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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
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.
A. General Information
1. Inspector: 21
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address arllhat�Pte
information reported below is true, accurate and complete as of the time of the inspectic`a�. Thmnspection
was performed based on my training and experience in the proper function and mainterzmce id on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Secttsta' 15640 of
Title 5 (310 CMR 15.000).The system: ll'--,► -n
cJ� cep
A
® Passes ❑ Conditionally Passes ❑ Fails
3 �
ElNeeds F he Eval ion by the Local Approving Authority y.-h '-t
O
co m
0
10-14-10
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.
P/ge",U.
tt>msp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Dispose ystem
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C4�M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is
required for every Centerville MA 02632 10-14-10
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally
unsound, exhibits substantial infiltration or exfittration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health.:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless.Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a mannerwhich will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of.a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of'Health-(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has aseptic 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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10 °
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
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 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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`fifes" 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
El
Area IWPA) or a mapped Zone 11 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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�7M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
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 b the owner, occupant, or Board of Health
P 9 P Y � P
❑ ® 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 CM 15.302(5)]
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
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
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 10-14-10
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): canons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
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) (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:
2004 -- _ _-----—--------—_�.�---- —
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document-03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Building Sewer(locate on site plan):
Depth below grade: 13"
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):
5..
Depth below 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: 1000 gal
Sludge depth:
10"
Distance from top of sludge to bottom of outlet tee or baffle 22
Scum thickness 271
Distance from;top of scum,to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape
t5insp official document-03/08- Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
u 4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
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.):
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
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):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments note if box is level and distribution to outlets equal, an evidence of solids carryover, an
( q � 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.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
2-500'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 empty at in inspection with stain line at 6"from bottom of
chamber.
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
A
6k
eck
1�10
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
248 Nottingham Dr
Property Address
Ron Timm
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10,
fleet
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 10'.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form G3�
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `
,M 248 Nottingham Dr
Property Address
Assetl i n k
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every 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.
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
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number = ,
B. Certification ! r
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 inspectlon. Tli-e inspection
was performed based on my training and experience in the proper function and main enance-of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Se tion 15-.340 of.
Title 5 (310 CMR 15.000).The system: --..•
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5-13-08
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.
t5lnsp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every 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.
1�1'1
C:�
B) System Conditionally Passes: d
❑ One or more system components as described in the "Conditional Pass"section need toibe-j
replaced or repaired. The system, upon completion of the replacement or repair, as'approved_by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not I
determined,"please explain.
❑ The septic tank is metal and over 20 years old" or the septic tank (whether metal or riot) 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.
k A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
G
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M4.1248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (corl
❑ distribution boi is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless.Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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.
r ❑ 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.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well". `
Method used to determine distance:
*" This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
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 1/ day flow
❑ ® Required pumping more than 4 times in the last year,NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El E An portion of cesspool or privy is within 100 feet of a surface water supply or
YP P P Y PPY
tributary to a surface water supply. ,
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in.31.0 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
LL ❑ ❑` 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.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every 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)]
t5insp-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
-every page. City/Town State Zip Code Date of Inspection
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
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 4-08
D ate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp•03/08 - Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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) (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:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is Centerville MA 02632 5-13-08
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 13"
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: 5
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: 1000 Gal
Sludge depth: 8
Distance from top of sludge to bottom of outlet tee or baffle 24
Scum thickness
2"
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
14"
How were dimensions determined? Tape
t5insp-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
N a Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every 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.):
Good condition with all baffles in place.
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: r
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 248 Nottingham Or
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
j
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
r
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ teaching pits number:
� ® leaching chambers number:
2-500'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 with no sign of failure.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 12 of 15
4
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
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
J
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.):
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
� s s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 248 Nottingham Dr
Property Address
Assetlink
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
I
i
get e,
L2e4 k—
I � C
67
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'4 M
248 Nottingham Dr
Property Address
Assetl i n k
Owner Owner's Name
information is required for Centerville MA 02632 5-13-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers-(attach documentation)
® Accessed US.GS database - explain:
You must describe how you established the high ground water elevation:
Original design plans show no water at 12'.
t5insp-OW08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
s-+
Town of Barnstable
OF SHE Tp�
Regulatory Services
rsrnB�>r ; Thomas F. Geiler,Director
1639. ��� Public Health Division
AlEO MA'I a
Thomas McKean,Director
200 Main Street,- Hyannis, MA 02601
Office: 50&862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit". .
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
Q:\SEPTIC\Disclaimer Private Septic Inspections.DOC
TOWN OF BARNSTABLE
LOCATION zfzl .&IVl'.e SEWAGE #
VILLAGE Ors eVZ/1& ASSESSOR'S JMAP & LOT 171
INSTALLER'S NAME&PHONE N0. ,��9"y20 , %73S Jasa4 U4iaHrno s
SEPTIC TANK CAPACITY /DOO // // `
LEACHING FACILITY: (type) -S®o ZGno�i �blA9",4--(Iiile)
N0. OF BEDROOMS
BUILDER OR OWNER _►//=i"� Lls �/� "
PERMITDATE: S l.3—D% COMPLIANCE DATE:
1i
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �_ ��
i1�atTir��ll�dv! Sri��1: ,
�,
s
h
I��G C
f
2/� �3, � c �< �
_ �� � ___�
z�-
� ��
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
application for Migpozal *pgtem Construction 3pertnit
Application for a Permit to Construct( . )Repair(grade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. (t ,7�1- r/ 4,41,! a-, Owner's Name,Address and Tel.No,
Assessor's Map/Parcel /
7/- 3
Installer's Name,Address,and Tel.No. 50E-�'20—`/�3� Designer's 14ame,Addre and Tel.No. s'D8-39f'-Q723
✓OSr;/�� L,-�Us9/�i^�,S �g�l Ls�hG�nnS'��'r/iC%S
[/f l V 6/
Type of Building:
Dwelling No.of Bedrooms _:5� Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
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(Answ r when applicable) 2r"_gZo// a =S"DO 6'0/L.i_-,ali awAZ,h/s 5
Gr/iTLi y
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 by this.Bo f Hea th.
Signed t, Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. /Ls � Fee
r Entered in computer:
;t+ THE COMMONWEALTH OF MASSACHUSETTS
- Yes ,.
"PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE., MASSACHUSETTS
application for Bizpo$al &p$tem Co.nztrurtion Permit
Application for a Permit to Construct( . )Repair(grade( )Abandon(< ) ,O Complete System El Individual Components
3r
Location Address or Lot No. C/E /voh� hwsy9 U/ Owner's Name,Address and Tel.No.
'g
Assessor's Map/Parcel
/7/- 37
Installer's Name,Address,and Tel.No. 502'y�✓�'y7�� Designer's r4ame,Add s and Tel.No. 5`0�' ��%f'�%23
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other.Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
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(Answ r when applicable) rl��oll I
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 by thisBoard of Health.
Signed ` -414-- ff� �?.1�� nf-7 _ Date /
Application Approved by ,��, /ij _ U�yA. f�i�/� �' t `�-\ Date
Application Disapproved foi the following reasons
Permit No. r Date Issued ..--'2316H
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance µ
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( C-)Upgraded( )
Abandoned( )by /1),
at has been construct d in accordance
with the pro}'�sions of Title 5 and the for Disposal System Construction Permit No,. �U[)�I a dated <57 3 t/
Installer ✓osrlal ,/2191c1`vvS Designer
The issuance of-this permit shall not be construed as a guarantee that the syste"'Nw``ill function as d igned.
Date �hq//lIL/ Inspector I taJ,1�ti, 1 -
V
/ `----------------------Fee----
NO. G-� ✓(� •�'
r` THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Miopooal *potem Construction Permit
Permission is hereby granted to Construct( )Repair(4--)-Upgrade( )Abandon( )
System located at
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:Cons e- 'To PP Y n mus be co pleted within three years of the date of thi erntit.
Date: �� Approved b �` /
� /
TOWN OF BARNSTABLE
LOCATION °�y8 1'�d ���'`� � SEWAGE # '�✓�' 3
VII.LAG ASSESSOR'S /MAP &LOT '0 37
INSTALLER'S NAME&PHONE NO.i
SEPTIC TANK CAPACITY ii �
LEACHING FACILITY: -(ryp�)
2`5-42� ra ��,r�irr, -� size)
NO. OF BEDROOMS 3
BUILDER OR OWNER
PERNSITDATE: S l3 Dy COMPLIANCE DATE: ,-
i Separation Distance Between the:
Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching*Facility(If any wetlands exist Feet
within 300 feet of leaching facili
II Furnished by
�t/atP y OeI IM%
Bic c
w
Town of Barnstable
�OFIME ram,O Regulatory Services
Thomas F. Geiler,Director
* BARNSTABLE,
MASS. Public Health Division
1639• ♦0
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: `> Z , o
Designer: /a,_Ij Installer: e S tc
Address: Address:
r�2b6 �
On � ECG was issued a permit to install a
(date) Q ' t (installer)
septic system at /`����'f �A�''� -I)r based on a design drawn by
II (address)
G�J ,
�'��� dated -7 o
(designer)
V I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State & Local Regulations. Plan revision or
certified.as-built by designer to follow.
(Installer's Signature) •
SPOMRD
Z"4 Z,4 r,/u #20X3
N
Q
(Designer's Sign a (Affix D I ere)
s`r�ONAL(�e1
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DI ° CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
f TOWN OF�ARNSTABLE
0 t D/'.
SEWAGE #
LOCA "bN ie
VILLA"GE CeH rem t 3b ASSESSOR'S MAP&LOT
INSTAL. ER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY J CV/ 0 n
LEA,CfIING FACILITY: (type)
w j�e/S (size) SOU s
NO.OFBEDROOMS
BUILDER OR OWNER
PERWrDATE: COMPLIANCE DATE;
Separation Distance Between the:
Maximum Adjusted,Groundwater Table to the Bottotn of Leaching Facility ---_Feet
Private Water Supply Well and Leaching Facility (if any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
,Furnished by. - — ---
aGG''�
Q rLl- qS .
for
A ,� -�7 '
TOWN OF BARNSTABLE
LOCATION ✓Vote D�• .,._.�.._., SEwAc;E #
VUTAGE!2✓t r V.I e ASSE-SSORI l &LOT
SHMC, "TANK C:A1)ACZTX
I/ G PACILITY: (type) c-4420144,:S » �. ._ (size)a—500 S
N0,0P BEDROOMS _-3
,LULDP,R OR_a
Separation D7istanu;Betweep t6c:
MAXirau �ijttstt d Utaui�tlW,tter.���lt;t��tltn l c�tt ai x achirt . "trt;ility �,�.».. �.w� ee ¢
Pri'vato Water Supply Well and Leaching PoWity (If my walls exist
On site or witbia 200 feet of leaching facility) ..�. w•��.. � �.� ret
Scigo of Wetland turd Leaching facility(if any wetlands exist
within 301)feet leacwttg.laciti y) �- _ eet
Purtuished by,
i
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(3�C- 7'
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COMMONWEALTH OF MASSACHUSETTS
Z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
FAILED MAP _ n �
INSPECTION PARCEL � �3
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 248 Nottingham Drive
Centerville MA 02632
Owner's Name: Beverly Lemoine RECEIVED
Owner's Address: Same
Date of inspection: April 30,2004 MAY 13 2004
Name of Inspector: PATRiCK M. O'CONNELL TOWN OF BAR
ABLE HEALTH DEPEPTT..
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
CERTIFICATION STATEMENT
1 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 m 11111111181
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a` HOFi� O�
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: •••..•••••..
e
_— Passes s : • TRI ••��
Conditionally Passes ;
Needs Further Evaluation by the Local Approving Authority 0f
XX_Fails =
Inspector's Signaturj Date: 4/30/04 �'' S�Q�,�QQ``,,�`
_ ii.��ratra�t11e����
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.
Notes and Comments: Leaching pit full to top of structure.
****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.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 248 Nottingham Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes, no or not determined(Y,N,ND) in the__for the following statements. If"not detennined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 248 Nottingham Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
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.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I 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 coliforrn
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 248 Nottingham Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
— _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_.X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet fi•om a private water
supply well with no acceptable water quality analysis. IThis system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
_Yes_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 If 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.
Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 248 Nottingham Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ __ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks
_X_ _ Has the system received normal flows in the previous two week period
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection
_X_ — Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ __ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out'?
_X_ __ Were all system components,excluding the SAS, located on site?
_X _ 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 ?
_X _ 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:
Yes no
_X_ ___ Existing information. For example,a plan at the Board of Health.
_X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 248 Nottingham Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 4
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2002—38,000 gal.2003—62,000 gal.= 137 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Last pumped August-September 2003
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X Septic tank, distribution box,soil absorption system
_Single cesspool
_ Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous.inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 248 Nottingham, Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
BUILDING SEWER: X (locate on site plan)
Depth below grade: V
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance fi-om private water supply well or suction line: 45'
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: X (locate on site plan)
Depth below grade: 2"
Material of construction:—X--concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 8.5' long x 5.2' wide—1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: trace
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Tees intact and clear, liquid level at bottom of outlet pipe
GREASE TRAP: No (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 248 Nottingham Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
TIGHT or HOLDING TANK: No (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: _
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: No (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: -
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n
Page 9 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 248 Nottingham Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: Two 6x6 pits in series.
leaching chambers, number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields, number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc,): Overflow pit full to tOD row of holes
CESSPOOLS: No (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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
Page 10 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 248 Nottingham Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
SKETCH OF SEWAGE DISPOSAL SXSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Nottingham Drive
I i
d I
1 �
�Q� I MIS
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j y qb
in
Page 11 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 248 Nottingham Drive,Centerville
Owner: Beverly Lemoine
Date of Inspection: April 30,2004
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
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)
_X__Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water less than el.30 and topo map shows property above el.40.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
A." d DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP� V
PARCEL : —
LOT l$ -
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION 3�.
Property Address: 5,qu CIN 0 C', 3�53
Q_ P�ke.rwlle MCI J
Owner's Name: :(2 m m v P,f y Z RECEIVED
Owner's Address:
Date of Inspection: �3 I.9, APR 0 2 2002
Name of Inspector: (please print) '� n)n �h(`ter ICI TOWN OF BARNSTABLE
Company Name: �aj)_,_5�jt`5�'(i+tom �5 2P�1� j nS Pect�o� HEALTH DEPT.
Mailing Address: P.O. Bc X al)
lc
Telephone Number; _�o -&n
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant/Passes
to Section 15:340 of Title 5(310 CMR 15.000). The system:
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: �� � ��. Date: 3/Lz/o
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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM=NOT Fi.OR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM,
PART A
CERTIFICATION (continued)
Property Address: Qn:tt iCIQ 4UW Di" —
d �pflQ
Owner: %n f »_
Date of Inspectio : j�k lag
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ZI 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound;not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
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(sJ amxeplaced
obstruction is removed
distributioff box is Ieveled or.replaced.
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
I
r
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
c� SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2U (1otti0 CA .ncim Ds-
P.2 n_+mac'U i 11 f(1 C.,
Owner: -rcj m m 'L
Date of Inspectio : 3 Ip�
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL, INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL--SYSTEM INSPECTION FORM
PART.A.
CERTIFICATION(continued)
Property Address:- `),H 1�' 'n c:t 1% ham Dr-,
Owner:
Date of Inspection: lag('0
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
7 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
Z Rsquid depth in cesspool is less than 6"below invert or available volume is less than''/s day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
Xof times pumped
y 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
ater supply.
y portion of a cesspool or privy is within a Zone I of a:public well.
— Any portion of a cesspool or privy is within 50 feet of a private water supply well.
L 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 conform bacteria and volatile organic componnds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is.equal:.to or less than.5 ppm,provided that no other.failure criteria
are triggered.A copy of the analysis must be attached to this form.] .
f10 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design slow of 10,000 gpd to 15,000
gpd• i
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems.in.addition to the criteria above)
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 H 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.
I
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2 i,)cd 0GT+1"1C4 hcA,M Of%
Le_D-ie-cViI(-e, Ima
Owner:
Date of Inspection. 3 job `
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
YNo •
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?
YHave
Has the system received normal flows in the previous two week period?
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 th affles 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?
r
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a-plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
I�
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Z 1^15 Coit 1`[yA 11<:4 M. t.,
Owner: j -IL 2t�c`U i II
Date of Inspection: 3 jdo,Ic a
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):�_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: _
Does residence have a garbage grinder(yes or no): 11Q
Is laundry on a separate sewage system(yes or no):-no[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):�O
Water meter readings,if available(last 2 years usage(gpd)): 2_7 Qd
Sump pump(yes or no):J]Q .
Last date of occupancy:LC.L(j p I o
COMMERCIAL/INDUSTRIAL
Type of establishment: .
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date.of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Home &-)n e r
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined? Durnp Slip
Reason for pumping:-mil C,i n r W OC -p_
TYP F SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight.tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
r"r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1HCK
Lent-ecilil�M-q
Owner b; ,
Date of Inspectio : 3_Ja )o
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: _(locate on site plan)
Depth below grade:_
Material of construction: oncrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:_l oo o Gallons
Sludge depth: i C/�
Distance from top of sludge to bottom of outlet tee or baffle: ]h �\ _
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: j G 0-
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Le-nfZr 00 C Ian)j t.J ooh
GREASE TRAP:_(locate on site plan)
Depth below grade:_
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued)
Property Address: Dntii� ,cn �^
Ileilfl� .
Owner:
Q 2—
Date of Inspection:
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: JL14f no rki� nr
Owner:
Date of Inspection: 1,0a joQ,
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Teaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
k-Ja� h I� �c111 P,'� Wri,Cp Dr��
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
0
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �,Wr{ I IOTt�11A lft1 fit,
Owner: "fa m m
'Date of Inspection: 1/p.1 Jp1
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
i
3
i
` r
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
(t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: a bl!d n D tk i nG'hGrn V ,
GLLT�U
Owner: 'fom Z,, f,(`�Z.
Date of Inspection: 3 19.jnj_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water')4 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
/hecked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
]1
TOWN OF BARNSTABLE �\
L N `I N� f)y SEWAGE #kti ltc,hcaga (,L�. r�...�
VILLAGE t>?i+,P-C t -e_ ASSESSOR'S MAP & LOT .
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1CX-)O Qc 116(1S
LEACHING FACILITY: (type) eALh P i tS (size) (ok
NO.OF BEDROOMS 3
BUILDER OR OWNER:rQ LD V.it Ct,Z
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching-facility) Feet
Furnished by
' �
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No......---------'-------O CG �� p�? �. Fss.. .�..........
1 THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
!!7 ............O F................ ��✓J ��-G.------------------------
Appliration for UiopooFal Works Tonotxnstion thrutit
Application is hereby made for a Permit to Construct .�o or Repair ( ) an Individual Sewage Disposal
System t• C _Tr,tiy�,��.
....... .. __......_....� . ..L�...................... ........................... ...........
Location-Address or Lot No.
�1r p""'.p^ y4T !
Owner
a Sal f i.[ Address .
.. ............ — ....__............_.
Installer Address
Type of Building Size Lot_-_`7t. I.Sq. feet
V Dwelling—No. of Bedrooms--------.. _-_-_Expansion Attic ( ) Garbage Grinder ( )
U —
Other—Type of Building ............................ No. of persons__ ----_-__-___-___-__.__- Showers ( ) Cafeteria ( )
Q' Other fixtures ..................................
W Design Flow...................5.__�...._.___..gallons per person per day. Total daily flow..............1.3'_:0..............gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----_-------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box {,,,) Dosing tank (
'~ Percolation Test Results Performed by.............................Glr1 ___ Date...______....._�;/Z� .
Test Pit No. 1 _g._minutes per inch Depth of Test Pit....f_, _._ Iyepth to ground water...... _.._.
f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�-
x r
O Description of Soil....---•----------••---•----•-------------65-..-•--••--L
x ----
U -----------------------------•---.........................-----------��-% c�---- C - -----------� = ��=' ------
W ------•--•---------------------••--------------------- --� %
U Nature of Repairs or Alterations—Answei-t plicable............................................................ ................................
-•----------------------------------------------------------------------------------------------------••---•....--•-------•-•---••------------------•------•----•----------•-----•------......•--.-•.---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT E 5 of the State Sanitary Code—The undersigned further a ees not to place the system in
operation until a Certificate of Compliance has been issued by the board health. e i
Signed--------- ----------- ----------------••--•••--- D7te
Application Approved BY :_.. --------------------------------- ------9. `-�- ................
Date
Application Disapproved for the following reasons-----------------------•--------•------------------------------•---------.......................................
......................................._.................................................................................................................................................................
Date
Permit No------v.-J.!01-------•------------------ Issued.-------j- -3 d q
Date
1
No---------------------- Fes$.;.: 1C.'..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
w- OF............... .f ..�1 1 t ..........................
Allp iration for Rspoottl Works Towitrurtion ramit
Application is hereby made for a Permit to Construct�k✓�) or Repair ( ) an Individual Sewage Disposal
System at: �`1 ,�'- %
-• ..... _ ....... - -- ...... - 1 --
Location-Address or Lot No.
......................_.....---- _f '� ,� >< ........_ .. ........�r-0.--•--..�..........•-------
.-------•-. ---•--.....__.. w r
Owner Address
,�r� r a"' /
.............................. '°- f=,( 1'./'_-.....- ........ ....................................... - 9�.:""_._.......--•---•--•--......----••---
Installer Address
QType of Building Size Lot_. 74__r 7..Sq. feet
Dwelling—No. of Bedrooms........ 7?..............................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons............................ ;Showers ( ) — Cafeteria ( )
QI Other fixtures ------------------------•••--•----••------•--.
d ------------- ------------------------------------•-----------•------.----
W Design Flow..................... ..............gallons per person per day. Total daily flow__..._.....Ii.3..LD..............
WSeptic Tank—Liquid:capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----------_------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ) Dosing tank
Percolation Test Results Performed by.................. 4 � ._:_..y''_.._.._....... Date...........f........ .............
Test Pit No. f�...minutes per inch Depth of Test Pit..... ._._ 'epth to ground water......... .....
44 Test Pit No. 2................minutes per inch Depth of Test Pit---- .............. Depth to ground water-_--- .._:. _.
..................................•-------•--
O Description of Soil......................................... � �� ---------•�=--(). t`7� - ...............................3 ° ` ................................._.
x ----•----•------•-....••-•••••-•------••-•-- -----•-----•..... r (00 . .ox.."r . s .�; t
V
G
x �.
UNature 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 TITI.I; 5 of the State Sanitary Code—The undersigned further a reel not to place the system in
operation until a Certificate of Compliance has been issued by the boar of health
Signed.........% -` -----•----•---•-------•
Or
/ Diate.Application Approved By ---�----------•--------------- �-------.-----•-----------------•--- ....... �'��� .- •-----------
Date
Application Disapproved for the following reasons-------------------------------------•------------------•------------------------•---------...--•-•-•----••••-_..
...............................•-•••--•-- ►
...••. ._...-•-•------•••--•---•-••-•-•-----••._.....--•-•-----•---•••-------•----••------•-------- --------- �--------•-••-------•-•-•---
Date
Permit No-------- ---------�- Issued ✓ ..........................
Date .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
of�!'",K^ O F................. L(S/ /�•!'
.... .................. .........:..............:........:............................
C9rdifiratr of Tontplitturr
THIS IS TO CERTIFY, That the Individual Sew Disposal System constructed (, or Repaired ( )
.v
Installer _
at............................... .� ............................ -- -----•---�� - f �f"G , =
* ........................
has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No... "'•_l Q.(o....... dated-----)__2RANTEE
?41 -----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GU THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................. Inspector.....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1..... �^� ...........OF..................... .- /�d. /.tee--•••-.......... O L�
...... ..... .. . .
NO......................... Disposal FEE........................
�otto�r:�r#ion Trutt
f r
Permission is hereby granted................................... ��'.�--f-----�--------=�--.:Q.:--..................................................
to Construct or�Repair (. ) an Ind•vidual Sew ge Disposal S tem /� �,
at No. ... .._.. °�f i '¢'7 't *,�t
't-----------------..........
Street
(�v /
as shown on the application for Disposal Works Construction Permit Na____ _____________ Dated____.__��2 ��____...___._..
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
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xa .CIVIL LAND . CONFORMS T0. THE ZONING LAWS'.fi , 'ENG INEER SURVEYOR OR,8Y� A.,,^
OF BARNSTABL , MASS
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^ v 'IRCIVIL ' LAND . - ..
F= ; ENGINEER SURVEYOR pR,BYs A -A -Al, CONFORMS. 'TO THE ZONING -LAWS
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G2EE>V/,i i<! 2.
E / E'E /NQ i CERTIFY THAT THE Fo yn/ns1 Tw
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991STEREO REGISTERED �gUT6
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,F ;� .,q.�, CONFORMS TO THE ZONING LAWS
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HYANRIS, MASS.
SNEET ,,L,OF,,,._,,. A E EG. LAND SURVEYOR
LO. ION �/ SEWAGE PERMIT . NO.
VI Lt. AGE
Coav-,L
� INSTA LLER'S NAME a ADDRESS
VVI�(5 f c)rn5 yil
B U I L D E``R OR OWNER
DATE PERMIT ISSUED ll
DATE COMPLIANCE ISSUED
2.q Z�
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No._..9 :. '. Fps.. '...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...........OF.....1:............ ..................------------------........_..................-----
Appliration for Disposal Works Tnnstrurtiun rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..... . ......... ..... .y .............. -------------------- -� ._.........C
....... ... ..
or
------
or
._......Lo .o - .. ...s ............................... .................................
i °dry I er �(
Installer Address
Tic of Buil g Size Lot.................... .... q.__ ..S feet
Dwelling—No. of Bedrooms...........................................Expansion Attic Crarb p ( ) ge Grinder ( )04 Other—Type of Building ............................ No. of persons------___-_____-._ Showers ( ) Cafeteria ( )
P4 Other fixtures .......---••-•-••-••-••-•.....
W Design Flow............................................gallons per person per day. Total daily flow............._..............................gallons.
WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No.....................Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------------_--- Diameter.____-__-___-__--._. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---------•----......--•••-•-••••••-•••••••-••••...........•.............. Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------------.........-..........................................................................................................
0 Description of Soil............ -----------------------------------------------------------------------------•------------.................................
V .....•-••-•••••-•••••---••••••••-••......--••••-•••••......-•••••• -------••.......••••-•...............•---•--•---•••--•••-•---•-•----•-•-•-•-••-••...-•--•--•-••....••--.._..................
W •-•-••••-•-•----------------•--••••••------•----•--••-••-•----••-....---•--------•----••-•••.........---•--•••. --------
j-
U Nature of Repairs or Alterations—Answer when applicable... ! /---J__.�1�
•••. --------•-----••••-•-•--•••---•••••••••••---••----•-••---••-••--••------••••••..........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a`Certificate of Compliance has been is ued by the board of health.
:.. ............................... ... ..... ..ate .
Application Approved By.._..----- = �1!.•• ... ........................ ... z'...........•-
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------------....•
..................................•-•-------•-----••----------------.......------...............---------- ............................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
FER...5... .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............OF...../.................................................................................
Appliration for Disposal Morks Toustrurtion tirrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Sy$ ,at:
I/ — e_9
................ .......................... .......................... .....................................................
Lo�jaf 7Aj5_r"�� or Lotlo.
.............. ... ................. ............................................
ess
---------------------- ---------
.....C
.... ..................................................................... ........ .. ;�. ..* ..............
Installer Address
Type of B il ii Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
u ,dig,
P4Other fixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid*capacity............gallons Length................ Width.........._..... Diameter................ Depth.._..__.._._....
W
Disposal Trench—No. .................... Width.................... Total Length_._................. Total leaching area....................sq. f t.
Seepage Pit No..................... Diameter.................... Depth below inlet.._................. Total leaching area..................sq. f t.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit___.._............._ Depth to ground water_.-___--__.._........_..
Test Pit No. 2................minutes per inch Depth of Test Pit._._._..........._.. Depth to ground water..__._..................
cr ---------------------------------------------------.......*----------***------------------------------------"...............
0 Description of Soil............ . :=� ed- -----------------------------------------------------------------------....................................................
.................................................................... ... ..............................................................................................................................
U
......................... ................................................................................... ......................... . ......... .........
..............
U Nature of Repairs or Alterations—Answer when applicable-__( 'i, .... ...
.............................................................................................................. .. ....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben is by the board of health.
Signe . ........ PA.9-e,� 47
..........
ate
.... .... ..................... ..... .......... ...................
Application Approved By........... e*
Date
Application Disapproved for the following reasons:.................................................................................................................
.......................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........I............I..................0 F..... ..............
......................................................
...............
TyWrtifiratr of Toutpliatur
THIfl IS,,TV CER TIF Y jhq the Individual S ewag Dip al Sys structi d)(I, R fired
, �4 L 0 r
by----- -------...................... ... .........., r ..
H........................................ ................... g............................
.................... ........... - ------- .. ..... ......................................................at:..... --------------------
------ accordance w Utl the provisions of TIT L� 5 of The ate Sanitary Code as described in the
has been a, F
application for Disposal Works Construction Permit No..-_.. .......... dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... ................................. Inspector./Z'A!�t.....................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR HEALTH
................... .......................0 F.....................................................................................
No......................... FEE........................
Permission is hereby granted
............................................................3............
to Constpmt-,(
' ........................... .....................---------- ........................611:7
or Repair I ivi ua ew P 9—S r,
.2— -------- ----
.................
Street
v-,Zt' Permit
M"
Street
as shown on the application for Dispo' -, corks Construction Permit tNo.--;.... ......... 4)ated..........................................
116ard of Health
ATE ---
... ... IV ...............
...........*---------------- -------- ..
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
l 0:& AT i S E W A C R M I T N0.
VILLAGE _ �� f
INST.A LLER'S NAME i ADDRE S
CRAIG AAEDEIROS.WSQ.,
s
i t
142 §AW2rctjon sfr►�ot
b BUILDER OR OWNER Hycnnis, Maas, 775-0828
OA T E PERMIT ISSUED
DAT E COMPLIANCE ISS,,,UED ��_
i -
�,: Li . .
STAAIVIqfD IVOT 5
l) P15 PLC is fog 7Nt' REMUZ_ OF A aE0PT7c s'Y,67V01
ALL MV AL(AffON PROCEDURE.-, AND MATERIALS HAIL CONFORM TO 310 CMR 15000, THE STATE ENVIRONMENTAL CODE,
TITLE 5, AND THE TOWN OF _15.4r^1: 1b SUBSURFACE DISPOSAL REGULATIONS
3) NO DETERMINA IION HAS BEEN MADE AS To COMPLMA CE OF AVAILABLE PROPERTY INFORMATION WITH RECORDED DEEDS
OR ZONING REGULATIONS.
4) TOWN WATER DOES A OT SERVICE THIS PROPERTY
5) THERE ARE NO EXISTING WELLS WITHIN 200' OF 1 HE r'_,O_ OSED SOIL ABSORPTION SYSTEM
6) ALL COVERS OF SYSTEM COMPONENTS SHALL BE BROUGHT TO WITHIN 6" OF FINISHED GRADE
7) ALL SYSTEM COMPONENTS SH_I,' RLMA ACCESSIBLE FOR INSPECTION. NO STRUCTURES SHALL BE LOCATED DIRECTLY
UPON OR ABOVE THE COMPONENT ACCESS LOCATIONS, WHICH WOULD INTERFERE IIITH THE PERFORMANCE, ACCESS, INSPECTION
\ PUMPING OR REPAIR.
8) NO DRIVEWAY, PARKING OR TURNING AREA, OR OTHER IMPERVIOUS AREA SHALL BE LOCATED ABOVE A SOIL ABSORPTION
SYSTEM, EXCEPT WHEN VENTING HAS BEEN PRO VIDED.
9) SEPTIC TANKS, GREASE TRAPS, DOSING CHAMBERS AND DISTRIBUTION BOXES SHALL BE PLACED ON A 6" STONE BASE
TO ENSURE STABILITY AND PREVENT SETTLING.
ti6 6 �p 10) OUTLET DISTRIBUTION LINES SHALL REMAIN LEVEL FOR A MINIMUM OF THE FIRST TWO FEET OF THEIR LENGTH.
11) ALL SYSTEM COMPONENTS SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10'
OF DRIVEWAYS OR PARKING OR TURNING AREAS, IN WHICH CASE H-20 COMPONENTS SHALL BE USED.
1,2) ALL BUILDING SEWER LINES SHALL HAVE AN INNER DIAMETER OF 4" AND SHALL BE CAST-IRON OR SCHEDULE 40 PVC.
Exist �� � 13) THE DEPTH OF THE TOP OF ALL SYSTEM COMPONENTS "SHALL NOT EXCEED 36 UNLESS VENTING HAS BEEN PRO VIDED.
.�056 ��� Gas 14) W THE AREAS OF E'XCA NATION, EXISTING GRADE'S SHALL BE REESTABLISHED UNLESS NOTED AS PROPOSED CONTOURS.
15) IF SOILS ARE ENCOUNTERED DURING THE EXCA VATION OF THE SOIL ABSORPTION SYSTEM, THAT DIFFER NOTABLY FROM
` r. ,� . 1 HE DEEP OBSERVATION HOLE LOG, CONTACT THE ENGWEER BEFORE PROCEEDING.
PROPOSED LEACHING FACILITYProposed D— ox `�� �, ��' 16) CONTRACTOR TO VERIFY LOCATION OF ALL UNDERGROUND UTILITIES.
Trio„ Cone ,500 Gal Chambers (A �°
(24 x 4—8 x 8 —6 ) or similar o 01%0
With 4 ' stone around ►�.oiD �� \ qqq
Total Dim. = 25 x 12. 6 EVst DEEP OBSERVATION
DESIGN DA TA
Water HOLE LOG
Existing z fi o� Test Hole #1
( �`1 .::::`:; �. s �'� / 2 (EL = 9? v f)
Test Pit \� Number of Bedrooms: J sou sou u
v ` (�ii) (ft) Horison Texture 1�Co�,
�° i a p� rt� Garbage Grinder: N0 (USDA)
Existing .� '�s '0 / \� Design Flow. 3�0 _/2 `tbo ioYR�� z
1,000 Gal S`
� S—Tank �'� G (110 Gal/BR/Dap x Number of BR) /2 ' Z `�`� 3 z5 wo S -7'5 %f R 514,
Septic Tank: /.�00 6-( 32 -/o Fs' %'�.o C , &'( 10YR611,
Existing Pit to be \ o y (Minimum = Design Flow x 200%) C�,c��iftr pumped/filled and removed ��'�.`� ')
as required. Leaching Area:
�� '� ��r `7 FJ Deep Obs Hois Date:
So
S id a wa 11: u Evaluator. i
Eo S'rJNc
Witnessed� Fero Rate: l
(2 Sidewalls x z�__Ft x n) + /SU Sail Survey De.oripttoa�" GAAv R
�s
3 1 S Geologic Xaterial: OUTWASH
(2 Endwalls X 12' FT x Z Ft) Depth to Standing Water. NA
Depth to peeping Water. NA
Bottom: Depth to Hottling(color): NA
Est Seasonal High GV- NA
Z - Ft x I __
Z Ft) USGS Observation Weit NA
OQ Date of Last Massumment: NA
Long Term Acceptance Rate (LTAR): 0. 74 Comment.` 5"/°
Leaching Area Design Capacity: 3 `f q
(5idewall Area + Bottom Area) x LTAR 6,P
,'A
ot� W! Sl l/
►A
FF
TYJP OF MAL
FOUNDATION
EL a O •&v Raise covers to within 6" of
S finish grade install risers as needed
N.G. GROUND SURFACE EL_� �',O __
�' D �, PROJECT LOCATION -2-`i 3 NA� M
GROUND SURFACE ELF_' � .
" MIN 1NsrpI Q�u �T oto c�ti'r{U,
TC- OUTLET PIPE LEVEL r -
FIRST TWO FEET
Z '7 N VENT REQUIRED ASSESSORS MAP l - — LOT
r, 2"MI1V-3"MAX TOP EL
-1_I 100 MIN 2' LAYER DOUBLE WASHED T
10" " Box iia'- liz' STONE �b �PQ APPLICANT.
INVERT EL a 14 01 G'O -a - - - - - - - - - - - - Z`/ o � e vac r L f �o nrt.
c1 W5TALL ZABEL INVERT EL 3 • - _ _ _ _ _ - r` ' �l.��� EFFECTIVE
a. FILTER d srvxa aasN INVERT EL `n C.0 �4`g tt n
c c
INVERT EL GAS BAFFLE v 4t C f n r v 1 P r 02 b>L
P ro ed c1i{,Z /W� � C'�q�, rr
INVERT EL P� r 3/4•- 1 1/2' DOUBLE
6" STONE BASE D - Box WVERT EL w/ y S/ dNLf /q,�p,� t WASHED STONE
I PREPARED BY
ems, (TYPica1J b.
C X If,
`1 I BOTTOM EL T A & M Land Services
1 + l,u o o Gal Septic Tank(Typical) ( �
y ! Drive
EL �s•� 15 Sunset
BOTTOM OF TEST HOLE e. / � South Yarmouth, MA 02664
(508) 394-2723
AM SCALE ,, / P 1= Zo r , DATE.- �/7 a
�v C(1S MAP
REV.
D Tviro- 40- 313 f3 .FREE?- 1 OF