HomeMy WebLinkAbout0452 OLD CRAIGVILLE ROAD - Health �^.
Odd aigville Road
Centerville P
247 029
I
0 2 y�
s
UPC 12543
No. 53LOR �fibsrco
HASTINGS, MN
i
Commonwealth of Massachusetts � " O°29
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
2 OV C1,a,,,,A -PI,
Property Address 64Fa t
Owner Owner' Name "
information is
required for everyG✓ ®Z j 6 �O{jam
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any-1,i
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not /r
use the return
key. Name of inspector
V)
le�l Co any Name
/gZ � �
Company Address
City/Town State Zip Code
—L/ I%t :53<
Telephone Number License Number
B. Certification
I certify that I h e personally inspected the sewage disposal system at this address and that the
infor/perform
rted below is true, accurate and complete as of the time of the inspection.The inspection
wasased on my training and experience in the proper function and maintenance of on site
sewl systems. I am a DEP approved system inspector pursuant to Section 15.340 of
TitleR 15.000).The system:
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10, eL,= Date
' Z� �f
Ins is Sign
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP.The original should be sent to the system owner and copies sent to the
buyer, if applicable,and the approving authority.
'*This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments
Y?-dj/',',17e2A4Aj4
Property Address
"e 4:�Za —
Owner Owner' ame
information is 1 Z/ 6-5D
required for every �'V
page. Cityl I own 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) Syste Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins.doc-rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System F Not for Voluntary Assessments
p
Property Address
706
Owner Owners ame
information is OZ(30 T 4' i--S'— l
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑I ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect'public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments
� ? ea �'
.GfA/lA/1 �
Property Address
Owner Owner's me p information is "�w J Add
required for every
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50.feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ®/ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ 1-4 Liquid depth in cesspool is less than 6" below invert or available volume is less
/ than Y2 day flow
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Dis osal System F rm-Not for Voluntary Assessments
Property Address
e
Owner OwneM&yt
,,�,g
information is !/l�C� 9430 /4-mei .,5 g
required for every
page. CityrroVn State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 IV), Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ❑ �14
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"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage QDisposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner' am
information is ?6 P 01aa �IS
required for every �dd'
page. City own 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
❑ L/ 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?
[2 ❑ 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?
[D/ ❑ Was the site inspected for signs of break out?
E ❑ Were all system components, excluding the SAS, located on site?
L/ ❑ 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(6)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
I '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
Property Address
Owner Owner's a /information is
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes L1/ No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes P No
information in this report.)
Laundry system inspected? /►��❑ Yes ❑ No
Seasonal use? ❑ Yes VNo
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
4: Title 5 Official Inspection Form
Subsurface Sewage Disposal System F m-Not for Voluntary Assessments
Z .
Property Address
Owner Owne Na
information is
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
AV,
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: ' e
Type of System:
[� Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
I '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal Syst m Form -Not for Voluntary Assessments
3-Z 00
Property Address
✓�L
Owner Owner's me.
information is ,�j�� 0
required for every
OM44
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade: feet
Mater' I of construction:
cast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Materi of construction:
ncrete ❑ 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:
Sludge depth:
t5ins.doc•rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments
Property Address
Owner Owner's e information isj'j�!�d
required for every
page. City/Towntate Zip Ce CFafe of Inspe6on
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
2rl
Scum thickness
Distance from top of scum to top of outlet tee or baffle 15'
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle_ condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
l5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Syste F rm-Nol for Voluntary Assessments
y
Property Address, G
Owner owners e
information is
required for 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.):
44 gW �o�S AAA- P Nwa—
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Dispos stem Form-Not for Voluntary Assessments
s�
Property Address
N C
Owner Owners
information is
required for every
page. City/ own State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
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.):
2
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System For of for Voluntary Assessments
Property Address
vce:&A
Owner owner a
information is oL/�y ��required for every O /�
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching 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.):
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage isposal System F rm -Not for Voluntary Assessments
". OU
.�
y�
Property Address G
Owner Owner's N
information is
required for every
page. Gtyfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
a
Owner Owner's=N �ne�
information is �Ji,
required for every Lb
page. cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
7ha
public water supply enters the building. Check one of the boxes below:
nd-sketch in the area below
❑ drawing attached separately
Z.
v o d
Dig.
Li—Loc
�y Z- 10
C-Z �
C 3V
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
IBM Title 5 Official Inspection Form
Subsurface Sewage Disposal Syste orm -Not for Voluntary Assessments
LI-5-z 0a
Property Address
G
Owner Owners me
information is 0 2 z+ ?
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
heck Slope[C
Surface water
[Check cellar
❑ Shallow wells
Estimated depth to high ground water: f
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
C
Owner Ownerj NarAe
information is ��—
required for every ow
ja,el
page. City n State Zip Code Date of Inspection
E. Report Completeness Checklist
inspection Summary:A, B, C, D, or E checked
Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
ID/System Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
7
•
Town of Barnstable Barn
Regulatory
Services Department """mfta'ft
mma
"BM
Public Health Division I
200 Main Street, Hyannis MA 02601 200�
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7014 1200 0001 0358 3896
April 30, 2015
James Wright
3434 S Mesquite Ridge
Bisbee,AZ 85603
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
• The septic system located at 452 Old Craigville Road, Centerville,MA, was last
inspected on 3/26/2015, by Shawn Mcelroy, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system" Fails" under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Leaching pit with high liquid level <12" below pit(per Town Code 360-9.1)
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S. CHO
Agent of the Board of Health
•
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\452 Old Craigville Rd Cent Apr2015.doc
Town of Barnstable
+ BARN9TABLE, �
,� Regulatory Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-8624644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/7/15
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
Leaching pit with high liquid level, <12"below pit (per Town Code §360-9.1)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
7 ,
Commonwealth of Massachusetts U
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes Fails
❑ Needs Further Evaluation by the Local Approving Authority
3-26-15
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 con s of-use
at that time. This inspection does not address how the system will perform in the futur under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface SewageFED)ispo.sa)tem ge 1 of 17
T
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
pc°�M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
,m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
B. Certification (coat_)_
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water.
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I _
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c�M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
® ❑ 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
El ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont..).
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50-feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
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
El ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information_
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report-j
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 3-2015Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection F rm
0
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville. MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)_
Approximate age of all components, date installed (if known) and source of information:
1960's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC Orangeburg
® 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: 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:
Sludge depth:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
l�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
D. System. Information (cont-)_
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑- No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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 ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
�I
f
Commonwealth of Massachusetts
m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)_
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 1-6x8
❑ 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 cesspool had stain lines above the inlet invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 2-Inline
Depth—top of liquid to inlet invert N/A Empty
Depth of solids layer N/A Empty
Depth of scum layer N/A Empty
Dimensions of cesspool 5x5
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
The first cesspool has blocks that are unstable and shifting. The second cesspool has stain lines
above the inlet invert.
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)_
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
) '�.
a
r
C_
4 y
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
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 USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
' Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 452 Old Craigville Rd
Property Address
James Wright
Owner Owner's Name
information is required for every Centerville MA 02632 3-26-15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist-
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
NO. ®< Fee
THE COMMONWEALTIi OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for h�)6upgrade
oral *pstem Construction Permit '
Application for a Permit to Construct Re air Abandonpp ( ) p ( ) ( ) El Complete System El Individual Components
µ9.a.
Location Address or Lot No. yT Z OLD C A) Owner's Name,Address,and Tel.No. �
.., L.4Cf/R9ewCE- l21�CG�e
Assessor's Map/Parcel �y��2� �L 7 la r ea
In Caller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Gnn�S �'Awb�vic.�(
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons 'L-- Showers( ) Cafeteria( )
Other Fixtures 7
Design Flow(min.required) ,J-30 gpd Design flow provided ..7 5b gpd
Plan Date Number of sheets Revision Date
Title i til /'
Size of Septic Tank 15 0 a G A(1"� S.T, Type of S.A.S. C�4G N/4 F4
Description of Soil N $ r6+
Nature of Repairs or Alterations YK
er when applicable) -J-AIS1_4 L
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 Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Bo d of a y
Sign Date / 2 7
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
Fee �b V P a�- ..-
THE COMMONWEALTh OF MASSACHUSETTS Entered in computer: Y,�'-
- - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS I
Rpplitation for Mis ostd *pstem Construction permit
Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components ~'
Location Address or Lot No. 4TZ pLD C A��(//��� '�j . Owner's Name,Address,and Tel_.-N/o.f
r�1
OVI
Assessor's Map/Parcel 2 C0 02,9 C,LJ' /J!`�� L46V1Cr14'C r- PC cov 4/j fi . �
Pa
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
''VIA D1 ,QY/b
�v' lvb�iL�v
Type of Building: f
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building -C L C_i tii Fi No.of Persons 2— Showers( ) !Cafeteria
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title nit
Size of Septic Tank 15 U 0 G A C l-u"V S,r, Type of S.N.S.
Description of Soil q' S-T AA_
s �
Nature of Repairs or Alterations(Answer when applicable) _� lWS i)(C 4-
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 55 OTTh Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Bodrd of ea
S ign Date 12-7
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued 1 5
--------------------- ----------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance i
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
at 4 52— 0/cO�po`,0 \1 lk e has been constructed in accordance
with the provisions of Title 5 and the for
isposal System Construction Permit No—'I 3 J`96 dated
Installer ���t--\X2 Designer �e\gam
#bedrooms Approved desi ow J: 330 gpd
r
The issuance of this permit shall not be construed as a guarantee that the system wil4unc on,as design
Date �1) ' / (' Inspector
I �
----- ----------------------------------------------- ------
No. -C �C %� Fee /Q v
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
30isposal *pst Construrtion Vermit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at �7 2 OL-0 C 6A /-b/ 'tip Cc w-r,?e li
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction imist bbe`com. leted within three years of the date of this p rmit.
Date J 7 t�� Approved by
f '
Town of Barnstable
oFt ro�� Regulatory Services
o�
Richard V. Scali,Interim Director
• snWsTnai.e, +
.W: ��g Public Health Division
Arsn 39. Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: ./oot Sewage Permit#2DL5-2- ®Assessor's Map\Parcel2 27-t-sl
Designer: V),1> NJw¢,J Installer:
Address: /CN Address: C5 4,L4C)uo 1�
q4�6464f6 py�q��G �
On 92Zd� __964Q�7 tWLL& was issued a permit to install a
(d e) (installer)
septic system at � �[� �4IWIQ9'��� based on a design drawn by
(address)
_6.. Mobovi dated -1 OD �I
(designer)
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. Strip out (if required) was inspected and the soils
were found satisfactory.
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. Strip out(if required) was inspected and the soils
were found satisfactory.
I certify that a system referenced above was construc_;�- -Tliance with the terms
Of the ap oval letters (if applicable) 4���t1 OFil4gs���4
o�sA DAVIDC:.-)
c�
ti •
MASON
(Installer's Signature) No.1066 o Gam,
STE��
's'tN1lARF"�
Designer's Signature) (Affix Designer S amp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. 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:\Septic\Designer Certification Form Rev 8-14-13.doc
rc TOWN OF BARNSTABLE n
LOCATION �� OLIO C RA 16 U ILLe 'RQ SEWAGE#
VILLAGE W T_2 n IALL —ASSESSOR'S MAP&PARMEL;y 7 PVees
INSTALLER'S NAME&PHONE NO.'DP n n►5 6 31 5S J9
SEPTIC TANK CAPACITY ® (2/4L
LEACHING FACILITY:(type) 1-to(,9)W6 G "6'eCS(size) ��� �x ,�.1
NO.OF BEDROOMS rr 3
OWNER " (.
PERMIT DATE: COMPLIANCE DATE: 3,e PT, ,30 IS'
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 y
site or within 200 feet of leaching facility) 1" Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) $114 Feet
FURNISHED BY 1 h �� ILL.
c7�►� GRAIC VILE. 2
j�wv G� S.i
CAL LC
House,
3 z oid C rev r lQ
A r� Zo d
191
a � 2 ]c
, ag
C 3 313
TOVM OF�A'�NSTt�a�31a�
�.ocpL�'t01+i rGz SEWAGE ._
>VILL.AGL Ce.�
n sm : rt�s>vA E m-PHOl r� o. `
is`ITdCxAl� (:A1PACITY
SS
LACIItNG +ACII I'I°Y`.(tea) (site)
+ J r
-OFB�r -,.. .... pin p.� . . .. ..:
NJ�l DER--09
7777--.
PirFtMI'F']�I�'X'lw
Cf�1VAbCall�i�It r11�'1i'17,. --
Sep,Arntio¢t l��%t�rara Iiatv�eet�t17o. ,
MEiXit In rti A'4jWWd GjoondmWecrrA6le.to tltie i3ommol�C;achtn k?�ic;�lit�
Feet
I�civUfi�; n�i Vfc 1 �cl Y,eua64i � ?�taality (Lf�ny iv�;14s cxlst
An—
If,seta oe ev3t1►n�40 feet uk iatechio �sioiut}�)
F?ci,i:crfi�pl t9and and lLeac un IFacxlity al'y a llall d�,exist ,be
�t�i#i;�iti;�Q�1 feeg�l•lencli►ng j `' �---�---�-
6���
�'
��
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�' w
Q G ..
,.
TOWN OF BARNSTAppBLE \
Ltn 'ION ` 5-a o 1 ClAj v, SEWAGE #
VII L GB Cl1s+Tt/v►)t� ASSESSOR'S MAP & LOT gLq 7
INSTALLER'S NAME&PHONE NO. t
SEPTIC TANK CAPACITY Ca SSPOO I
LEACHING FACILITY: (type) WV 00) (size)
NO. OF BEDROOMS 3
BUILDER OR OWNER A1/i
PERMITDATE: COMPLIANCE D TE:
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 f leaching fa ility) —�— 1 Feet
y Furnished b
r
rOoM
a
a 130 ay
TOWN OF BARNSTABLE
AT 0
LOCATION JrY '�17 Vi J SEWAGE #
VILILA,GE ASSESSOR'S MAP Sz LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 16-D6 ize
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OW:0WR ! Ii t- S 1A
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
^ Y ,
_ �.
x�f
1
�� � �
� E O
q� �j i�
����Gr f
a�
�_ -._ —_
Town of Barnstable P# 2
d(.•tlla .
' Departilnent of Regulatory Services
{ Public H � •' F ealth Division Date
�'s7D 200 Main Street,Hyannis MA 02601
' rflt 6AA'i h
�rn
Date Scheduled_ ((��
T1ma . 1'� Fee Pd.
_Z:
Soil Suitability Assessment for Sew ge Disposal
Performed By: (j n
r✓ Witnessed By: Gov, �J
Location Address
LOCATION& GENERAL FORMATION
(�T/n ,
/-/(_ 0&,D C R A IC/V I�LC • g D Owner's Name LQit/u t ne,—
ce w-1,e A V 14 i < Address
Assessor's Map/Parcel:2 Y7 0Z LOIJ f a � � /,J 1, J
Engincer'e Name r! I/
NEW CONSTRUCTION REPAIR
Telephone#
Land Use 7
Slopes(%) Surface Stones
Distances fiom: Open Water Bwly________,___
ft ._Posslblc Wet Area ft Drinking lVafor Well . ft
Draihage Wey —ft Property Line
--.fl Outer R
SIB'TC19'(Street name,dimensions of lot,exact locations of test holes&pera tests,locate wetlands in proximity, to holes) '
Parent material(geologic)
Depth to Bedrock
Depth to Groundwater. Standing Water In Hole:
Weeping fl'om Pit(inee
Estimated Seasonal High Groundwater
Method Used: DETERMINATION FOR SEASONAL'1H6411 WATER TABLE
Depth Observed standing in obs.hole:
DvA to weeping from side of obi.!tole: In. Depth to soli mottles[
Index Well#I —Ill. Groltndwaler Adjuslment Ilt'
Reading Data: Index Well IeYol •• 1`r•
-- --_ AcU.thctor„ _ ! AtU.ptloundwtiter Level
,,
Observation PERCOLATION TEST
fF raffia a S
HOIO 9}'S 6 ��:• 4.6 T 3,i e
. C� ------- Time at 9" •+:a�
Depth of Pere "
Tlma at 6"
Start Pre-soak Time @
2 Time
End Pro-soak
Rate Min./luch
Site Bu►tability Assessment: Site Passed Site Failed:
Additional Testing Needed(YIN)
Original: Public Health Division Observlition Hole Data To Be Completed on Back
***If percolation test is to be conducted witiun 100' of wetland,you must first notify tlxe
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:ISEPTIC\PERCPORM.DOC
V
DEEP-OBSERVATION HOLE LOG U01e
Depth from Soil Horizon Soil Texture Shcl Color Soil. Other
Surface(in.). (USDA) (Munsell) Mottling (Stnucture,Stonei;Boulders.
rteietency,96 aravell
o
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other.
Surface(in.) (USDA) (Mudeell) Mottling (Structure,Stoncs,Boulders.
Conalstenov.%Orayel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soli Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structurc,Stones,Boulders.
Canalstenev.%Gravoll
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Boll Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Slopes:Boulders.
Consistency.
y
Flood Insurance Rate Map:
Above 500 year f iood boundary No_ ' Yes -
'Within 500 year boundary No V,/ Yes '
Within 100 year flood boundary No. Yes .
Depth of nturaRy Occurring Pervious Material
Does at least four feet of naturally occurring pervI us aterlal exist in all areas observed thrpughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pery us matorial?
Certification
I certify that on `Q el. (date)I have passed the soil evaluator examination approved by the
Department of Envlr mental Protection and that the above analysis was perforpted Py me consistent with .
the requir ,expertise d e ri cc described in 10 CMR 15.017.
Signature Date � f<>
QAS EPTICkPHRCPORM.DOC
I
I z 23
' COMMON-�Vv,;.A.LTH OF MASSACHUSETTS
EXECUTIVE OFFICE C)F ENVIRON1v1EN'I'AI�1FFAIR5
> DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
SEP 0 12004
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION Y,APPARCEL S)
Property Address: Se? t < Rod
No . 'JT
Owner's Name:
Owner's Address:
Md 4
Date of Inspection:
Name of Inspector:(please print) i�!�te1 f1 e1f/GT
Company Name: k-.,?ea- txS
Mailing Address: ' -1 ox 9St
Telephone Number: SUBr31s3S—'7 $
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP\
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
k. Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fans
Inspector's Signature: 2jDate: O G
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 flow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6i15r000 page I
r
Page2ofll
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:�[,5�
Owner- at_
Date of Inspection•
Inspection Summary: Check A,B,C,D or E i 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
15303 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 replaced or
repaired-The system,upon completion of the replacement or repair,as approved by the Boar of Health,will pass.
Answer yes,no or not determined('Y,N,ND)in the for the following statem if"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank is imminent_System will pass inspection if the
existing tank is replaced with a complying septic tank as approv by the Board of Health.
*A metal septic tank will pass inspection if it is structurally d,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is a
ND explain:
Observation of sewage backup or b our or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,se or uneven distribution box-System will pass inspection if(with
approval of Board of Health):
roken pipes$are replaced
obstruction ik.>emoved
distn%Wan box is leveled or replaced
ND explain:
The syst equired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection' (with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
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Page 3 of 11
OFFICIAL INSPECTION FORD a NOT FOR VOLUNTARY.' ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: �o� v l Cy 1`r e
e �
Owner: GVD
Date of Inspection: D
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in ord 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 w. 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public he h,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within so feet of a bordering vegetated etland or a salt marsh
2. Svstem will fail unless the Board of Health(and P blic Water Supplier,if any)determines that the
system is functioning in a manner that protects the blic health,safety and environment.
_ The system has a septic tank and soil abso tion system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface ater supply.
The system has a septic tank and S and the SAS is within a Zone I of a public water supply.
_ The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well"*.M. od used to determine distance
"This system passes if the ell water analysis,performed at a D£P certified laboratory,for coliform
bacteria and volatile or c compounds indicates that the well is free from pollution from that facility and
the presence of amnion' nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no'other
failure criteria are tri eyed.A copy of the analysis must be attached to this form.
3. Other:
3
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Page 4 of I I
OFFICIAL.INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SERFAGE DMOSAL SYSTEM INSPECTION FORM
PART:A-
CERTIFICATION(continued)
Property Address: 0 A4 C
Owner: d �j
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for ail inspections:
Yes N
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
,LC 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'/2 day flow
jr 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.
C Any portion of a cesspool or privy is within a Zone 1 of a public well.
f Any portion of a cesspool or privy is within 50 feet of a private water supply well.
p< 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 colibm bacteria and volatile organic.compmmds
indicates that the well is free from pollution.from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the System fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility w' a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or`bo"to each of the folio " g
(The following criteria apply to large systems in ad ' " to the criteria above)
yes no
_ the system is within 400 feet of urface drinking water supply
the system is within 200 et of a tributary to a surface drinking water supply
the system is I in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone H of a p "c water supply well
If you have answ d"yes"to any question in Section E the system is considered a significant great,or answered
"yes"in Sectio above the large system has failed.The owner or operator of any large system considered a
significant under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. system owner should contact the appropriate regional office of the DepartGment.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLJST _
Property Address: / �-+�' r��C ^mot
3
Owner: j054I
]Date of Inspection:
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
_ Has the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
— Were as built plans of the system obtained and examined?(If they were not available note as NIA)
_ 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
othibaifles 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 Systems(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)J
5 `
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Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:. AA
Bate of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): S Number of bedrooms(actual): _
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 or no): N
Is laundry on a separate sewage system(yes or no):A!!�- [if yes separate inspection required)
Laundry system inspected(yes or no): A10
Seasonal use:(yes or no): AV Water meter readings,if available(last 2 years usage(gpd)): ��(t7
Sump pump(yes or no): ISO
Last date of occupancy: C vlr
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.20 "1d
Basis of design flow(seats/perso ft,etc.):
Grease trap present(yes�or no):
Industrial waste holding resent(yes or no):
Non-sanitary waste disc ged to the Title 5 system(yes or no):_
Water meter readin f available:
Last date of occu cy/use:
OTHER(de 'be):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped:______gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):—
6
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Page 7 of 11
D
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: e/sa B(a C.TC vlk t- J'
d w Vt
Owner: :` o �__
Date of Inspection: s/ Qq
BUILDING SEWER(locate on site plan) .
H
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:W
Material of construction: concrete_metal_fiberglass yethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Ce sate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: .
Sludge depth:
Distance from top of sludge to bottom o utlet tee or baffle:
Scum thickness:
Distance from top of scum to top outlet tee or baffle:
Distance from bottom of scum ottom of outlet tee or baffle:
How were dimensions der ed:
Comments(on pumping r ommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet inv evidence of leakage,etc.):
GREASE TRAP: (locate on site plan)
Depth below grade:—
Material of construction: concrete 6etal_fiberglass_polyethylene_other
(explain): T
Dimensions:
Scum thickness:
Distance from top of scum top of outlet tee or baffle:
Distance from bottom o cum to bottom of outlet tee or baffle:
Date of last pumpin
Comments(on p ping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to o et 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: T t_P-r, !�14 1.tE+t
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: _ (tank must be p at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete tal fiberglass`-polyethylene other(explain):
Dimensions:
Capacity: Ions
Design Plow: lons/day
Alarm present(yes or no):
Alarm level: in working order(yes or no).
Date of last pumping:
Comments(condi ' of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must ened)(locate on site plan)
Depth of liquid level above outlet inv .
Comments(note if box is level and stnlbution 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 amber,condition of pumps and appurtenances,etc):
8
Page 9 of 11
OFFICIAL INSPECTION FORM"NOT FOR VOLUNTARY H ASSESSMENTS
NTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ /f C
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching 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.): � rr `
.4 t
lus a S'X? ,� �16r rT `C
A.
rq
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: �_ i h t 14.4
Depth—top of liquid to inlet invert: !��
Depth of solids layer: 31`
Depth of scum layer. _ t"
Dimensions of cesspool: C
Materials of construction:
Indication of groundwater inflow(yes or no): Nb
Comments(note condition of soil,signs of hydraulic fail e,level of ponding,condition of vegetation,etc_):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition o oil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
I
9
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: ` 5X Oki 64�1(
Owner:
Date of Inspection-
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet Locate where public water supply enters the building.
a�
s
�n
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ffnn
Property Address: Ys�o DICX Ccak VM4
41
Owner:
Date of Inspection:
SITE EXAM
Slope q es
Surface water
Check cellar Y115
Shallow wells 0
Estimated depth to ground water -2 ' eet
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)
O Accessed USGS database-explain:
You must describe how you established the high groundwater a evation:
T Lzt,,,,A- aAA P_QQV
I
1I
•ti
ASSESSORS MAP : 2�1
-- -- ------- ---- TEST HOLE LOGS
PARCEL: Z� ,,,,�,�
1) The installation shall cornt�� Gvith Title Valid "Town o� l3uard ol:
FLOOD ZONE: �tf S01 L EVALUATOR: I ( health Regulations.
WITNESS - 1 _��
REFERENCE: �5 - �( �' 2) The installer shall verify the location of utilities, sewer inverts and septic
—' u % ���� � _ . ._�� DATE V � 1 components prior to installation and setting base elevations.
PERCOLATION R ,,fE: 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
two feet out of the d-box to the leaching shall be level.
14'4. V D � y' &D 4) This plan is not to be utilized for property line determination nor any other
w� TH- i TH-2 purpose other than the proposed system installation.
Iml� S 5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over H 10 septic components.
L04U �jv�1 {g� ,( 7) The property is bounded by property corners and property lines.
�a ✓ �� 8) The property owner shall review design considerations to approve of total
MAP Z 11 � it L ,✓ design flow and number of bedrooms to be considered for design. Receipt
LOCATION of payment for the plan and installation based on the plan shall be deemed
yr,1 approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material
per Title V abandonment procedures. Those within the proposed SAS shall
be removed along with contaminated soil and replaced with clean sand per
Title V specs.
/ 101 - 10%uo 1qf G � ' wvqfd 10M 10)System components to be 10 feet from water line. Sewer lines crossing the
-7ZJ Z water line shall be sleeved with 4 inch SC1140 PVC with ends grouted if
/ -- applicable. The proposed SAS is being installed below the water service
_ 5�� Z �Q line. The line is to be sleeved as aforementioned and maintained in place.
SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the
owner to ensure such.
-- - FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such
exists.
Z7Z. BEbROOMS AT // v GAL/DAY/BEDROOM - 0 GAL/DAY 13)Tne installer shall verify the location, quantity and elevation of the sewer
Z 1p lines exiting the dwelling prior to the installation.
--�.,.- 0 SEPTIC TANK
14)"Phis plan is representative only that a system can fit on a property meeting
_ --- "Title V requirements.
GAL/DAY x 2 DAYS
- � GAL
USE GALLON SEPTIC TANK
SOIL ABSORPTION SYSTEM
- -
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:>I DE AREA: '?� Z.6 "f ► r �b��1 ( 7
BOTTOM AREA: XNo.1066
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MASOPi R; ,
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S..EPJ I _� SYSTEM SECTION x 7n'' n
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1 Fi iD
00 GAL WOO, ID
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SEPTIC TANK
10
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SITE AND SEWAGE PLAN
LOCAT I ON : `f Z 01 G ) \fUJI RO 1D
PREPARED FOR : De,k )k//�-,7 r�+02
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SCALE: A
8 DAV I D B . MASON RS DATE: ld I
DBC ENVIRONMENTAL DESIGNS
EAST SANDWICH . MA
W DATE HEALTH AGENT ( 508 ) 833- 2 177
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