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Home My WebLink About0026 MUSKEGET LANE - Health 26 Muskeget Lane Centerville A= 170-037 EMEAD No.Z-153LOR UPC 12M omwd oan • do&In USA towmi) �u■o��snoowut SHCRUM aatsMi +R wwwswoow�aoa s Commonwealth of Massachusetts ! � Title 5 Official Inspection Form C�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is enterville MA 02632 5-7-20 required for every C _ 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. A. Inspector Information �� fy,508 Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address East Falmouth MA 02536 City/Town State Zip Code , 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes t. 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5-7-20 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent t 90 the system owner and copies sent to Y the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r_ 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (Whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts 4, Title 5 Official Inspection Form i-i Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ ND (Explain below): ❑ ' distribution box is leveled or replaced El ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed El ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 r Commonwealth of Massachusetts y Title 5 Official Inspection Form If' ,'ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 .� Commonwealth of Massachusetts ,w Title 5 Official Inspection Form hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln J �s Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville• MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No, ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available.volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: t. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must-indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well It5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .T. ,> 26 Muskeget Ln f' Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. .. 1. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® " ❑ Pumping information was provided by the owner, occupant, or Board of Health El ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z. '❑ 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? ® El Wasthe 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: ® ❑ r 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)] r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ,. Title 5 Official Inspection Form %l Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments ,fo!' 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 5-2020 Date t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection Form hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "a" 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Watertreatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner----pumped 11-2019 Was system pumped as part of the inspection? ❑ Yes ® .No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln `r- Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under.contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 18" 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.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts j Title 5 Official Inspection Form I� w:� �I'C�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s_ >' 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"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: 1500 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles;installed and no sign of leaks e. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 i Commonwealth of Massachusetts r� Title 5 Official Inspection Form f� µ. I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V, r � :r_ 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: _ feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts r� y Title 5 official Inspection Form ;�4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville' MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.)Y ( 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, an evidence of solids carryover, an 4 Y rY � Y evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 4.N. Commonwealth of Massachusetts Title 5 Official Inspection Form 6lt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 I Commonwealth of Massachusetts y Title 5 Official. Inspection Form i hi Subsurface Sewage•Disposal System Form -Not for Voluntary Assessments a FNry fir;. , ? 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition and empty at inspection with stain line at 6" off bottom of chamber. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form ! i�► Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction:' Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts n x ,w. Title 5 Official Inspection Form- ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.-Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately lP I; f Q �58• s 1 � ,. • r • l 35 6 0 -3 Y r [ t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form iMI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: , Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts " p Title 5 Official Inspection Form i'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Beverly Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-7-20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 'V �� UG��SC� 4n w y to A Y;t rA-A�< w i7"GieN --�•.--___. _ _ _., �?�,�,�� _ ter_ '" _ P,. act 'b*V I �d kN a Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments } ,M 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector:. Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification t --a 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. Tl �inspection was performed based on my training and experience in the proper function andan aintenance-of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1'S.340`of Title 5(310 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails i:"? °a N-) ¢ ❑ Needs Further Evaluation by the Local Approving Authority f 10-26-11 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.. / 1 1 t5ins.11/10 Tdle 5 Official Inspection Form:Subsurf4,,w. posal System•Page 1 of 17 v t r , Commonwealth of Massachusetts W Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i GM 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 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: System is in good working order with no sign of failure. 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): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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): ❑ 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•11/10 Tile 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 V61untary Assessments 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville ' MA 02632 10-26-11 page. City/Town 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 El ® 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 '/day flow t5ins.11/10 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 wM 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 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•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 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 (f 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR'15.203 (for example: 110 gpd x #of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M y 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 201gpd/2yrs Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 10-2011 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: t5ins•11/10 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 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 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: N/A 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) (f 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 16"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: 1500 gal Sludge depth: 12" t5ins•11/10 Tttle 5 Official Inspecton 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 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 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 20 Scum thickness r 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 t5ins•11/10 Title 6 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official-Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. City/Town ' State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 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 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.): Good condition with water at working level and no sign of back-up from chambers. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology- Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition and holding 3" of water with stain line at 6" off bottom of chamber. 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 t5ins-11/10, .. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts i W Title 5 Official Inspection Form . o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. Cityfrown 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: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments ,M 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. City(rown 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 31p, o I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. CitylTown 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: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans on file show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 M 'r 26 Muskeget Ln Property Address Judith Aboudi Owner Owner's Name information is required for every Centerville MA 02632 10-26-11 page. Cityrrown 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•11/10 TrUe 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCA i'IOrd o� p "t/ u k e 9 e f L h SEWAGE # VrI:.AGE__( 7 e�✓ I�,� ASSESSOR'S I�iAF&LflT INSTALLERS NAME&PHONE NO- SEPTZC TANK CAPACITY J5 QC C L/ -- LEACHING FACILITY: (typz) �t 71M l.e l,.3 (size) 7_ 6 L -S No.OF'BEDROOMS 4 r '=1 BUILDER OR OWNER _ pERWrDATE: Between tbe: `1 COLIANCE DATE; ' Separation Distance . Maximum Adjusted.Groundwater Table to th Bottom of Leaching Facility Feet (; an wells exist Private Water Supply Well and Leaching E .iley �f y Feet on site or within 200 feet of leaching fir-ility? ----- Edge of Wetland and Leaching Facility(If anyi�tlands exist Feet within 300 feet of caching facility) Furnished by UP 'o .c - ID - C. tin o- � o c � �� 7Oq- O3 7 s No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[pplication for Migogal *ppgtemc Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) O Complete System LrIndividual Components Location Address or Lot No. Owner's Name ddre s and el No. Assessor's Map/Parcel Installer's Name,Address,and Te.No. Designer'31vame,Address and Tel.No. -7 _7PJ?3ff Type of Building: 7 Dwelling No.of Bedrooms Lot Size7, /sq.ft. Garbage Grinder(wo n Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow � � gallons. Plan Date 66 a �!14-2 Number of sheets f Revision Date Title / Size of Septic Tank ✓ Type of S.A.S. ' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b s,Board o eal // Signed Date L�/� Application Approved by Date z G 2 Application Disapproved for t e following reasons Permit No. 20o-^ 3 7Date Issued U THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT,IVY that the On-site Sewagg Disposal System Constructed( )Repaired( )Upgraded(� Abandoned( )by lC)�/" ! C—ee , at 2 "f-f 462<eep to 4 e!5e &1*VI has been constructed i accordance with the provisions of Title 5 and the Disposal System Construction Permit No. 00 _ dated f-' 2 b Installer Designer The issuance of thi7pe t shall not be construed as a guarantee that the sys'ei, i`11 funz/tion as ne 1. - Date `� ! l IQ) Inspector 1 !M�►Y Cr ---------------------------------------- - No. Duy2 --3 I Fee - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Dig;pogaf *p.5tem Cots trgrtion Vermit Permission is hereby granted to Con ct( )Repair( )Upgrade( )Abandon System located at / iU � G�`�� 1,4 r and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co stru t. n must be completed within three years of the date of this t. Date: Approved by +„ r •.,,,, /1 �+/Q � y _,� $ ,ice:. F_No. L Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBYC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS t � 01ppricatfon for Mf5pooal *p!Oem Construction Permit 'f Application for a Permit to Construct( )Repair( )Upgrade(t/")Abandon( ) O Complete System QIndividual Components Location Address or Lot No. Owner's Name Addre s and Tel No. 7 Assessor's Map/Parcel cy CAwAw e�l/h Installer's Name,Address,and T}.No. C �"`' Designer' ame,Address and Tel.No. Type of Building: �l Dwelling No.of Bedrooms `7 Lot Size / sq.ft. Garbage Grinder( � _ Other Type f Building y No.of Persons Showers( ) Cafeteria( )Other Fixtures Design Flow 1 , gallons per day. Calculated daily flow gallons. Plan Date X/7 7Z1a:Z ' Number of sheets / Revision Date Title / Size of Septic Tank Type of S.A.S. —.�Cl4 �Q/ G r�'107 Description of Soil i / u �P�.•r �jf'�17i 8�3. '� r Nature of Repairs or Alterations(Answer when applicable) a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issued byrthis Board o / Signed Date 61 h Application Approved by Date /a G; Application Disapproved for t e following reasons Permit No. 0 022— 3 3 Date Issued � D Z 0 -B FABLE LOCAV.Tw V)ijLA c f IiSS'F.S�OR' ' P Lttyt` . s'IL ,. 9iOft-T 01 NO Sl too PE�11DtA'i�: :G�3AAiCE D� `' S�p�auan3)t�n►ae H�hra�n:�e _ Maxi iam us d a ta' BothomofL Fari�ZtOWNEIL Pmrat atarSa Sir f►elt au�I mS bm Y tsIN,a � 3 feat &diet£� do�<�.eaci�nug 'f�txf��v�►etta+d�exist � Fiu�usbed b3►` �6 C, CJ4GK f ' r O oa cl 0 f-3 6 7 ' Q-3 - a� „ TOWN OF BARNSTABLE LOCATION o2G /�(,�.r�� .L.� SEWAGE #a6YJg- 3�Y VIJ..tAGE ASSESSOR'S MAP & LOT. 170—017 INSTALLER'S NAME&PHONE NO. L!,4711,,al,o✓ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Kj (size) r/x 22"A.2 NO.OF BEDROO BUILDER O OWNER PERMIT DATE. $a'e s— COMPLIANCE DATE: v- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility PY 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 Qua r Ji . O W'6.. s7 i TOWN.OF BARNSTABLE LOCATION -�W /li,s T. .L J SEWAGE VILLAGE C>9 i✓rt ASSESSOR'S MAP & LOT i 7dr—®T 7 INSTALLER'S NAME&PHONE NO. 46*4h)U% �a�f�r�� o✓ y29 4y,1 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) t4G G6 C «n (size) 'A.2 NO.OF BEDROO BUILDER O OWNER PERMU DATE: $a'0'2 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted'oGroundwater Table to the Bottom of Leaching Facility ��j 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 I O 57 I i I TOP FNDN, AT EL. 52.75' _ SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) TO - ENGINEER. AH OJALA, PE MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 51.7' WITNESS: DAVID STANTON Y STONEY IFF RD. 2" DOUBLE WASHED PEASTON PATE: JUNE 27, 2002 ELEV. 50.3' RUN PIPE LEVEL I ` Locus FOR FIRST 2' 3' MAX. PERC. RATE _ < 2 MIN/INCH z GALL N SEPTIC 48.9 t* CLASS I SOILS P# 41 EGEr z eo TANK (H- 10 ) «a 48.41' C7 m F-1 0 O 0 m ED O g ' (RE-USE) BAFFLE 48.58' �_ 48.22'IyO o m m m m o C7 Ea. �' 3' ® SIDES H1NCKLEY6' CRUSHED STONE OR MECHANICAL B $ 2 Q CI C7 Cl Cl C7 46 22' Q ELEV. CHAPPgOUI1CK COMPACTION. (15,221 C23) `' 0' 51.4 DEPTH OF FLOW = 4' ( 2 % SLOPE) ( 1 7 SLOPE) 3/4' TO 1 1/2' DOUBLE WASHED STOHE A TEE SIZES, LS INLET DEPTH = 10" *CONFIRM PRIOR TO INSTALLATION OF ANY 6,p 10YR 3/2 OUTLET DEPTH = 14 PORTION OF SYSTEM B LOCATION MAP NTS FOUNDATION- EXIST SEPTIC TANK 16' D' BOX 21' LEACHING LS ASSESSORS MAP 170 PARCEL 37 FACILITY 4,82' 24wo 1OYR 5/6 49.4' 5� 3)63 + 5L4 C ' �0 69.,34, 41.4 -- M ED/COS I 14" MAPLE LOT 15 2.5Y 5/4 17,627t SQ, FT. 2" OAK + 50.5 + 5 + 517 + s1. 10" OAK 53.43 120" , BENCH MARK - NAIL SET IN NO WATER ENCOUNTERED Cl) �TH + 51. + UTILITY POLE. EL. 53.4 (ASS.MD) NOTES 1.5 + h + 0.35 + 51.4 + 507 SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) 1. DATUM IS APPROXIMATED FROM QUAD 1.7 RE.-USE sEsaTlc TANK + 50.2 3ESIGN FLOW: 4- BEDROOMS ( 110 GPD) = 440 GPD 2. MUNICIPAL WATER IS EXISTING 14" P.PINE JSE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8' PER rOOT. + 51.8 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 . CONCRETE SEPTIC TANK: 440 GPD ( 2 > = 880 �d AA�� (0 ✓ 5, PIPE: JOINTS TO BE MADE WATERTIGHT. � PATIO USE A 1 _ GALLON SEPTIC TANK (E ) pkv) ✓ 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 52.75 + 52.1 LEACHI G: P ENVIRONMENTAL CODE TITLE V. 51.03 O SIDES: 2(39 + 10.83) 2 (.74) = 147 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT N TO BE USED FOR ANY OTHER PURPOSE. + 51.8 ni EXIST. DWELL. BOTTOM; 39 x 10.83 (.74) _ 2 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4' PVC. ,,n TF 52.75' 1.8 _ TOTAL: 621 S.F. 459 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT e JSE (4) 500 GAL. ACME OR EQUAL) LEACHING INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED + 50.8 �- FROM BOARD OF HEALTH. 3 (:HAMBERS WITH 3' STONE AT SIDES AND 2.5' AT 10, PUMP & REMOVE (OR FILL W/CLEAN SAND) FAILED LEACH PIT 52,0 "_NDS .,�0.3 �, - g1 s LEGEND TITLE 5 SITE PLAN �., S PAVED O •1 � DRIVE / 100.0 PROPOSED SPOT ELEVATION OF 26 MUSKEGET LANE 100x0 EXISTING SPOT ELEVATION 51 o IN THE TOWN OF: \ \ su 4 PROPOSED CONTOUR ( CENTERVILLE) B A R N S TA B L E 100 EXISTING CONTOUR PREPARED FOR: JUDITH ABOUDI + a' 20 0 1. 50 20 40 60 ------ BOARD OF HEALTH 49.4 APPROVED DATE MA SCALE: 1" = 20' DATE: JUNE 27, 2002 off 508-362-4541 fox 508 362-9880 Of Ad. down Cope engineering, inc, P`0 OF Mqs o� ARNE 9� yr ARNE H. s . .. H. ZF c OJALA •�, CIVIL ENGINEERS U OJALA � CIVIL N o No. 2 348 Q No. 30792 L AND SURVEYORS 02--208 939 vain st, yarmouth, ma 02675 A H. OJALA, .L.S. DATE