bogert
Owner Owner's Name
information is required for every Centerville Ma 02632 10-2-17
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE
1 �
LOCATION l 5'L 11 OVJ Q M 9y ('i'ct?�� SEWAGE# .2 0I_7— 3q__7
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. S rV CgJgc ..,,.7
J
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS OWNER 60 a r+
PERMIT DATE: I I 1-4- COMPLIANCE DATE:
—r
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 facilit Feet
FURNISHED BY
110 r3.
Ile, 14 Inn
o ,
No. ?0` Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ' Yes
ftphtatlon for Misposaf *pstem Construction 3perimt
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. f! O nQ!�'10 1"C Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel ��/ - Y f�I`eLai)
Installer's Name,Address,and Tel.No. �p�j y 0�77 Designer's Name,A dress,and Tel.No.
1ha zw S
Type of Building:
Dwelling No.of Bedrooms Lot Size '19�cl�,6f5' sq.ft. Garbage Grinder( )
Other Type of Building ___ [Z ve �l4�� No.of Persons Showers( Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) A h re MI1t2 014 Ta Vv
/
�.�G r Stl►°IGi �.��iGl'1 i�'P s L�QS�e iid/1
Date last inspected.
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the E nmental Code 0111ot to place the system in operation until a Certificate of
Compliance has been issued by this Boar e
Sign Date I
Application Approved by F7. Date /
I
Application Disapproved by Date
for the following reasons
Permit No. r1-O Date Issued
--------------- ------------------------------ ----------------------------------- -
No. )U act Fee 6-0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal Opstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at + ��� � t/'✓ `"
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be co�leted within three years of the date of this permit.
Date _ Approved by -
No. Fee /
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Mispo9ar *pSt>em Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
r
Location Address or Lot No. a Q no hl!3� d�e Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel I�/ - J� (_ ee,, mlle E 1,I I -l—
Installer's Name,Address,and Tel.No. Z,,*6 y 77 pl77, Designer's Name,AZ dress,and Tel.No.
Type of Building:
,Dwelling No.of Bedrooms Lot Size (��`� sq.ft. Garbage Grinder( )
Other Type of Building veS1�drIJ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) PV 14, gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
'? Title
Size of Septic Tank Type of S.A.S. a
Description of Soil
Nature of Repairs or Alterations(Answerwhen applicable) p n(� f VQII e C7 TG11
r V
Date last inspecte :
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Emir nmental Code d=not to place the system in operation until a Certificate of
Compliance has been issued by this Board 'He
Signe i (�"' n Date + f
Application Approved by ?j. , 1 9 1 C� Date
Application Disapproved by Date
for the following reasons .
Permit No. {S Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
v �
at � ( as been constructed in accordance
with the provisions of Title 5 and the for Disposal System,Construction Permit No.��� ' dated d r
Installer Designer ,� !
#bedrooms A-- Approved design flow y V gpd
The issuance of this permit shall not be cdnstruegl.as a guarantee that the system will'funotion as designed.
t� J t jy
Date { 1 " 1 J Inspector
No, Fmi...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......../-�Al..----.....OF.... .............................
Appliratinn for Dispwi al Works Tonstrnrtiun ramit
415vsystem
Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
at:
-------........... ....................•- ----•-•• ------ -------_..
Location-Address or Lot No.
C'G� � ._..: ?_��`W-�---------------------------------------
�''�/� Ow er a Address_....------•...................1._... 1----•-•----............-•--•-•-------...---.._....... .........-------- -•• -•-- •-•-••
Installer Address
d Type of Building Size Lot_ .-/rI ........Sq. feet
aDwelling—No. of Bedrooms..............3...........................Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
PL Other fixtures --------------••-•--••••-•••••-- -
W Design Flow________________..._._...___.___._._gallons per person per day. Total daily flow____________330 -gallons.
W Septic Tank—Liquid'capacity��O__gallons Length"....'-.... Width_!� ""__. Diameter________________ Depth_.r'8_:v-
x Disposal Trench—No. .....1___________ Width.....ALI...... Total Length......:30....... Total leaching area---3A5.....sq. ft.
Seepage Pit No-----------_-------- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )a Percolation Test Results Performed by-__ h! ................. ................. Date..F __Z T. � �_
�__....
Test Pit No. 1__4,Z:____minutes per inch Depth of Test Pit__1............... Depth to ground water........fa
fT Test Pit No. 2_!�::.2-_.__minutes per inch Depth of Test Pit....Z3Z"____ Depth to ground water.........f...........
••--• ---------------------------------•-----••••----------•-...... .... ..------•----•---• ..............................
0 Description of Soil___O-
SAD _ Su 3:Sbi� 3"-'-3e."6/Z�V�z 3.K y_ Loa - � o• • •--••_-- -------------•••--..._-•- •-------------------------------------•-•.......------••-
D..— B ''..�- � rY¢.= /3 z" �i�-/%�rytr ..9pi
_.....-----` ..... . ? -. .! .s - •--•--• .-- --- - _-. �
j
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 TI7 iE 5 of the State Sanitary Co e— The undersigned further agrees not to place the system in
operatio unti a Cer ificate of Compliance has bee i ued by the o th.
Signed_k_ ..... --••••-- -----�`-'---=---------------------•- - ------•---•-•--- --1' --�
Da
Application Approved Y ....__...... --•----�.---. Da+ -
Application Disapproved for throllowingreasons:-----•--------••---------------------------------------•---•------------------------ ••--• ••-•----••-------
--•----••----------•------...--•-•--•--•••--•--•--•-- ._..•---•-----•................. ---•--••---•-•-•-•••-•-•---••---•---•-----••-••-
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............................................................
fP�rrtifiratr of Toutpliaurr
HIS IS TO CERTIFY, Th t the Individual Seyrage Disposal System constructed (L.�or Repaired ( )
'C
by ---- .. ... -- --------•--•------------- -------•--•--•-•---•------_______-------•-•--•------------------
Installer
1 <
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 ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
a
DATE... G ... .............•--------........................... Inspector...._••-• . -•--•--•••-• .........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........OF......... `'�`�-5T.9 i '........................................ +�
L
No._.�S_:._- I FEE..... ._..
Disposal_IFo k on trwtivo rrly! p ,
Permission is hereby granted-------- --- ...........--.........................................
- ....-•-•...................-----
to Construct ( 1010r�Repair ) an Individual Sewa a Di osal System
....................................................
at No.----, ----- .10 _L?"� �;�a .� -�<------
Street gs_/=t��
as shown on the application for Disposal Works Construction Permit No................... Da ed_-_-__.6,:.�-�.�� ..........
.......................................0
.......................................................
--.�......................_
DATE............. o of al,
.........FORM 1255 A. M. SULKIN, Inky_ BOSTON
f
FIm
No a s .......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
................. v / 0F...!3/-�' �AS7-.9s3G6r
Appliratinn for Bivpnlitt1 Works Tnnitrnr#inn ramit
Application is hereby made for a Permit to Construct (/) or Repair ( ) an Individual Sewage Disposal
"�,-.System at:
/�1a�ivi9v Ci2cLt1. ' �- 17-C-7.eVi4ZdG La7;"/3v
.......... ..._....... . •-..... ...............-•-•- ............. _..._-••---..................................•-•---••-----•---••.........------........----------
Location-Address or Lot No.
.z�r�G�� �BL .....�--- ------------------------- ---------------••------------____..___....-______-_------••-•----••---------_--............------
y Owner Address
Installer Address _
UType of Building Size LotZ?.Gys_._.____._._Sq. feet f
Dwelling—No. of Bedrooms.............____3___________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ----------------•-------------------•--•--------------._....----------------------------------------------•--------•----------...--------...•-•.-•-•--
W Design Flow............................................gallons per person per day. Total daily flow.---._.._.__33�_-_-________.._.._..__gallons.
WSeptic Tank—Liquid capacityA?o? -..gallons Length 6.�_...... Width¢"16.'...... Diameter................ De th..�8.a--
x Disposal Trench—No. ..--_/..._.._.._.. Width._.._la____-_.-__ Total Length-----'3a__..... Total,leaching area_3 ......sq. ft.
Seepage Pit No..................... Diameter.................--- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by..&'-P ..45_:___-*;;� ................ Date- ___Z� 157.4
....c...__._. .'.___--.
Test Pit No. 1._4 _ ..---minutes per inch Depth of Test ..... Depth to ground water....... ;;------.
Gr~ Test Pit No. 2.�:._Z.....minutes per inch Depth of Test Pit----e3 ..... Depth to ground water........................_
a -------------------------------------------------•-------------.....------..........._;...
Description of Soil 3a'-_-. Su�3- Sai4• -70 -36 /Zs?/&--x. 3� - to 11
� -•-•--•-------------------•----------------....................................................- ----•----•--------
O i +/G` s/.v!) eD�•_ 84" N 7�- FiH�- s 47� ` !�''- 13 Z" 'OLV&P-/-tivc- •SAx.-t>
----------------------••-------------••-------•--•--••-----...__......
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 TITLE 5 of the State Sanitary Co e—The undersigned further agrees not to place the system in
operatio unti a Cer ificate of Compliance has bee i sued by th o h lth.
SignedV � �
App lication A pproved
Application Disapproved for th ollowing reasons----- -----------------•-----•-••----••----------------••------•-------------•-------------------•--=-----.......
------------------------------------------------------- ----------------------•.......-------•.......................................................................................................
Date,
PermitNo...... .............................................. Issued_.......................................................
Date
„► a Syc��-T ,�`,o F Z 5NE"2 TS
w
�V 1
3
$1
---
�oB,53 it
31 S
4211
Zo T -30
ter, N Z Zy 9 S” -5�,T 31,
10
.,
W)7w
P Sip Ftow-aiGlv3o e s
AP°
So LSZZ&V.. of So 48' 4-'I 44J 4Z 1
4AIC, /3oC�ti45> c Sa,oo /VoT�'- CZE 1/�T7anis 8i95" a�
/�SSv�-i�sv DA-rti•�-s
LOCATION
SCALE . / 30 ' . . . DATE . . . . . . . . .
PLAN REFERENCE
OF
Ecru F»G. 5 . . . . . . . . . . . . . . . . . . . . . . . . .
:LLEY . . . . . . . . . . . . .
N0. 2610
aft LI;i r , I CERTIFY THAT THE ...... . .. ......
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REQUIREMENTS OF THE TOWN OF
WHEN CONSTRUCTED.
DATE . . . . . ... . . . ..
CEDeGC lgGA�G�`Z - PST/���T� REGISTERED LAND SURVEYOR
• a i d �.SyT Z �/� 7-
TOP OF FOUNDATION
s„ CONCRETE COVER
•;' CONCRETE COVERS
"e 4'�CAST IRON II � m r)nsVr '
,,87 OR SCHEDULE 402 MAX. 12"MAX.��
P.V.C. PIPE P.V.C. SCHEDULE 40 PVC.(ONLY) -T
PIPE- MIN. 3 mow'
PITCH 1/4"PER.FT. PITCH 1/4"..PER.FT. Di�'r sons p,�--c�sr
e Wi174 nle�x" Fto k/-
. e �Tt.•ToF
o' INVERT srs v6 Dil�sew2s
INVERT
INVERT /OK3o' i 3,e
SEPTIC TANK DIST. w '•�
n INVERT EL..3`jLS. . BOX EL38-s8 >_
e' EL.-�9�7�z.. GAL. INVERT INVERT /� v� :;a 3/4"TOIV2*
EL. 8.7,,� w w
EL.3�:Sq ; �o WASHED
w STONE
—H 0,
PROR LE OF GROUND WATER TABLE
CAl
SEWAGE DISPOSAL SYSTEM s 0scs-WAn/-7L
;F-
C2ov..iD
NO SCALE L��/E"L Ca�puTz�77av,
P-4z o 3
SOIL LOG WITNESSED BY :
DATE �t� .Z�./98S TIME. � :00 /07 AH�S �^%�•r✓, BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 , ENGINEER
ELEV. .37c3 .3 7 o . . . ELEV. 4n
DESIGN DATA :
M C /�- 36 62AyG2 NUMBER OF BEDROOMS '3 . . . . . .
s�,D TOTAL ESTIMATED FLOW GALLONS/DAY
coot
Fc 6,L 11 SAID BOTTOM LEACHING AREA 300 , SQ.FT. /PIT/C,P,D,
ez.3Z, �Z 3o `�bZ
4.' 'll
~�D//%NG- M�"3/�u SIDE LEACHING AREA .90. . . . . SQ.FT./ PIT/Zoo C•pZ),
cz.�0.3 0 �F/ivE
S^ p GARBAGE DISPOSAL !�!�?^! .(50% AREA INCREASE)
AW
ez. ,,�ATOTAL LEACHING AREA . . -�BQ. . . . SQ.FT
PERCOLATION RATE .�'�Gr. . . . . . . . . MIN/INCH
/ Z.U,30
9¢a LEACHING AREA PER PERCOLATION RATE Sao.. SQ.FT/C,A,D,
WATER ENCOUNTERED
NUMBER OF LEACHING PITS . . . . . . . . . . . .
APPROVED . . . . . . BOARD OF HEALTH r
7-
DATE . . .
AGENT OR INSPECTOR
jk� OF hfgs� �atitli OF 1 r
EDW ST
J �g
Lo7 vl/30 `'<< A. H LL v o
JNo. 26100 � � R' �
IsT
L a a';� Surr
PETITIONER
I
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location,.— hp�ono�/ e jeCL.cr Ce"7a-ZV/44e- Lot No. 3b
Owner' Address: BAru✓.sTf4BG� �1�9ss
Contractor: Address:
Notes:
STEP 1 Measure depth to water table 7,8 3
to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Z /z7/B�
date
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and. determine:
A) Appropriate
index well !. /W ,7-30 .
B) Water-level range zone . . . . . . . .
STEP 3 Using monthly report"Current
Water Resources Conditions"
determine current depth to
water level for index well . . . . . . Z/8,S
mo yr ,
STEP 4 Using Table of Water-level
Adjustments for index well
STEP 2A current depth to
water level for index well
(STEP 3) , and water-level
zone (STEP 2B) determine
water-level adjustment . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
STEP 5 Estinate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 3
_+. -7-
EDWARD E. KELLEY
REG. LAND SURVEYOR
CUMMAQUIDI MASS.
02637
TEL : (617 ) 362-2266
January 23,1986
Town of Barnstable
Board of health
Hyannis,Mass.
Refi Lot #30 Monomoy Circle,Centerville
85-619
The sewage system was installed in accordance with the approved
plan and conforms to Title V and Town of Barnstable health
requirements.
OF
STETSON
Nq a E.
Q KFL F
gyp' 'fi o rv)
V' \pef•\ , � Ar�y4w
Re a n Reg. Proe�: �i�'ona1�=,L:and Su veyor
$4Rrat a �i��41. Li
10CATION SEWAV E PERMIT NO.
VILLAGE
INS TA`ILL+ER'S NA�M+ E ` & ADDRESS
-�
B U I L D E R OR OWNER
C
DATE PERMIT ISSUED �'� alp
DAT E COMPLIANCE ISSUED 6�Zs � S
4'
t
o
�7
,i •� 39
i
F f{
,
G c l '
,�
AsBuilt Page 1 of 2
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME i ADDRESS
C�.� �- l..z�,a•� CE�� Sir �`4 . � ���.s�z��
BUILDER OR OWNER
- - G��1eL� r�r��
DATE PERMIT ISSUED !r
-
DATE COMPLIANCE ISSUED o/zblgs
i
O
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