HomeMy WebLinkAbout0035 OUTPOST LANE - Health oe-
35 Outpost Lane (Centerville)
A= lea - 103
TOWN OF BARNSTABLE
Lr„CATION L� �`-'` ���"� SEWAGE #
VILLAGE `x�` � ASSESSOR'S MAP & LOT ti
Il`vSTALLER'S NAME&PHONE N0. IN
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS �1C_
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
I
n site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts �ar 03
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane; Centerville
Property Address r•,
Chute,Adam Michael&Tara Jean
)wner Owner's Name s>
formation is 35 Outpost Lane, Centerville ✓ MA 02632 4/22/19
squired for every i /Town
,age.. C tY State Zip Code Date of Inspection `
Inspection results.must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Ming out f When A. Inspector Information illing outforms:
in the computer; Jorge Miguel ise only the tab Chavez, g
.ey to move your Name.of Inspector
:ursor-do not Speakman Excavating LLC
Ise the return Company Name
.ey:
15 Speak Way
Company Address
Harwich MA 02645
City/Town State Zip Code
508432-5565 S114294
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
(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
4 -Z'6 (Cl
Inspe 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 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.
Kinc dnr, rav 70ennt R Title 5 Official_Inspection Form:.Subsurface Sewage:Disposal.System.-.Page 1 of.18
Commonwealth of massacnuserm
�o- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane, Centerville
Property Address
Chute, Adam Michael&Tara Jean
)Wrier Owner's Name' v
nformation is 35 Outpost Lane, Centerville MA. 02632 4/22119.
equired for every p
)age. Cityrrown 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:.
2) 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 structuraly
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 Jf it is structurally sound; not leaking and if a Certificate of
Compliance.indicating that the tank is less than20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5i=.doe rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of18
commonweann of massacnusetts
Title 5 Official Inspection Form M
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane; Centerville
Property Address
Chute, Adam Michael&Tara Jean
Dlwner Owner's Name
equine for
is 35 Outpost Lane, Centerville. MA 02632 4/22/19
'equired for every
)age.. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):.
El 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 pipes)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 ofthe 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:
El 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:
15inso.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of massachusem
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
35 Outpost Lane,Centerville
Property Address
Chute, Adam Michael &Tara Jean.
Jwner Owner's Name
nformation is 35 Out ost Lane, Centerville MA 02632 4/22/19
•equired for every p --
)age. 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 fall 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 equa
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
t5inw.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
35 Outpost Lane, Centerville
Property Address
Chute, Adam Michael&Tara Jean:
wrier Owner's Name
formation is 35 Outpost Lane, Centerville' MA 02632 4/22/19
quired for every
age. Cityrrown State Zip Code Date of Inspection.
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El Z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in cesspool its 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 clo99ed or
El 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.
El ® Any portion of a cesspool or privy is within a Zone_1 of a public water supply
well.
❑ E Any portion of a cesspool or privy is within 50 feet of a private water supply well.
0 0 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-
1:0,000 gpd.
The system fails. i have determined that one or more of the above failure
criteria exist as described in 310 CUR 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
El El 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
Ain-H.,•.rwv 712AMIA Title.5 Official Inspection Form;Subsurface Sewage.Disposal.System.-Page 5 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
is
35 Outpost Lane, Centerville
Property Address
Chute, Adam Michael&Tara Jean
)wner Owner's Name
riformequined for every tion is
equir 35 Outpost Lane, Centerville MA 02632 4/22/19
e -
)age. 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 anyquestion 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 ad inspections:
Yes No
n ® Pumping information was provided by the owner,occupant, or Board of Health
0 Z Were any of the system components pumped out in the previous two weeks?
Z 0 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?
Z Ell 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?
E ❑ Was'the>site inspected for signs of break out?
E 0 Were all system components, excluding the SAS,.located on site?
Z ❑ 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?
® 0 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
Z El
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insn Mr..•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments
35 Outpost Lane, Centerville
Property Address
Chute, Adam Michael&Tara Jean
>wner Owner's Name
iformation is 35 Out ost Lane, Centerville MA 02632 4/22/19
squired for every p
age. CityfTown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550
Description:
Number of current residents: 3
Does residence have garbage.grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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 ED No
Water meter readings, if available(last 2 years usage'(gpd)):
Detail:
2017:67000
2018: 135,000
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurfaoe,Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments
35 Outpost Lane, Centerville
Property Address
Chute, Adam Michael &Tara Jean
)wner, Owner's Name
,formation is
squired for every 35 Outpost Lane,'Centerville MA 02632 4/22/19
age, City/Town State Zip Code Date of Inspection
D. System Infor
mation (cont.)
2. Commercial1industrial 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
«.,,..,H:.o„anannaa Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane, Centerville
Property Address
Chute, Adam.Michael&Tara Jean
3wner Owner's Name
nforequine tifo is. 35 Outpost Lane, Centerville MA 02632 4/22/19
�equited for every
)age; Cityrown State. Zip Code Date of inspection
D. System Information (cont.)
4. Type of System':
Septic tank, distribution box, soil absorption system
0 Single cesspool
Overflow cesspool
❑' Privy
[❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
0 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 l/A system by system operator under contract;
01 Tight tank. Attach a copy of the DEP approval:
❑' Other(describe):
Approximate;age of all components, date installed(if known)and,source of information`
10/11/83 per 000
Were sewageodors detected when arriving at he site? EJ Yes 0 No
5. Building Sewer(locate on site plan):
Depth below grade: 457
fleet
Material of construction:
❑cast iron, ®40 PVC ❑other(explain); -
Distance from private water supply well or suction line: feet
`
Comments(on condition of joints, venting, evidence of leakage, etc.):
Building sewer in good condition; no evidence of leakage or failure.
t5insp:doc•rev:7126/2018 Tige 5 officiai insnedon Form:Subsurface Saweoe oisoosai system•Pane 9 of 1R
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
35 Outpost Lane; Centerville
Property Address
Chute,Adam Michael &Tara Jean
Dwner. Owner's Name
-formation is
•equired forevery P 35 Out ost Lane, Centerville. MA; 02632 4/22119
gage: Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.7"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age, years
Is age confirmed by a Certificated Compliance? (attach a copy of certificate) ❑ Yes ❑ No
- 1000 gal
Dimensions:
. Sludge depth: 4„
30"
Distance from top of sludge to bottom of outlet tee or baffle
2„
Scum`thickness
Distance from top=of scum to top of outlet tee.or baffle 411
Distance from bottom of scum to bottom of outlet tee or baffle 12"
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 is in good condition, PVC:tee on inlet and precast tee on oulet in place;,no evidence of leakage,
t5insp.doe rev.7/26/2018 Tiide5'Official'Inspection Form;Subsurface SewageDisposal`System Pape 10 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane, Centerville
Property Address
Chute, Adam Michael&Tara Jean
Nner Owner's Name
formation is 35 Outpost Lane, Centerville MA 02632 4/22/19'
ige. for every Cityrrown State Zip Code Date of Inspection
age.
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
El 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 ❑other(explain):
Dimensions:
Capacity; gallons
Design Flow: gallons per day
tFlncn Mr.•rev 712612.018 Title 5_Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18.
commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�e 35 Outpost Lane, Centerville
Property Address
Chute,.Adam.Michael&Tara Jean
Weer Owner's Name
tformation is 35 Out ost Lane, Centerville MA: 02632 4/22/19:
:qutred.for every
p
age: City/Town State Zip Code Date of Inspection
D. System Information (cone:)
8. Tight,or Holding Tank(coat.)
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 N/A
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)
Unable to Iodate.Dbox.Tried to follow the pipe but Soil conditions made it difficult to find Ran water
in the house with leaching pit open`and there was a normal flow to pit.
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:'Subsurface:Sewage Disposal System•Page 12 of 18
I
Commonweann of nnassacnusew
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane, Centerville
Property Address
Chute, Adam Michael&Tara Jean
wrier Owners Name
formation is 35 Outpost Lane, Centerville MA OM2 4/22/19
quired for every
age. Citylrown 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.
1.1.. Soil Absorption.System(SAS)(locate on site plan, excavation not required):
If SAS not located; explain why:
Type:
leaching pits number: (1)VxV
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ in system
Type/name of technology:
t5inso.doc-rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System r Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 35 Outpost Lane, Centerville
Property Address:
Chute, Adam Michael &Tara Jean
weer Owner's Name
formation is 35 Outpost Lane, Centerville MA 02632 4/22/19
squired for every age. Cityrrown State Zip Code Date of Inspection
D. System Information (cone.)
11. Soil Absorption System(SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,etc:):
Leaching pit is in good condition,with 31"+/-of water,there is a stain line at 17"+/-from bottom of
invert,there is no vegetation or any sign of 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 El Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane, Centerville
Property Address
Chute,Adam Michael&Tara Jean
1wner Owner's Name
iformation is 35 Outpost Lane, Centerville MA 02632 4/22/19
squired for every
age. CltylTown 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,):
„ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
i
Vommonweaiin W massacnuseus
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Outpost Lane, Centerville
Property Address'
Chute,Adam Michael &Tara Jean
wrier Owner's Name
formation is 35 Outpost Lane, Centerville squired for every p MA 02632 4/22/19
age. Cityfrown 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
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L a
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5insp.doc-rev.V26l2018 Tr3e 5 o=,peS Vie, =cai r gjv;L,•dax S?Rc_pison".I Sva=m.P: t��,is
I
commonweann of massacnusetts
F Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
35 Outpost Lane, Centerville
Property Address
Chute, Adam Michael&Tara Jean
)wrier Owner's Name
I.formation is 35 Outpost Lane, Centerville MA 02632: .4/22/19
I for every
gage. CitylTown 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: 17.1' +/-from bottom of leaching
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
0. 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:
Elevation at property: 60'
Bottom of leaching: 8.9,
Closest body of water, Wequaquet Lake; 34'
Ground water at: 17.1' +/-
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insoAm•rev.7/20/2016 Title 5 Ofticiallnspeclion Form:Subsurface Sewage Disposal system•Page 17 of 18
yommonweailin OT massacnuserm
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane, Centerville
Property Address
Chute, Adam Michael&Tara Jean
)caner Owner's Name
,formation is 35 Outpost Lane, Centerville MA 02632 4/22/19
squired for every p,age Gityfrown 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 thissection.
® B. Certification: Signed&Dated and 1, 2, 3, or4'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
,s. 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.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal system•Page 1a of 18
Commonwealth of Massachusetts
u . Title 5 Official Inspection Form L
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 35 Outpost Lane ne,fk 3
Property Address u
Dean and Joan Jefts
Owner Owner's Name
information is
required for every Centerville Ma. 02632 04/10/2015
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
use the return Name of Inspector
key. p
Cape Septic Inspections
,*y Company Name
624 Old Barnstable Road
�I Company Address
Mashpee Ma. 02649
City/Town State Zip Code
508-280-3356 S13938
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
0 Vll 0/2015
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 thefuture 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
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is Centerville
required for every Ma. 02632 04/10/2015
page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is
required for every Centerville Ma. 02632 04/10/2015
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is
required for every Centerville Ma. 02632 04/10/2015
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 Y day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is
required for every Centerville Ma. 02632 04/10/2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•'' 35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information
equir for
is every
Centerville
required for eve Ma. 02632 04/10/2015
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is
required for every Centerville Ma. 02632 04/10/2015
page. Cityrrown 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
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
in 2014 60,000 gallons were used and in 2013 13,000 gallons were used
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
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:
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
bV•,� 35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is
required for every Centerville Ma. 02632 04/10/2015
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is Centerville
required for every Ma. 02632 04/10/2015
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1984
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 25"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1611
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: Standard 1000 gallon septic tank
Sludge depth: < 1„
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information
equir for
is every
Centerville
required for eve Ma. 02632 04/10/2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
39"
"
Scum thickness < 1
Distance from top of scum to top of outlet tee or baffle 811
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? Field Instruments
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The septic tank is structuraly sound and has a concrete baffle tee on the discharge side of the tank.
Also note there is a irragation line over the discharge cover. The cover can be removed but one must
be carefull while digging. I would recommend the new owner contact a local septic pumping co. and
put the septic tank on a maint. plan based on the age and the future use of the system. The Baord of
Health has a list of pumping co.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
V . Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.•' 35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is required for every Centerville Ma. 02632 04/10/2015
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'' 35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is
required for every Centerville Ma. 02632 04/10/2015
page. Citylrown 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"
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.):
PumpChamber locate n
( o site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is required for every Centerville Ma. 02632 04/10/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
The cover to the leaching pit is raised to grade. At the time of the inspection there was 16 inches of
standing water in the six foot pit.There is a stain line higher but the leaching pit did not have signs of
hydraulic failure and it meets the requirements of the Barnstable Health Dept
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,••�' 35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is
id for every
Centerville 02632regure . 04/10/2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
Dean and Joan Jefts
)wner Owner's Name
quire d fo ti fo is
every
s Centerville Ma. 02632 04/10/2015
squire
,age. 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
7
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
't 35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is
required for every Centerville Ma. 02632 04/10/2015
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: 15 plus feet
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:
I augured a hole at a lower elevation and shot it with a transit to show five plus feet of seperation
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
35 Outpost Lane
Property Address
Dean and Joan Jefts
Owner Owner's Name
information is Centerville
required for every Ma. 02632 04/10/2015
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
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab '� �
1. Inspector. /. t ( I I r
key to move your
cursor-do not Michael Kellettuse �� f
key.the return Name of Inspector
Aardvark Environmental Inspections
Company Name
PO Box 896
Company.Address
East Dennis MA 02641
Cityrrown State Zip Code
508-385-7608 SI 3742
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
09/19/13
Inspect 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 tiow the system will perform in the future under
the same or different conditions of use.
A 0/15 2o03
t5ins-11/10 Title 5 Official Inspectio Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. Citylrown state Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for"yes "no"or"not determined"(Y,N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. City/Town state Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes(cunt):
I
❑ 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
Tvin3=l lil u We 5 Official tnspeMon Form:Subsurface Sewage Disposel System=—Page 3 of 1,7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ug
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
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 Y2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is
required for every Centerville MA 02632 09/18/13
page. Cityfrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
v
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. Cityfrown state Zip Code Date of Inspection
C. Checklist
Check if the following have been done..You must indicate"yes"or"non as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS,located on site?
® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins•11/10 Title 5Offcial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. City/Town state Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[f yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 08/13
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): canons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (f yes,attach previous inspection records,if any)
❑ Innovative/Altemative 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 VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components,date installed Qf known)and source of information:
10/11/03 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.1
feet
Material of construction:
❑ cast iron ®40 PVC []other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
3"
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 official inspection Form
"s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
,
page. Citylrown 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 28"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle 5°
Distance from bottom of scum to bottom of outlet tee or baffle
15"
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.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments condition of alarm and float switches etc):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Orfeial Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
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.):
The box was level and ight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Soil Absorption System(SAS) (locate on site plan,excavation not required):
If SAS not located,explain why:
t5ins•11/10 Title 5 Offxial inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official inspection Form
sI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt:)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):
This system has a 6'x6'precast pit surrounded by 2 feet of stone.There was a foot of liquid with a
stain line 8 inches above the liquid.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. Citylrown 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
18 24 14
27
16
34
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is Centerville MA 02632 09/18/13
required for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators,installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Outpost Lane
Property Address
James Hannoosh
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/13
page. Cityrrown state Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A,B, C,D,or E checked
f
® 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS hL
BUILDER OR OWNER P
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching,facility)
Feet
Furnished by
L .76 ........... A
23
a 13 Q
AA Q t,
66 3q
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=172103&seq=1 9/17/2013
L-0 CAT ION � SEWAGE PERMIT NO.
VILLACE
INSTALLER'S NAME i ADDRESS
e U I L D E R OR OWNER
DATE PERMIT ISSUED
I�
DATE COMPLIANCE ISSUED ��
�n 34, "
�9
THE COMMONWEALTH OF MASSACHUSETT�'
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at
........... ............O(J-1 0!&..... . .... . ........*"C*..Z.....*...*.....
12
wnor Address
Installer Address
........"..Expansion Attic Garbage Grinder ( )
Z Other Distribution box ( ) Dosing tank ( )
------''''-------' --
Agreencut:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
| the provisions ofTL ITi LE 5of the State Sanitary Code-- The uo�lcroigucdturder agrees not to place the system in
operation until a Certificate of Compliance has been issueg^. the bo a h.
� --------. �� �~
Application Dv ____
Date
Application Disapproved or e following reasons:...............................................................................................................
-
`-No .-_. FEE..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH •
OF.............s..... a
Appliration for Diopo,ittl Workii Tomitrurtion rrmit�.`
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
..c .. .�. . •-...--._.. ....... ...............................
..... . _.
Loca io •Add ss o N
o,
: ,.•.• ----•................................
r
Owner Address
W
Installer Address
UType of Building Size Lot...........................Sq. feet
Dwelling—No. of Bedrooms.__............................Expansion Attic ( ) Garbage Grinder ( )
aOther
—Type of Building ---------------------------- No. of persons............................ Showers ( ) Cafeteria ( )
d / Other fixtures ---•••......-•••••--•................ ..••---•-••-..•••••---•-•---•--------•--------..-•--•-•••--••--•--.........................---••-•-•---......
Design Flow............................................gallons per person per day. Total daily flow........... ..................gallons.
W Septic Tank—Liquid capacity
/4Otgallons Length................ Width................ Diameter................ Depth..............
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...`6.&.sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Res is Performed bY.......................................................................... Date........................................
Test Pit No. 1 .: minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li, Test Pit No.,. iinutes per inch Depth of Test Pit.................... Depth to round water........................
-� - �- P P P g
------------........................................................................................................................................
O Description of Soil.__._. ....
-•-•• •----.....-
----•---•--•----••......--•------•----•--- ••---•-•-•----•---••----•-•....................•.._........_..
W
----- •-•••••.•-••-•...--•----•-•...
UNature of Repairs or Alterations—Answer when applicable................................................................................................
-•------------•-------------•-...-•-••••-•-••-•-•••••-•••......•••••••-•-•----...---.......-•---••---•••--••-•••--•-----------•-•----....--•-•---•-----••-••-••-•-•••••----•-•-••••.....................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 5 of the State Sanitary Coder_—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue y the boar f Beal h.
j
Signed.-_.. ...: .. ...-✓.. ................. --/.. l .......
c .
Application Approved BY /G/, f� '� at
.................... Date•••••----.....
Application Disapproved for a following reasons:-•------------•-------•--•-•--•------•--•---•---••---••-•-•--•••-•-••-----•---•••...............................
........-•-•••-•-•••••---•-•_....--•--•--.........-••----••••••-_........•-•••--••--•-•-•-•...............__....•.._.._.__....•••-••-•-••••------.......•---••---•••-•-••--_......_.........-•----...._..
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Tprtif ira.te of Tontpliatta
TA HI,. C FYFr%That t Indi idual Sewage Disposal System constructed ( or Repaired ( )
by....._ .:.W-z '- �.-G' "Y..aC l.. - Installer
-----.....--•----•-----•--.....---•--•...............................
C� __.
at...----------._-f5'�- --.......................................
has been installed in accordance with ie provisions of T�TJ _ �S,A The State Sanitary Cad s scribed in the
application for Disposal Works Co truction Permit �o............. ................. dated_. ____.l.__ ..� ......................
THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE
SYSTEM W CTION SATISFACTORY.
DATE._....: ...�.....�.L�...-•------------------------------------------------ Inspector-•-•-•-- ---- --.....---...•-•----------•----....--••-•------------.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
N�..............••....... FEE.........................
i000l o ko ontr ua p mit
Permission is�r"eby grante e ` , r-%....._ ...•.---..(_[1 ,l/! l7/ lac.
to Constructep ' ual.._Sewlage Disposal System
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Street
as shown on the a licati n for Disposal `Forks Construction Per o.'................. Dated..........................................
- 7 Board of Health
DATE..... ..... .......... ,
FORM 1255 ":4. M. SULKIN, INC., BOSTON
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LEGEND
EXISTING SPOT ELEVATION Ox0 CERTIFIED PLOT PLAN
EXISTING CONTOUR — _ 0 —__ a� �c�� oT �� Cd-7A
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FINISHED SPOT ELEVATION [ ] ROBERTgRUCE a C= A/7- '` -
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APPROVED BOARD OF HEALTH 's' ,•�Vk�o�' l�AJ$,hS''Ar. L.4"ASS*
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DATE AGENT SCALE, / ` = D DATE, '? /;
LDREDGE ENGINEERING CO. INC N�c"v��►s
CLIENT. I CERTIFY THAT THE PROPOSED
EGISTERE REGISTERED J08 N0. BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
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ENGINEER St
OF BARNSTAB E , MASS.
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