HomeMy WebLinkAbout0540 OLD STAGE ROAD - Health 540 Old Stage Rd .
Centerville
A= 190—074 - 001
o.2 12534 /'
= TOWN OF BARNSTABLE
LOCATION Si-10 dJA She, rA, SEWAGE#
VILLAGE Cep ;y;\1c. ASSESSOR'S MAP&PARCEL 00— 07Y7�
INSTALLERS NAME&PHONE NO. 77i 'GJCM
SEPTIC TANK CAPACITY \9#0 4puea
LEACHING FACILITY:(type) (size) =Z�'f �C2,� >t 2
NO.OF BEDROOMS
OWNER
PERMIT DATE: `ZG l6G COMPLIANCE DATE: qV
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
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LOCATION S 4 U 6 f GW SEWAGE# '
VILLAGE 620(e rV l t t ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY nn(®0 0
LEACHING FACILITY.(type) I" (size)
NO.OF BEDROOMS 6
OWNER l kk0Ule�
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY eCO — TeCA 64 K 5 P,
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
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. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms to the
computer,use 1. Inspector:
only the tab key
to move your David D. Coughanowr
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental
Company Name
r� 43 Triangle Circle
Company Address
Sandwich MA 02563
'eh0/ City/Town State Zip Code
508 364 0894 1328
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
L,4 (z 61*„ IGS October 9, 2009
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.
� I
D�
t5ins•09/08 Title 5 Official Inspection Form:Subsurface ewage Disposal System•Page 1 of 17
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does.not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Alle
n Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 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 Form - Not for Voluntary Assessments
540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 '/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°wM 540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9 2009
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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): n/a Number of bedrooms (actual): 6 in house w/
2 systems
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a - no plan
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G'M , 540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 October 9 2009
required for ,
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
This dwelling has a total of six bedrooms and is served by two septic systems. The system detailed in
this report receives one portion of the flow and the second system, detailed in a separate report,
receives the remainder.
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 ears usage d 78 gpd
9 ( Y 9 (gpd)):
Detail:
2007-2008
Sump pump? ❑ Yes ® No
Last date of occupancy: unknownDate
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. Cityrrown 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:
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):
Septic tank and leach pit
t5ins-09/08 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
�M 540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 October 9 2009
required for ,
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age unknown. As built diagram in owner's possession dated Aug12 1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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.):
No evidence of leakage or backup into dwelling was observed.
Septic Tank (locate on site plan):
Depth below grade: 1
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:
8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth: 4 in
t5ins-09/08 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
540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. Cityrrown 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 30 in
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Probe to top of tank
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
Grease Traplocate on site plan):
( P )
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 October 9 2009
required for ,
every page. Cityrrown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9 2009
every 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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. Cityrrown 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.):
Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No
standing effluent was observed to a depth of 2 feet below the top of the leach pit
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-09/08 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
•''ya 540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 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
540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t
iy
Q
�sf{ Z�tIL �t
Z U✓IZ Tt 20 f t
3
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is required for Centerville MA 02632 October 9, 2009
every page. City(rown 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: 18
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database -explain:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 18 feet above
groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
£ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 540 Old Stage Road -system 2 (north side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 October 9 2009
required for ,
every page. Cityfrown 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
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 September 30, 2009
required for p
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
I
forms the
computer,
r, use 1. Inspector:
only the tab key
to move your David D. Coughanowr
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364 0894 1328
Telephone Number License Number
B. Certification
E3 o
certify that I have personally inspected the sewage disposal system at this address",and that th'e ,.c
information reported below is true, accurate and complete as of the time of the inspection. Th,e=�nsp�#ion
was performed based on my training and experience in the proper function and rndil tenance-of on
sewage disposal systems. I am a DEP approved system inspector pursuant to 4ection 1U40
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fail' --t
'.0
❑ Needs Further Evaluation by the Local Approving Authority CD rn
Ola11��\
oj- �- September 30, 2009
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.
� b
6
t5ins•09/08 Title 5 Official Inspection Form:Subsurface SewLjosal System•Page 1 f 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is p
required for Centerville MA 02632 September 30, 2009
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 September 30 2009
required for p
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is p
required for Centerville MA 02632 September 30, 2009
every 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 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 '/2 day flow
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 September 30 2009
required for p ,
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09108 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
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is p
required for Centerville MA 02632 September 30 2009
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
El E Were an of the system components pumped out in the previous two weeks?
Y Y p p p
❑ ® 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
® El 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3-this Number of bedrooms (actual): 6 in house w/
system 2 systems
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd for
this system
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
0 540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is September 30, 2009 Centerville MA 02632 Se required for p
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
This dwelling has a total of six bedrooms amd is served by two septic systems. The system detailed
in this report receives one portion of the flow and the second system, detailed in a separate report,
receives the remainder.
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)): 78 gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is p
required for Centerville MA 02632 September 30 2009
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:
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:
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•09/08 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
C4M , 540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 September 30, 2009
required for p
every 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:
Age: 3+years. Certificate of compliance issued 8/4/2006 (Board of Health permit#2006-335
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 3
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.):
No evidence of leakage or backup into dwelling was observed.
Septic Tank(locate on site plan):
Depth below grade: 2
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:
10.5 ft x 6 ft x 5 ft(1500 gallon)
Sludge depth: 2 in
t5ins-09/08 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
�M 540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is P
required for Centerville MA 02632 September 30, 2009
every 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 32 in
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design Plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
N Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° w 540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 September 30, 2009
required for p
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.):
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•09/08 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 540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 September 30 2009
required for P
every page. Cityrrown 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 at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box appears level with no evidence of leakage in or out. Few solids in sump. A bucket of water was
poured into the distribution box and was observed to pass through in a rapid and unobstructed
manner, and could be heard splashing down into the leaching gallery.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 Se tember 30, 2009 required for p
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number:
1
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into
the distribution box and was observed to pass through in a rapid and unobstructed manner, and could
be heard splashing down into the leaching gallery.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is P
required for Centerville MA 02632 September 30, 2009
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5ins-09/08 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
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 September 30, 2009
required for p
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
At- W
C�1- 1g z
�2-39 i
A 3R-"�
o
I e �
VdA4
_ - y " -e
t5ins 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is P required for Centerville MA 02632 September 30 2009
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: 18
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: Permit issued 7/26/2006
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows no groundwater or mottling was
encountered to a depth of 4 feet below the bottom of the leaching gallery in a witnessed test pit on
6/1/2006. Town of Barnstable GIS Department records indicate that the property is over 18 feet
above groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
540 Old Stage Road -system 1 (southwest side of dwelling)
Property Address
Allen Mikkonen
Owner Owner's Name
information is Centerville MA 02632 September 30 2009
required for p ,
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. (5b 33-5 THE COMMONWEALTH OF MASSACHUSETTS FEE ®v
BOARD OF %HEALTH �
f✓ OF ,� I^wJT� �•P
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade (( ) Abandon ( ) - V/C.mplete System ❑Individual Components
Lo�atiod-n ,2 is N )
Map/Parcel# Address G
Lot#/ / Tele hone#
�30t7}J d�y` L��//"".0 Sl'PJrw�v/�'
Installer's Name Desigg�r's NamNam
�Jf l�lG�dJf�� � /�•/�i �/J '73
A dress Address
T S/21- 8'ci� �, Sb T-
Telephone# Telephone#
Type of Building: ��S�e�-� iuL Lot Size TS'r Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( ) AIC)
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required) 330 gpd Calculated design flow 3-77 gpd Design flow provided gpd
Plan: Date Zewe > Number of sheets /� Revision Date
Title 3' S / 01 ,��'�f r 7?) L-m Ii-lwi
Description of Soil(s) <t /ot
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agree:IPWTplat the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signe Date
Inspe 'z $'tom 49
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
' `r N�o. �10 733,5 THE Cd1�7MONWEALTH OF MASSACHUSETTS FEE•
O A R D O F - H(EJ'A LT-M* l
OF lrrNJ7irJ/yr ,
APPLICATION FOR DISPOSAL SYSTENfCONSTRUCTION PERMIT
w.
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon Complete System ❑Individual Components
!/ Lo¢atio�`'_� .r ` ��/� 0��r s J��P'S-f /7� `•�'�cl�
Map/Parcel# Address
Lot#/ 1 , '� Telephone#
�i•+�,':�•-••,vp5^
C 141ler's Name ,� _n Desigg;r' ame
Aefdress Address
Telephone# Telephone#
Type of Building: )gK$d1-r" 41w L Lot Size rf,g 32 Sq.feet
Dwelling—No.of Bedrooms 3 Garbage Grinder Ale)
d
g ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
., � Other fixtures
Design Flow(min.required) .330 gpd Calculated design flow 3 J gpd Design flow provided 33 gpd
Plan: Date Jn.e / -2aV 6 Number of sheets I Revision Date
Title f S/�r �s h—� S�/0 04:4 fA s !t 1 !-r 74,.-,.,J1, AP9
Description of Soil(s) 1� 44#1
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 01raG(t E.,,V �i_c /s'J
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspection
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
NOl-�W� THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Promplete System //
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired(t r)-<graded( ),Abandoned( )
by: 3,V, �,d1c7 r ��wJ n tG�Io,J
at S'��O r,I C/ 7rr S e has been installed in accordance with the provisions of 31p. CM 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. 6 3�Sdated 7/ 1w A Ap roved Design Flow 3 3 7 (gpd)
Installer t _
Designer: Inspector L ( vaJ, ate )F7
The issuance of this certificate shall not be construed as a gu rantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
- ------- - -----------------•----_ .-„_.-_----------------._.__-- ----------
No. -335 THE COMMONWEALTH OF MASSACHUSETTS FEE DO
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( U grad ( ) bandon ( ) an individual sewage
disposal system at f 1/O 4Z Cf P 8,0 ( • Yrc./ as described
in the application for Disposal System Construction Permit No.,,- '-�3 7 dated A
Provided: Construction s daall be ompleted within three years of the date of his permit'Al I ca )onditions must be met.
Date Board of HeAlth 1
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS-,BOSTON
;t
FROM :down cape engineering inc FAX NO. :1508362gee0 Aug. 10 2006 11:26AM P1
e
' 'own of Barnstable
Regulatory Services
a _ Tho nas F.Geiler,Director
WAAM Public Health Division
Thomw McKean,Director
200 Win Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 509-790-6304
Installer& Designer Certification Form
Date: (a Sewage Permit# 20011, --333—AsaMWS MapTareel. 1,90 7,�4",
Designer: OW V\ C_.s.,9 f rA,-, Installer: n � p►t
7-
Address; Address: 11F LC
A 1i'l� A mall s
On 7 ?to c( l �r,41,eA,� Cor,11-rd,6^� was issued a permit to install a
(date) (installer)
aeptia cystem at i`l /J—r based on a deeigm dra-wn b},
(address)
le- dated CO /1/0,d
(design )
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.
H OF MA
%r•
ARN W eir
OJALa
(Installer's Signature) CIVIL
No 3C792
�4
'�'S10NAL ��6
(Design Yr's igif ) (Affix Designer's Stamp Here)
PLEASE RETURN TO --BARNSTABLE PUBLIC HEALTH DIVISION CERTIIF•ICATE OF
COMPLIANCE WILL NOT BE ISSUED .UNTIL ROTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU
Q: Certification form 3.M-04,doc
L !!'CA I LON / f SEWAGE PERMIT N
VILLAGE
PY1 r v(
I N S T A LLER'S NA E i ADDRESS
yC
B U I L D E R OR OWN ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED :®
i. . 'ti:
. F
. s
E• . �- c'�
�. �
� .
e.
I' 29
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ToV.,W/ ................OF........ ...........................
Appl ----
Appl ration for Disposal Works Tonstr 7YY ,
rt JIMAit
Applicationis hereby made for a Permit to Construct (4 or Repair ( ndividual Sewage Disposal
Sy ....I A........ ... ..................................... -T:_----I........ .... »....
tig<Add.... .......... .......»... ...........
�.or t Nam......................».» ...
Owner Address
.............................. .-•.... ._....-.--• —.............I .............--••------....------................................•.....
Installer Address
Type of Building Size Lot..ZQ4.414.... f
U Dwelling—No. of Bedrooms-----....--•.3............................Expansion Attic ( ) Garbage Grin er
Other—Type e of Building No, of persons............................ Showers — Cafeteria
a YP g ----........••••--.........- P ( )
p" Other fixtures ...............................................................
Design Flow..............S-5.......
..... ......gallons per person per day. Total daily flow...............
W gn - ----• P P P Y• Y � -�.............gallons.
WSeptic Tank—Liquid capacity7��G7..gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width....... Total Length...............7--- Total leaching area...................sq. ft.
Seepage Pit No........../........ Diameter........d8........ Depth below inlet......�r ....... Total leaching area..2,P.0..sq. ft.
Z Other Distribution box ()C) Dosin tank ( ) /
1.4 Percolation Test Results Performed by. �X.1 ._t.�!S.. .v AXDate......... .��s: _......
,.a Test Pit No. 1.......z ..minutes per inch Depth of Test Pit........!-Z...... Depth to ground water...........!...........
LT. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ..............................
.......................... ------
•--•----------
-...............
...---•-•••-•------------------------......
..........
........
0 Description of Soil..............•--........................................
--•-------.....•-•-•----•--•-•------------------•----------••-•-••--•-........•------•...---.....-•---•--••-•--...--•---------••--
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
•--•-•---•--------•-•-•---•-•-•-•..............................................................................•--------------------...--------.....---•-------------•----•---•••---.........--•--......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITa 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b is b the board�j fhealth.
ig �� �' �v�- ---_....
Application Approved By...` Tle; -•
Date
Application Disapprovef o the f oll ng reasons:..........................................................................................................----
................................•.........................._...-••--------•..............---..........._.---•----•-----••••-----•-•----......-•--•••••-------•---••--•--•••--••-----•-••••---........_
Date
PermitNo...................................................»»» Issued......................................................»
Date
1'
\1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tau�-/A................OF..... ..........................
Apliliration for Disposal Works Tonstrttrtion Errant
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: )
... .... l.L (J�JTlr ►� ... L: ......_....�.:'`?.. .......... . .............. T:........ ............___...._....
« ..0:..n Address..............•---------...._._.... .�or Lot N ...................... .....»....
Owner •Address
w
Installer Address
Type of Building Size Lot...
Z v4__41.4....Sq. feet
Dwelling—No. of Bedrooms..............3...........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
� Other fixtures .....................•--•-----..........................................---.......................--------•---•-----...........-•-•-••............_...
WDesign Flow................�........./...-......gallons per person per day. Total daily flow................ F.30.............gallons.
WSeptic Tank—Liquid capacity!_pW?.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching arm...................sq. ft.
3 Seepage Pit No........../........ Diameter......... Depth below inlet......Z-2....... Total leaching area..ZC?0..sq. ft.
Z Other Distribution box ( )0 Dosing tank ( )
Percolation Test Results Performed by. .....�`�_ ..f._... tr Cha/E5 Z �5 8.�
t � ..-. .:. : .........L. Date -•--•---•----......! r
64 Test Pit No. I......z:--..minutes per Inch Depth of Test Pit........ Depth to ground water........././..........
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
..............................•--......--............--....................._......._...................
O Description of Soil.......................................................
... ................ ..--..........
---•-••--•----------------------------•------.............._.......---••-------...----............-----•-----...--------------•-----.........-----............---....-----.._.....-----•-•.............
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
................................................•------..................-•-•-•--•----------•--.............-----•---•--..........................-•----.............---....................._......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 71 TALE 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
ign ....................•-•-•-•............---•---•-•-•....................••..........-• .e?'....•-•••-
.... to
Application Approved By.... .... - .�`' `'" '
Date
Application Disapprov or he following reasons:.....--••.............................................•----..........----•----....--•-•........•••........---
.............••--•..........•----•-••---•-•-•....•••----•---••....-----•••••-•--••--••••.......•-•-•••-----•••.........••-••------------------•---•------........•-•---••-----•-•------.............._
Date
PermitNo......................................................... Issued......................................................-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... .........OF t. ��C� . ........... � 2iJsT-A ............................ ....
fUrtifirate of Toutpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal Syst on tr ed ( ) or Repaired ( )
by nj ......... ..............................................
. •
r -
at.............."�.+.....�/.4�f_�� _r� ..... Z�. ...
------ -------------------------------•-------------------- -- ----•----------•-
has been installed in accordance with the provisions of TI F 5 of The State Sanitary Coded, ribed in the
application for Disposal Works Construction Permit No. .....rn .............. dated...e"_ _: ._... .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR NTEE THAT THE
SYSTEM WILL FUNCTION SAITISFACTORY. J�
DATE.. ..... /�•. .�j.......�.............. Inspector------.. .............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........OF...................... ...... .......r ... .-4-
.............................
No ............. ,..
F a a.. ................
Disposal No f9uits u0ion f rrutit
Permissionis hereby granted.................... ................ •-•-----...------•--.........---•--..........------........_.....................__..
' to Construct „or Repair ) pal Sew e D sal System
atNo...... ..._ �....... ......... ........................................................
Street
as shown on the application for Disposal Works Construction Permit No............. : Datedt _" ......_..........
.....................•••.._..•-•--•..•. ---••.....................................................
` G Board of Health
DATE-----•... LIJ.... ' ..............•--•-----••......•--•••-
FORM C-1255 CITY & TOWN FORMS, INC.369-9708
SINGL.C- FAtAtLY - "� BEORooM
No GAa.eA�E (,wNDE2
o^41hY FL.ow A I10 A 3 = 33oG.Pp
5F-PTIG TA� JK = 33ox15o°/• =�9/F6.R �
L 1=AeM _
I D1 SPoSA` PIT wSlc Goo G�A�-.. � E
PrT poot
��DErJa�� AQUA = 13z S.F 9s•c
\3z 6v= "A 2 5= 33C) �.P fl �y�•
So�M .AeeA= \13 s.F. �oT 9.
-roTA\- DE51G�1=lL{3 6t'C7 I
FLOW = 330 6.Pp. x 9Sf9 d
97. 1
j F E RLo L..PT o�1 f21�T'�: 1'� I N Z.NS t►J,o� L�-.� V z9..� \ 8 i
6. 7
Ile> fir. 9 a9_t i
. 97•
,A of nt,�,�
ff '� FACHARD o ALAN IL,
I A. e� W.
BAXTER o� chi JONES G 4/d'LL.
No.2404841
0. 251 y: 9f3•/3 _ �G•g7
�•9 9B i
e
To FND= 98.0
S�,44 INV.
�o
.Svt� oiC_ P I ST. GAL'.
p
Gs3L• BvX INV.
SgP7{G 9�SZ
3 ol
LEAG,/ 9�L,0 TANFG
y P.T
W13,.314 93 L+
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3
l CE.2TIFIEp P�-oT PLAN
AT<✓
REF r=z6N C.E i
• I � GERTI,FY TNAT 'TNE .PeoPosE�l-ISC.SNowN
► e.,q SOW GOMPL%?5 VJITN 7- G7
AWD 56Tt�4GK 26Qv12>~MEN7"> of TNE-
-T&WN O� L'SAeF.15TABl.E AND IS �.IoT �.(�ZSO �G. /33
Locp.TED •WIT0jW •T E F%.oaD PL I&114
�ATEGr,T BAxTEcze ?.I` L- INC.
REG 15-c f2�v I..AN o 5 u>zv EY�es
'TItISY PL.�►�1 I �j Nei' BN5c o ob AN OSTE2vIL LF-- MASS•
1)45TRuMENT 5uZve`( �-rHE oFF5ET5 6WOULD .SE'A!f1,4 / -7<� /i✓G'.
NoT D� vSEDTo DETE.FL1�1►-i� Lor LI�IE.�j- APPLICA►�T
- < j" Igo
No..........y._...s-�.... FE$........ ......:._...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... .-----------.....OF.......................................
AVVftra#ilan for Di-epos al Works Taivatrurtinn Frrutit
Application is hereby made for a Permit to Construct ( Wor Repair ( } an Individual Sewage Disposal
System at
...... ........ a:�..j... ..,. . . .. .SA. ................................. .......................................
ocation-Address / ' or Lot No.
. ---l:�ff�4... ='- ---------------li-1-:KY.��./..1....----...----------------------...---...........----...--------------............................
W Owner �� 1 Address
,� ....................:.... . .X-c.- --------...... 71 Address
•--------•••-•--------..._......_..................---
Installer Address
Type of Building Size Lot.................... .....Sq. feet
�-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons..........--.............--- Showers ( ) — Cafeteria ( )
d Other fixtures ------------------------- ------------------------•---
w Design Flow............................................gallons per person per day. Total daily flow............................................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.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.--.--.............. Depth to ground water----..........--..--....
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
P4 ---•------------------------------------••-•----••--------•-•-------•-•--•-----•-....._....•..------.........................................................
0 Description of Soil........................................................................................................................................................................
x
c, --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
w
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------•------------------------------------•--------•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee , ' tyed Wha�of
Signed. ------------------------ r
�� Date
Application Approved BY................ ..•--....... `"---�-a----••`P_
Date
Application Disapproved for the following reasons:-----•------------------------------------------------•------•-----------------------.......................
.........................................................................................................................................................................................................
Date
Permit No.....712___ `r
--.... 111..-•---•--•------------------------ Issued........................................................
Date
.,... ......................
THE COMMONWEALTH oFmAssAoHuSsTrs
U����� ���� ���� A�������U� �
BOARD_�� ��, HEALTH
,�� , , ,
--'-------_'_-��p----_----�--
('
Applic�tion',is hereby made for,a Permit to Construct or Repair an Individual"S�wage Disposal
System at: tj 17._i*"
............ ...........
.. .....0
All
� ____-----
' A�,�"
------------r'�--'~�-�-------'°r--'-^~-~'°--'--'--- -----'---'----------'_-------------'------'-----
I"�a�, Aa��° -
Type ~ Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons...............----------- 5bovrcra ( ) -- Cafeteria ' )
~~ Other fixtures Design ---'------'.------------_-------._.-.-.--.------------_.-----------'_--
Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid*
.--.-yaDoou Length................ Width.... ........... Diameter---------------- Depth................
Disposal Trench--No. .................... Width.................... Total I.cogtb---..... ...... Total leaching area--'-.'--_-sq. f t.
�7 �Sceyuge Pit No-----.--. Diaoocter----.--- Depth below iolc�---'-----' Totalleaching ��r� -.------'aJ. �.
Other D�tr�odoobox ( ) Dosing tank ( )
~~ Percolation Test Results Performed 6y.......................................................................... Date....................................
-
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water.-_'___--
44 Test Pb No. 3................minutes per inch Depth of Test Pic.-.------.. Depth to ground wuter-.-'.----... �
0 -----------_'-'-------_--_--__-_--_-'-'-_---'--'_-------------'-----_---_
DescriptionofSoil.------'----_---_--------------'-----------_-_-.--__.________________.___.________.
_---____--'-.--.___--------__'__'---_-_-_-_-_-_.--__''__-__..__--__'-----'---------'----
17� .--_---_--._'-_'__'_--------_----'--__--'-_--_---_-'---'--':-_--_-----_--_--------'
U Nature of Repairs or Alterations--Answer when applicable...............................................................................................
....................................................................................................................................................................................................... �
Agreement:
The undersigned ogroca to install the uforc6cacribed Individual Sewage Disposal System inaccordance with
the provisions ofTI'Aaj 5of the State Sanitary Code— The undersigned further agrees not to place the system in
operation notJ.0 Certificate of Compliance has tha; of V
ILS��uc�. ____
Signed..�t4- ____________ ................................
Bv- �` Date
� ApplicationApproved ' -----�+--.-------_-------------------------'--- -'---'...'c-��'��-..-____
Date
8yybcu1uou Disapproved for the following reasons:................................................................................................................
..... .....�-.--__.__.-____-__'-_____-_'---__--
.y7'/ Date
��� Issued.�������������������........'.....
, ---
| THE COMMONWEALTH ormAssxoHusErrs
�
BOARD OF HEALTH
^ 01 .................................. �
THITIS- TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
Installer
has been instilled in accordancewiththe provisions of TITLE
5 of The State Sanitary Code as described in the
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRJJO AS A GUARANTEE THAT THE
NCTION SATISFACTORY.
THE COMMONMEALTH OF MASSACHUSETTS
to Construct or-'Repair ( )e) an Individual Sewxe Disposal -System
as shown on the application for Disp�dAVorks Cons&�6.tion�,Permit No..7---,./................ Dated... -7
~`
DATE........................................... B'o'a'r d)ryiff e a I th
^ |
�
�` ' |
SYSTEM PROFILE NOTES r wequaquet
FTOPPN. AT EL. 58.1' r�Nor To SCALE) 1. DATUM IS APPROXIMATE NGVD ACCESS COVER TO WITHIN 6" OF (7N. GRADE (
ACCESS COVER (WATERTIGHT) TO PROVIDE INSPECTION PORT -0 WITHIN 3" OF FINAL GRADE �o
j , WITHIN 6" OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING
56.0 MINIMUM .75 OF COVER OVE.F. PRECAST
- 2% SLOPE REQUIRED OVER SYSTEM 56.0' e40
06
n/
\:E
53.1 _ RUN PIPE LEVEL 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. D o a�°K
XISTING FOR FIRST 2' o o
PROPOSED 1500 2 DOUBLE WASHR PEASTONE 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO
GALLON SEPTIC , /// OR GEO FABRIC H- 10, EXCEPT HI-CAP INFILTRATORS WHICH ARE H-20 o �'
52.76' 52.51 52.5
TANK (H- 10 GAS C71 �� 52.06' 5. PIPE JOINTS TO BE MADE WATERTIGHT.
BAFFLE 52.23
0 52.0' 4' AT SIDES a
SLOPE s" CRUSHED STONE OR MECHANICAL 1.5' AT ENDS 6. CONSTRUCTION DETAILS-TO BE IN ACCORDANCE WITH
( 2 `COMPACTION. (15.= [211 MASS. ENVIRONMENTAL CODE TITLE V.
DEPTH OF FLOW = 4' 2'
7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO WCU11�
TEE SIZES: - 10" 14" , =fig � 50.0' BE USED FOR ANY OTHER PURPOSE.
INLET DEPTH
OUTLET DEPTH = 14" 3/4" TO 1 1/2" DOUBLE WASHED STONE 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.,,,,, Route 28
H-20 HI-CAP INFILIRAT02 SCALE 1' = 2,000'
( o SLOPE) ( � � SLOPE) 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
LEACHING WITHOUT INSPEC11ON BY BOARD OF HEALTH AND PERMISSION
FOUNDATION 17' SEPTIC TANK 28' D' BOX 6' FACILITY 18,t OBTAINED FROM BOARD OF HEALTH. ASSESSORS MAP 190 PARCEL 74-1
*THE INSTALLER SHALL VERIFY THE LOCATIONS ALL SYSTEM COMPONENTS SHALL BE MARKED 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING LOCUS IS WITHIN AP OVERLAY DISTRICT
OF ALL UTILITIES AND ALL BUILDING SEWER WITH MAGNETIC TAPE OR COMPARABLE MEANS DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION
OUTLETS AND ELEVATIONS PRIOR TO INSTALLING ' FOR FUTURE LOCATION. OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO
COMMENCEMENT OF WORK.
ANY PORTION OF SEPTIC SYSTEM
G.W. EL. 32.0't AS- PER TOWN G.W. MAP
11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
LEGEND REMOVED 5' AROUND AND BENEATH THE LEACHING AREA.
100.0 PROPOSED SPOT ELEVATION
+100.00 EXISTING SPOT ELEVATION 372.25, SYSTEM DESIGN.
100 PROPOSED CONTOUR
GARBAGE DISPOSER IS NOT ALLOWED
100 EXISTING CONTOUR
DESIGN FLOW: 3 BEDROOMS 1(. 1 0 GPD) = 330 GPD
EXISTING WATER LINE \ LOT 1A \`
w ,,, ' � USE A 330 GPD DESIGN FLOW
\ 55,932± SQ. FT: SEPTIC TANK: 330 GPD 2 660
EXISTING GAS LINE \ ( � _
� �\ APPROXIMATE
UTILITY POLE \\ \ O�FR \�� BRTION OF EXISTING \\ USE A 1500 GALLON SEPTIC TANK
----
tiFq� �� SEPTIC SYSTEM ,-� LEACHING:
ODDRAINAGE BASIN
\ cr. G \Fc�R/c -i- -------- ��\ "� 7 SIDES 2(28 + 10.83) 2 .74) _TEST EST HOLE LOGS \ � � BENCH NARK - TOP CORNER \� � 28 x 10.83 (.74) _ 224.4
\ c CONC. STOOP EL. = 58.7 GARAGE BOTTOM:
DAVID FLAHERTY, R.S. TOTAL: 458 S.F. ' ..338 GPD'! ,
ENGINEER: \
USE (4) HIGH CAPACITY INFILTRATORS WITH
WITNESS: DON DESMARAIS, R.S. - \\ \\ � \ EXI R NG
DUNE 1, 2006 4' STONE ON SIDES 1.5' ON ENDS AND 14" BENEATH•
DATE: \\ �G��c \ \ DWELLING ONC• SHED
PERC. RATE _ < 2 MIN/INCH \ S6, \ \\ PAD
EXISnNG
CLASS I SOILS P# 11305 \ 3 Bit �\ 6" TREE
DWEIJNG APPROVED DATE '4.
_ BOARD OF HEALTH, MA
\ t3`
\ S TOP OF FNDN
ELEV. ELEV. PAVED DRIVE EL. MA � h<0
" TITLE 5 SITE PLAN
0" 56.0 p 56.3 \ OF
A q P i � CLEAN our /
LS LS `\ PQ Z.AGPOLF - 6" 'POPLAR (SAVE) 540 OLD STAGE RD.
10" ,OYR 3/2 55.2' 10" 10YR 3/2 55.5' ` � - �i� o ,;;, <6 ,' ,� CENTERVILLE (BARNSTABLE), MA
B B �\ �� �� / �/ •/ PREPARED FOR
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52 939 main st. yarmouthport, ma 02675
ADCE #06-127 0 10 20 30 40 50 FEET DATE A OJALA, P. ., S. 06-127 MIKKONEN.DWG (DDF)