HomeMy WebLinkAbout0606 OLD STAGE ROAD - Health 606 Old Stage Road
Centerville P
A = 191 017
*Pon&NWf
1521/3 ORA 10% P2
L O C A T 10 &pC S E AGE PERMIT NO.
VILLAGEOf
" ;Te, trt
I N S T A LL R'S` NAME i ADDRESS
BUILDER OR OWNER '.
R tclt 4' e,
DATE PERMIT ISSUED � ►
DATE COMPLIANCE ISSUED � �
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,4.r-• i
I
TOWN OF BARNSTABLE
+� ?OCATION 4 ®b �� y1 I J SEWAGE #
VILLAGE ClI-rc-f- lI e ASSESSOR'S MAP & LOT/C 0�
INSTALLER'S NAME & PHONE NO. J4Al
SEPTIC TANK CAPACITY /000
LEACHING FACILITY:(type) (size) h200
' NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER w ��
BE- 3LDER O OWNE ®��' L 4is i w y V-
DATE PERMIT ISSUED: % 5 E
DATE COMPLIANCE ISSUED_ ✓ `
VARIANCE GRANTED: Yes No 4/
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TO' N OF BARNSTABLE
}LOCA71ON 606 Old S�Qor ke SEWAGE #
ASSESSOR'S MAP & LOT I I
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACIL.=: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 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 &,g -Tech Sww Powwt Ool -105kr ht?7
LEACH
PIT
LOCATIONS
3
O D-BOX A D
SEPTICr7 1 23 f t 19.5 IFr- -
TANK U 2 28 f t 24 f t
3 34.5 ft 31 IF
4 43 f t 39.5 f t
A
8
1
EXISTING
DWELLING
# 26
w
Z
J
r
3
OLD STAGE ROAD NOT TO SCALE
ASSESSOR'S MAP NO. PARCEL
1_ DCA•Tlow SEYjAGE PE iR M T N
)Gar ae
-��
- ! t. L :AGk
i9STA LLER'S HAKE & ADDRESS
A ,v)'h
.11 U I L D E R Qil��
DATE AEI MI ISSUED
DAFT E COMPLIANCE ISSUED
��1
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y�
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No.�- .... F.......�:.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............ D(.( '.............OF...
ApplirFa#ion for Uhipmal Works Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (L<an Individual Sewage Disposal
System at:
Locati Ad ess /� or Lot
wne /¢ C- Addr�e�,s A
a ---•-•-•----•--•--•-• � d'...---- _-' �41_1�.------•----------•--•------... ___h ti+.UGf✓o._�....`...._..sz.. ll!/ t,S*�i s-A�Jt.....-----
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms........:3..............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
W YP g ------•-•------------------- P ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------•-•-•-••••••-•----••---••••-----•••••--•......-••••-----••......-•-••• --•••-
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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_______--:------•-__----
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------_.............
...................
-
ODescription of Soil.-----•-••- ...4``� .----- ��----•-•-----------------------------------------•-•--------- --.-------------------............_._.
VW ------------------------------------------------------------------------------------------------------------- = ------...............---------- -
Nature of Repairs or Alterations—Answer when applicable___; .. .,� _�_-•-_-_�OOo--S -Z----/Ot7o----
-----------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------•----•---••••
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TT�'Ir^
.�:IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b IT 'ssu d by the board of lie h.
.......... 9 6
Application Approved By•-••-.---•----•• -- ••••i 1 w" -------•-•------- ----- S --
Application Disapproved for the following reasons:_...---•--------------------------------------------------------------------------------------------------------
........---•-----•••-•-•------•-•-:••-......•••-•-•••----•--•-----•-•••••- ••------------
---------------•-------------- -------------------------------------------------------•------
Date
Permit� - -------�-�---------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_._---- ----1 W.-n............OF..,1.reA*o.:.4 4.4.0
,Appliration for Diopooal Works Cfonotrurtion Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair (t-j an Individual Sewage Disposal
System at:
lei Ce.,Ti�41,14.
------------•-••-•-----40---•----••-ocat-••• --•---------------• -••- •- --••---------•*-----------•-----•--c� ----..___-____--------------------------------------
Locati -Ad ress f or Lot -o.
---._..._�.Q / ------- - ----------------- /y�1 -y�
a --------------------\ ov'y ram/ wn frS1. F_.__..._...---'-••-----------•-- �. l f9..s � A/y... �.. /�<,
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms......... ................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building _____________________•______ No. of persons............................ Showers ( ) — Cafeteria ( )
� 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 ( , )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water___-__-__________.___--.
r-T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...___-____________•_...
a ----------
--------------- =....
�
O Description of Soil............ ----- �Uu•• _C_ -----------------------------•----------......_...-•--•-•--•---------..__....--•-----------------•---------------
x
f ------------------------------------------
Nature of Repairs or Alterations—Answer when applicable ---I --- S T `� /Or v 1 ,
U P ...�_ PP '� - Q .o
-----------------------------------•------------•--•--'-'--------------.._.._..-------------------------------------------•---------------........................................
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of ,:TTTF�.
L.E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n ssu d by the board of heglth.
-
.�-•`'""._-`� � , J .. - Dad
Application Approved By...........
..... .
D e
Application Disapproved for the following reasons:................................................................................
_.,
Date
Permit No--•--'---- L '------•------ -..-...._....--` Issued.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........OF........... 't` ?.... 1.11 S. ��� �--:_......_...
...
("Llrdifiratr of Toutp iattrr
THIS IS TO CERTIFY That,the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---•-•-•--- - �7 .t. t -,� 4
nstaller r r �
' - - _-- ------------------'----�--d-n LC�r'i/Li� -- -----------------•---•-=---
....at. l rf _.
has been installed in accordance with the provisions of TI TIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No .C__ ._._ ` _. dated__...----1.1-__-�------------------5,---------------
THE THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
C1DATE........................7.. _ ._ -----............................... Inspector......................_.... --------•-----............_..._.._...---•---•-•-
THE COMMONWEALTH OF MASSACHUSETTS
BOAR4 OF HSALTH
......................................
N0-? :....:::.-:=:.`::2 p FEE....................
Disposal Vorkg(�Tat w- tart ion rrutit
Permission is hereby granted....-----_.mil LA...... .....................................................................................
to Construct (^� or Rep it,(-) jn Individual Sewage Disposal System
at No. c ,� �"'if ..-)G �Lt C_?tt _
�.
�= _-_:o: .. --------------------------=------- - ----- --
r Street r
as shown on the application for Disposal Works Construction Permit Not___....`�-_>__j Dated.....
f._.__.........................
t _.
f
• J Board of Health '•--`�
`DATE_•- ! -=�- ------/•G_ =........................................
FORM 1255 HOBBS & WARREN; INC.. PUBLISHERS
f
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40,00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: Fill in please:
1 t o �&D ocic A-
�. � � APPLICANT'S _ YOUR NAME/S: c\Aks��rott
BUS NESS YOUR HOME ADDRESS: GoG Old
Nm
TELEPHONE # Home Telephone Number
NAME OF CORPORATION:
NAME OF NEW BUSINESS B-- VAKe- TYPE OF BUSINESS ,oti� �+waro✓ �' S ��ss Gw��" S
IS THIS A HOME OCCUPATION? YES NO
ADDRESS OF BUSINESS C06 OI S �G� u v'lt OZG32 MAP/PARCEL NUMBER , -l. I r [Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COM SI 4 ER'S OFFICE MUST COMPLY WITH HOME OCCUPATION
This individual as n of i rt ents that pert e (A�pei in to this type of busine-LES AND REGULATIONS. FAILURE TO
Au horize i na ** _ COMPLY MAY RESULT IN FINES.
O MEN
j t GL/
2. BOARI,OF EALTH
M
This individual ha rEej�nnformed e permit r ements that pertain to this type of business.
Abhorized Si e**
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
} Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
iG,M 5' y`e
Inspection results must be submitted on this form or on the offic_iaUitle-5-tnspectii n Form dated
6/15/2000. Inspection forms may not be altered in any way.�O.ECEA ED
A. Certification
Important: MAY, 0 5 2005
When filling out 1. Property Information:
forms on the
computer,use 606 Old Stage Road - Centerville TOWN OF HEALTH DEPT.
only the tab key Property Address
to move your Janet C. Lavigueur
cursor-do not m ^
use the return Owner's Name
key. 606 Old Stage Road O
Owners Address
VQ Centerville MA 02632
City/Town . State Zip Code
Date of Inspection: May 3, 2005Date
2. Inspector:
David D. Coughanowr, R.S.
Name of Inspector
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364 0894
Telephone Number
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this address and tt,,at the
information reported below is true, accurate and complete as of the time of the inspection. Ige inspection
was performed based on my training and experience in the proper function and malntenan of osite
sewage disposal systems. I am a DEP approved system inspector pursuant to S 0 o ection .34f
Title 5 (310 CMR 15.000).The system: 21 i
® Passes ❑ Conditionally Passes ❑ F >
El Needs Further Ev luation by the Local Approving Authority
May 3, 2005 0 �W-
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.
t5-2017.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
606 Old Stage Road
.Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," lease explain.
, P p
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
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Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
Sey`e
A. Certification Cont.
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
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
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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
t5-2017.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 3of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'GSM
A. Certification (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached
to this form.
3. Other:
t5-2017.doe•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
A. Certification (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered. A copy of
the analysis must be attached to this form.]
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.
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Page 5 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface S Disposal Sewage stem Form
Y
A. Certification (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
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.
t5-2017.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name 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 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, including 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(3)(b)]
t5-2017.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
/GSM
C. System Information
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May3, 2005
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Number of current residents:
1
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 48.gpd
( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: current_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:
Last date of occupancy/use: Date
Other (describe):
t5-2017.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
se Subsurface Sewage Disposal System Form
�M
C. System Information (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information:
owner
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Age: 16+ years. Certificate of Compliance issued 9/29/88 (Permit#88-584)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5-2017.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 9of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
�M Subsurface Sewage Disposal System Form
C. System Information (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 2feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewers appear structurally sound with no evidence of backup or leakage into dwelling
Septic Tank (locate on site plan):
1
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 El Yes ❑ No
certificate)
Dimensions:
8.5 ft x 5 ft x 5 ft (1000 gallon)
Sludge depth: 3 inches
Distance from top of sludge to bottom of outlet tee or baffle 31 inches
Scum thickness
1 inches
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined? Probe to top of tank
t5-2017.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
w Title 5 Official. Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'M
C. System Information (cont.)
606 Old Stage Road
Property Address
Centerville Ma 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
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 every two years. Tank and
tees appears 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
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):
t5-2017.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
aX Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
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 structurally sound with no evidence of leakage in or out. Some solids in sump.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5-2017.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
C. System Information (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1
❑ 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 pits appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. Leach pit contained 1 foot of effluent
and consisted of a 1000 gallon precast unit with 2 feet of stone.
t5-2017.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
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 ❑ lies ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5-2017.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 14 of 16
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'GSM
C. System Information (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name 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.
LEACH
PIT
LOCATIONS
3
o D-BOX A B
SEPTIC o 1 23 f t 19.5 Ft
TANK 2 28 f t 24 f t
3 34.5 Ft 31 ft
4 43 Ft 39.5 Ft
A
6
EXISTING
DWELLING
# 26
W
ZI
J �
W
H
' G
3I
OLD STAGE ROAD NOT TO SCALE
t5-2017.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title , 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
606 Old Stage Road
Property Address
Centerville MA 02632
City/Town State Zip Code
Janet C. Lavigueur May 3, 2005
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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:
Town of 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 25 feet above
groundwater table.
t5-2017.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,-
Page 16 of 16
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Complete items 1,2,and 3. A. Signature
1I Print your name and address on the reverse X ❑Agent
so that we can return the card to you. �. ❑Addressee
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OIor on tfie front if space permits.
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606 OLD STAGE ROAD DSO 3�.��t`
CENTERVILLE, MA 02632 I
III'I'III I'II IIII II�II II III II III I IN 11111111 3. Service Type ❑Priority Mail Express®
El Adult Signature El Registered MailT"'
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{ 4 9 8 8 12 8 9 in Delivery Restricted Delivery ConfirmationTM
7 015 17 3 0 0 0 01 fail ❑Signature Confirmation
nsured Mal Restricted Delivery Restricted Delivery
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PS Form 3811,July 2015 PSN,7530-02-000-9053 Domestic Return Receipt
LIM TRACKING#
{:"111) t First-Class Mail
Postage&..Fees Paid
USPS
Permit No.G-10
9590 9402 S122 5450 31
United States •Sender:Please print.your name,address,and.ZIP+41 in this box-
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� Town of Barnstable
°�� Health Division
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Hyannis,MA 02601 �
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