HomeMy WebLinkAbout1012 OLD STAGE ROAD - Health 1012 Old Stage Rd
Centerville
A=-172 - 107
0
UPC 12534
No.2_ ,ors
HASTINGS,MN
TOWN OF BARNSTABLE
LC-' ;ION �- SEWAGE #
VMLAGE �' �� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. ".r i-"7-7 4f��°'
SEPTIC TANK CAPACITYe— �f'�"
LEACHING FACILITY: (type)��/��� (size)
NO. OF BEDROOMS J � � � �5��✓�T�/�
BUILDER OR OWNER
PERMTTDATE: 9 f, '� � 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 d�' »j cif �' �
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TOWN OF BARNSTABLE
l,ra'.'.ION '� ? -G SEWAGE#
«CAGE "JT ASSESSOR'S MAP&LOT��� ✓r/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY'""'"T,
LEACHING FACILITY:(type) �' (size)
NO.OF BEDROOMS
BUILDER OR OWNER `� A
PERMIT DATE: 9. -'L �" 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
N
U /
J /
J
No._,, �n »— y Fee
THE COMMONWEALTH OF MASSACHU.SETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION TOWN OF BARNSTA.BLE, MASSACHUSETTS
Z(PpYication for Oigpogal 6pgtem'Congtruction permit
Application for a Permit to Construct( )Repair(elu'pgrade(Wbandon( ) Complete System O Individual Components
Location Address or Lot No.,,fV/a 4 e o . �79/e pro Owner's Name,Address and Tel.No.
Assessor's Map/Parcel�,;:1,a'
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel,No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building. � No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow s-5;1 eP- gallons per day. Calculated daily flow ® gallons.
Plan Date �-- `°P.�'' Number of sheets y Revision Date
Title
Size of Septic Tank `���'T/r�4 ,e. Type of
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system.in operation until a Certifi-
cate of Compliance has been issued th`s and ealth.
Signed P Date 19
Application Approved by Date
Application Disapproved for the#1owingg.'reasons
Permit No. _2j)0.0 �� Date Issued /3 G;S
No. �dU / J �l •r Fee 0�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yam/
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for Mie;pogal bp5tem Conotruction Permit
Application for a Permit to Construct( . )Repair( 4(pgrade( ;4don( ) ED Complete System ❑Individual Components
Location Address or Lot No. /tp/a aeQ J7,4,s�e_ ,o!o Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
1 p",f Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type,of Building R4do�-r No. of Persons Showers(; ) Cafeteria( ) �,
Other Fixtures ,
_ 1
design Flow ?y gallons per day. Calculated daily flow -�Q gallons:
Y,.Plan: Date �—��" �' Number of sheets 1 Revision Date
y�'^ Title
` Size of Septic Tank •c��.�T�'i+�.9 �'rro cr 9,de.Type of S.A.S. frC`'C<5 /� r 1 ire�<,Z
Description of Soil
,Nature of Repair's or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The utidersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
`iii accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b isiBo"d of. ealth. ✓
Signed nn Date
Applscation Approved by r A,-4 �ei1� Date -<l��
Application Disapproved for the fo "wing reasons
Permit No. UO Date Issued `/3--!/s-
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired ( /Upgraded( 4
Abandoned( )by //9J •�•�°`�BG'c�`� �'
at /O ,/.•� oC,p 2t '' 9-E` OP-gO G<r 2t' has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ydated
Installer .c�G�lacfGi�` Designer Z- O �l
The issuance of this permit shallrl��not be construed as a guarantee that the syste it fu do as designed.
Date `�1 � Inspector
No. — Fee d
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi.gpo5al *pgtem Cori5truction Permit
Permission is hereby granted to Construct( )Repair( 91"'Upgrade( Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of thi pe
Date:_ _�.3 Approved by `1�`' 1 �.
7V qi_. � • R L � -�
tea,
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
i
..............OF.......-1 / fJ--/ ...........................
Appliration for Dispasal Works Tum1rnrtion Famit
Application is ereby made for a Permit to Construct (,-fl or Repair ( ) an Individual Sewage Disposal
System at: 0
.............. ::�` d ,�' �� ��:�z'.__', f:..l. y. ............................................. r 1
Location-Addre s or No.
46
caner G Address
Installer Address
d Type of Building Size Lot-.� �I2_ ------Sq. feet
aDwelling—No. of Bedrooms.__..._.___.P -.......................Expansion Attic ( ) Garbage Grinder ((�✓(�
p-, Other—Type of Building ____________________________ No. of persons............................ Showers L�K) — Cafeteria ( )
a Other fixtures -------------------------------• -
W Design Flow............. - _________________________gallons per person per day. Total daily flow--.-..... _�' ...................gallons.
WSeptic Tank—Liquid capacity_!?D..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------/----------- Diameter__._.-I-L0-.._.. Depth below irr4et......fk.......... Total leaching area..�—f_6....sq. ft.
Z Other Distribution box_()o Dosing tank /�
'~ Percolation Test Results Performed by---------------- /��! __-___._....._.._._-._.._____.___. Date...1A 1_,.?' ..............
a
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water----_----__--_--__---.--.
Grq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a -••••-•• ........... •- --Z------------------------------------------------
Description of Soil (J-._! ... Nis..._..../ ............: -_•-• •-•••••••••-•-•-1. ._. ,f
V --------------------------------------------------------------------------- -J.....
W
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 TITIE 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.
.. . .......
Date
�j_ �APPlication Approved By---•_•• ..--•- � ......................... -----{
...... ='
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
---------------------------•----------•---------------------.._..--------•-------•------------•--•-----------------------------------------------------/------------------------------------------------
Permit No......................................................... Issued---- . ` .,/� ._.....Date
Date _l1_____
No.......... -...-----•• - _ -- y FIRs.... .y................
THE COMMONWEALTH OF MASSACHUSETTS---
BOARD F HEA6TH
........................................
Appliratiun for Uhipoli al Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct (Al or Repair ( ) an Individual Sewage Disposal Y
System at,, �}/
to
� LoJc�t�ion Addarr s or No
•••------- f :;.c4 ` ,s ue'- -
Owne �J�•- 7 Address "
a - ••--` ��,� ---------------------------------------------------
Installer --.,�
Address �
d Type of Building Size .......Sq. feet
U Dwelling—No. of Bedrooms............ ........................Expansion Attic ( ) Garbage Grinder
._.______. No. of ersons____________________________ Showers „ —Other—Type of Building __________________ p 1 (�'`) Cafeteria ( )
� Other.fixtures __._._...---•-------------------------------•--.._..------•-•••-----•----------------•--••--•-••••-•••..............................................
W Design Flow........:-r...........................gallons per person per day. Total daily flow.......12,:`.P_____._.._
............gallons.
WSeptic Tank—Liquid capacityAPP__gallons Length................ Width................ Diameter................. Depth................
x Disposal Trench—No_____________________ Width ......... Total Length.................... Total leaching area____.___:.:_._ sq. ft.
Seepage Pit No........ ----- P -...........� g ! ...sq. ft.
Z Other Distribution box,,,,.( ') Diameter.- Dosing tank th)beC I e __.__ Total area____
~" Percolation Test Results Performed by_______________ .................................•- -- Date- 2______
,_ Test Pit No. I................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........................
•-_••-•. • .......................................
O Description of Soil______ A./AOIV�ml......... .:._. .
c.� ------------------------------------------------•-- _------------he� �,6/� --.----•--------- -------- ------------------- ----------•----•-•----------------
w
UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
.....................--..........................................................- ............................................................... -
-----
Agreement
The undersigned agrees to install the afore described Individual Sewage Disposal System in accordance with
the provisions of TITU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been I sued by the bo rd of health.
Signed .........................
Date
Application Approved By...... - - .. --.
Date
Application Disapproved for the following reasons:=------•------------------------------------------------------------------------•-------------------------------
....•----....•------••-----••---••------•-••••---•-•-----•-•-•--.._...-•-•------•---••--•••-•-•-•-..._...._._...•--•--••••-•----•••----•-•••-•--••••-----------•-----•--••-----•----------•--••---••---
-' Date
Permit No..................... Issued -G ...........................................c
---- P--
Date
THE COMMONWEALTH OF MASSACH.USETTS
BOARD OF HEALTH
.......OF:...........
V (9rdif irate of Tome iaurr
THIS I O C RTI the div' al S . a e Disposal System constructed ( r Repaired ( )
`.
by...,,,..... . s = ...............................
Ins ler
has _Air in wit of visions of TI" `" of'I he State.Sanitar Code as described in the
p �/ Y. .
application for Disposal Works Construction Permit No.___ `1 _____________________ dated_--':1/•r_;.3,!___70',____.__.__________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATA........ '`-__`3�.__._.�.�......--••-••---------------- Inspector--- ----------- --- -.��� - ---_____------_---
THE COMMONWEALTH OF MASSACHUSETTS .
BOARD OF HEAL
T
y-
�. OF..... -
No..........A10.....
._ c� FEE---.....
E 1111110Fal V. rk TE tr riot
Permission is hereby granted------,., -- '���`. .__C-------------- ---------------------------
........................
to Constru ( r e r ( an Indivldu w ge I posal Syst
at No._,--- • --- .-._..
� '`
V"`' - i/ `.._. treet
as shown on the application for Disposal Works Construction Per 'fi o_______ ____ ____t ted____. ". �:_.. '-....._:
/
�r •---••---------------
---oar o ealtyh
DATE........ __...,_.._
FORM 1255 HOBBS-& WARREN, INC.. PUBLISHERS
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MEM- 4
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LOCATION #W SEWAGE ERMIT NO.
VILLXGE
INSTALLER'S NAME i ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED L31 _fig
DATE COMPLIANCE ISSUED
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-72
B U I-L D E R OR OWNER
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DATE CO-MPLIANCE. . ISSUED,_
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
!� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
0
V/ 1012 Old stage Rd. 4
Property Address
Casey Young t t�}
Owner Owner's Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code Date'of;lnspection
r`4
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 e
A. Inspector Information
filling out forms p
on the computer,
use only the tab Douglas Brown
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services Inc.
use the return key. Company Name
350 Main St.
Company Address
West Yarmouth MA 02673
City/Town State Zip Code
rermn 508-775-2825 S14297
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
�—�
' 19
Inspector' Ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This.inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town
-State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 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:
System in working Condition.
2) System Conditionally Passes:
EI 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):
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1012 Old stage Rd.
9
Property Address
Casey Young
Owner Owners Name
information is Centerville required for every MA 02632 7/15/2019
page. Clty/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ 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):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems: .
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (Cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %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 water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
k., Commonwealth of Massachusetts
x - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts `
Title 5 Official Inspection Form
Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owner's Name
information is Centerville
required for every MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x3=
330gpd
Description:
Number of current residents: 3
Does residence have a garbage grinder? El Yes ® No
Does residence have a water treatment unit? El Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 2017=85gpd
Detail:
2018=104gpd
Sump pump?
❑ Yes ® No
Last date of occupancy: Current
Date
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date
Other(describe below):
3. Pumping Records:
Source of information: No Records
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young.
Owner Owner's Name
information is
required for every Centerville MA 02632 7/15/2019
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
2005 Per BOH Records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade:
28"
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Line was checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code
Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1811
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: 1000Gal
Sludge depth: 4-5"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 24"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers
18" below grade.
l5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owner's Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene Y El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 1a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is Centerville
required for every MA 02632 7/15/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Oil
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.):
H-10 DB-3 with 1 line in and 2 lines out in good condition. Box is clean and level with minimal solids
carryover. Outlet lines equal with speed levelers in place. No sign of overloading or hydraulic failure.
Cover 20" below grade.
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 118
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owner's Name
information is Centerville
required for every MA 02632 7/15/2019
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2-500Gal
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
,P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is Centerville
required for every MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
2-500Gal Chambers with stone. Chambers found dry with no evident staining. No sign of overloading
or hydraulic failure.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
,T Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Volu
ntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owner's Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc:):
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
i
commonwealth of Massachusetts
pi Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16
Commonwealth of Massachusetts
11? Title 5 Official Inspection Form
' 'o
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
; F 1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is
required for every Centerville MA 02632 7/15/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: +10,
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Hand auger did not encounter water at 10'. Max bottom of leaching is 5'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1012 Old stage Rd.
Property Address
Casey Young
Owner Owners Name
information is
required for every Centerville MA 02632 7/15/2019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 1 e
TOWN OF BARNSTABLE
L ^,,.TON o�.� �.�,C
SEWAGE #
VILLAG
ASSESSOR'S MAP & LOT �� /o
INSTALLER'S NAME&PHONE NO. �''?&7 ,��_" ��✓�
SEPTIC TANK
LEACHING FACILITY:
(size)
NO.OF BEDROOMS `',
BUILDER OR OWNER
PERMI TDATE:
COMPLIANCE DATE:---------------------
"`/Ste"•,. J J
Separation Distance Between the: i
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)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet I
within 300 feet of leaching facility)
Furnished b — J FPPt
i
X S '
A
_ A
i
e
Commonwealth of MassachusettsT-
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1012 Old Stage Road-I
Property Address P
PON-
Philip Clement
Owner Owner's Name
information is
required for every Centerville Ma 02632 10-12-16
page. City/Town State Zip Code Date of Inspection
W
m
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 forms A. General Information
on the computer, J J
use only the tab 1. Inspector:
key to move your
cursor-do not Matthew Gilfoy
use the return key. Name of Inspector
B&B Excavation
r� Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113640
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
10-12-16
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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System was in working order at time of inspection and was pumped after inspection for maintenance.
System was permitted for 2 bedrooms but is large enough for 3 bedrooms (330 GPD). Owner wants
to add another bedroom and must contact town for approval.
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):
l5ins-3/13 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
1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. Citylrown 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•3/13 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
1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
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 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (Actual) _2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See below
9 ( Y 9 (gP ))�
Detail:
2014-49,0009allons 2015-61,000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
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-3/13 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
1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped driver- Pumped after inspection for
maintenance
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Tank size
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
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:
New leaching added to existing tank in 2005
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 16"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000gallons
Sludge depth: 101,
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
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 26
Scum thickness 5
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank was
pumped after inspection for maintenance and should be pumped every 2 years to prolong life of SAS
Grease Trap (locate on site plan):
Depth below grade: NAfeet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. Citylfown 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: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° .H 1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
11
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 was in working order with no signs of previous backup.
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.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: (2) 500gallon
chambers
❑ 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.):
Leaching was in working order at time of inspection. Chambers were almost dry when inspected with
no sign of back up.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
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•3113 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
1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
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
REAR
All-2T
A4-64'
Al -6r
82'-276
B3-521"
E4-60'
B5- 581
t5ins-3/13 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 1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
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: No GW 120"
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. 7-21-05Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Plan on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w.� 1012 Old Stage Road
Property Address
Philip Clement
Owner Owner's Name
information is required for every Centerville Ma 02632 10-12-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
0.
hereby certify that the engineered plan signed by me
dated �—,,concerning the property located at
Ur Z G� meets all of the
following criteria:
• Two soil evaluations excavated for detailed examination(no hand augering) and two
percolation tests shall be conducted.
• This failed system is connected to a residential dwelling only. There are no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility 'will-be located no less than five feet above the .
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the following: Q
A) Top of Ground Surface Elevation(using GIS information) �ov
B) G.W. Elevation +adjustment for high G.W. = Al /V o
DIFFERENCE BE EEN A and B
SIGNED : DATE: Z z
NOTICE
Based upon the above information,a repair permit will be"issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptic\percexemp.doc
A Own 0I Barnstante
Regulatory Services
t i 'Thomas F._ •�nrisr�ada, Genler,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644
Fax: 508-790-6304
Installer Des! ner Certification Form
Date: il
Designer: ✓n� I?- Innstauer: 71/h lye
Address: P
�. (�QK j 7 Address:
o —*-/—�, J-43260/
On / Q U M G•t ROE!�f
Fins—taller) was issued a permit to install a
(da e)
septic system at_100— (044 S��� based on a design drawn by
? (address}
D�19
"I (
Q. dated
des
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.
M OF ASS
DAVID 9cyc
J � D. m
alley' afore FLAHERTY. JR. N
No. 1211
So/sTEa�
s'�N/TARI
esigne 's Si ature) (Affix IDesigne p Here)
PLEASE RF TIJRN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CAPS ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH TDIVISION.
THANK YOU.
Q: ,ealthlseptic/Desiper Certification Form
General of
-for' of 60PG T1W
1. ALL PRECAST
TRAFFIC COMPONENTS TO"BE H-10 RATED. ALL COMPONENTS WITH ANY ANTICIPATED VEHICULAR
BE H-20 RATED.
---7
MP tfor-� 2. THE DESIGN OF THIS SYSTEM'DOES NOT ALLOW FOR THE USE OF A GARBAGE GRINDER.
CUAN 5 n 3. MUNICIPAL WATER IS AVAILABLE.
$C1�EDULE Q�eVG p(10£ 4. ALL CONSTRUCTION TO CONFORM WITH 310 CMR 15.000 AND ALL OTHER APPLICABLE-. LOCAL,' STATE
I�IM' �rr(N �f�' �. 5 AND FEDERAL CODES AND REGULATIONS.
. INSTALLER/CONTRACTOR TO REVIEW &VERIFY ALL ELEVATIONS AND DETAILS AND REPORT ANY
er DISCREPANCIES TO DESIGNER PRIOR TO CONSTRUCTION OR ASSUME ALL RESPONSIBILITY.
v
Z rslF 4_ r
'' 6. INSTALLER/CONTRACTOR IS RESPONSIBLE FOR MAINTAINING SAFE WORK AREA, VERIFYING ALL
dI'L�(�v,7L �� - wFrSr�fn UTILITIES AND NOTIFYING"DIG SAFE" (1-888-344-7233) 72 HOURS PRIOR TO CONSTRUCTION.
iPl•1 7. ANY CHANGES TO OR DEVIATIONS FROM THIS PLAN MUST BE APPROVED IN WRITING BY DESIGNER AND
pIfZt4 r1�,f!! p¢le Ft.
- °' � LOCAL BOARD OF HEALTH.
8. FINISH COVER OVER COMPONENTS-IS NOT TO EXCEED 3'-PER 310 CMR 15.000. 11 ' I
Flow �W� Mr�f 9. ALL ABANDONED SEPTIC SYSTEM COMPONENTS TO BE PUMPED DRY AND FILLED WITH CLEAN SAND OR
r u REMOVED AND REPLACED WITH CLEAN SAND.
tf V.= i � 1 o
rr 10. ALL COMPONENTS TO BE PROVIDED WITH WATERTIGHT ACCESS PORTS WITHIN 6"OF FINISH GRADE.
M!N _r
o p - - 11. ALL SEPTIC TANKS, DISTRIBUTION BOXES AND PIPING TO BE INSTALLED WATERTIGHT.
Rq R�
�V'= '�� 1�MlG I✓ U.z rp�¢p/ o a +�;�{��qi�CCT{ 12. NO KNOWN WELLS EXIST WITHIN'100''OF PROPOSED LEACH AREA. i
G �0) �v~ Il�� o p 13. NO WETLANDS WITHIN 100 FEET,OF PROPOSED LEACHING.
{� • i�RCtC11IcT , 14. THIS IS NOT A CERTIFIED PLOT PLAN AND UNDC R'Np'CIRCUMSTANCES IS THIS PLAN TO 6E USED FOR
} p17P 1 f5uTloN ° ° qq �� i s l ZONING OR BUILDING PURPOSES.
p " a IrC�V 15. LOT IS SHOWN ON ASSESSOR'S MAP 172 °AS PARCEL' 107_ ,fox 16. PARCEL IS IN FLOOD ZONE M A
-ro BF t4W4?T�5rF 6 S NP A-401n!p
000 &/ L�,a� (70 6E �tF oN F Qrn r ►N fi« i2.8 x25'�C2rrN��
Into Izc
h r sTln/( w RS r
- ��
4�i ) DATE OF TEST:
,:.0 l�vf S 5 r c r3 — ' _ FGFiv. = 0 1 1 . -- SOIL EVALUATOR: U r O 1-44f 2 -S'. r
Aron c. -- - p �T_
r36 fhm of T,-sr E 's L�v. = S BOO WITNESS: Af � _
/�la'i` � �� � "0 6►2avNQ pjt�T � .tjc6v"T1,ref.� OBSERVATION HOLE 1 ELEV.= 99.q OBSERVATION HgLE 2 ELEV.=
PERCOLATION RATE '4 2. MIN./INCH PERCOLATION RATE'"'L MIN./INCH
DEPTH HORIZ TEXTURE COLOR MOTTLES OTHE DEPTH HORIZ TEXTURE " COLOR ` MOTTLES OTHER
:1q_1 c MCs 2�S %VE:Ca2r:
'----- `� s -Q/
¢ ll S r ! WATER ENCOUNTERED AT IV Id- ELEV.= WATER ENCOUNTERED AT �� ELEV._ !
r NUMBER OF ACTUAL BEDROOMS 2
GARBAGE DISPOSAL UNIT NO
r TOTAL ESTIMATED FLOW j
(110 GAL/BR/DAY X 3 BR.) 330 GAL./DAY j
REQUIRED"SEPTIC TANK CAPACITY ERGO GAL.
SIZE OF SEPTIC TANK(EXISTING) 1000 GAL. I
f _ M SOIL CLASSIFICATION 1
DESIGN PERCOLATION RATE e 2 MIN./IN.�
'u, I _ EFFLUENT I
LOADING RATE 0.74 GAL./DAY/F I
\' I LI I LEACHING AREA (12.8'W x 25'L x.2'd) n71 FT2
Bottom: (12.8'X 25') = 320 ft f
G e 1 Sides:2(12.8'+25�x 2'= 151.2 fl
c� TOTAL LEACHING CAPACITY(AREA X RATE) 4, GAL./DAY,
�� •� RESERVE LEACHING CAPACITY �a GAL/DAY
`V O BBC/{ PROVIDE: (2)—500 GALLON CLAMBERS WITH 4 STONE AROUND
100
SITE AND SEWAG,E PLAN
'
#101 FOR
R -/� �.. .
0A
. � `�: ILA: �r � "
O �1l Flaherty Envir on a 1a°AS'er l ces
l l , A®,`S®.x.f
/V �Q.�w We/®f/eet MA 02667
Date: _ Scale: 1"= 20'
/�ZI�� HOF4f S r
DAVID yam, I
Revised: o cn
F D' Job No. 05-211
..
12 1
� i' T ISTEF''�
IDOL —PA-I 1 SANI7AR�P�
£ Sheet'/ Of
} ORIGINAL STAMP IN RED INK ONLY
�, i