HomeMy WebLinkAbout0030 OXNER ROAD - Health 30 Oxner Rd. (Centerville)
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 30 Oxner Rd
Property Address F�
Carolyn Campbell
Owner Owner's Name �+
information is Centerville MA 02632 2-4-16
required for every
page. City/Town. State. Zip_C-ode. Date.of Inspection ►•.
Inspection results must be submitted on this form. Inspection forms may not be altered Any
way. Please see completeness checklist at the end of the form.
A. General Information 67 //� 08
1. I nspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S 13971
Telephone Number License Number
B. Certification 0 ;
I certify that I have personally inspected the sewage disposal system at this address and that the
I 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 16.340 of
Title.5.(340-C.MR 1.5.00.0.)..The.system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluatio y the Local Approving Authority
2-4-16
nspectors 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-3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 C
s
Commonwealth of Massachusetts _
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M >'' 30 Oxner Rd
Property Address
.r' Carolyn Campbell
Owner :-> Owner's Name
information r is
or every Centerville MA 02632 2-4-16
required f
page. R City/Town State Zip Code Date of Inspection
, = B. Certification (cont.)
Inspection Summary: Check' A;B,C,D or€/-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 is in good working order with no sign of failure.
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):
_ a
t5ins•3113 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
30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
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(9)(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
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16.
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**.
r �N Y
Method used to determine distance:
** This system passes if the well water-analysis, performed at-a DEP certified laboratory,for fecal
coliforrn 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
a 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-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 '
wM 30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is Centerville MA 02632 2-4-16
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion.of a.cesspool.or,privy_is.within 5.0.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-
y 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 LI.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•3113 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
M 30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
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
I ❑ ®, 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?
® tEl . Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® , ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
' Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
ey�< 30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
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? (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 years usage (gpd)):
Detail:
Sump pump? F1 Yes Z No
Last date of occupancy: 2015
Date
Commercial/Industrial flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
r Basis of design flow(seats/persons/sq.ft., etc.):
Grease.trap.present? ❑ Yes. ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts ,
Title 5 Official Inspection-Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is
required for every Centerville MA 02632 2-4-16
page. Cfty/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
p 9
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes Z 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): ,r
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
y 30 Oxner Rd
GSM
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1980 with leach pit added in 1990's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 16"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.):
Good condition.
Septic Tank (locate on site plan):
8"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years.
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth;
12"
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
wM 30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is
required for every Centerville. MA 02632 2-4-16
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
,20"
3"
Scum thickness
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
13" �
How were dimensions determined? Tape
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 with baffles installed and no sign of leakage.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official, Inspection- Form
Subsurface Sewage Disposal System Form:-Not for Voluntary Assessments
30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is Centerville MA 02632 2-4-16
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
� n
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
' M f 30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
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 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.):
Good condition with water at working level and no sign of back-up from pits.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of-pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System SAS locate on site Ian excavation not required):
p Y ( ) ( P
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M a 30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) P
Type:
® leaching pits number: 2-1000 gal
❑ 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.):
Leach pits in a series with the first pit in good condition and water level 16"below outlet invert and
stain lines at outlet invert. The second pit was empty at inspection with stain lines at 30" below inlet
invert.
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-3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
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:
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 I n-spection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
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 j
10 �
{
All
t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not.for Voluntary Assessments
w 30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
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: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
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
30 Oxner Rd
Property Address
Carolyn Campbell
Owner Owner's Name
information is required for every Centerville MA 02632 2-4-16
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.IS or attached.in.separate file
t5ins-3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE-OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL P7Pp
ti f
Vt 1
' 001
;
TITLE 5
OFFICIAL INSPECTION:FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:.
1�—
Owner's Name: `
Owner's Address:
Date of Inspection:
Name of Inspector: please print)` 0 f • 53oi� K
Company Name.
Mailing Address: .U- `705�
Telephone Number: f5O9--7'�t 4' ?
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
- below is true, accurate and,complete as of the,time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a PEP
approved system inspector pursuant to
Section 15.340 of Title 5(310 CMR 15.00.0). The system:
+i Passes
Conditionally Passes
b�qeds her Evaluation by the Local Approving Authority.
iIs
Inspector's Signature: Date: G
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a.shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit.the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions-of use at that
time.This inspection does not address how the system will.perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
; 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'Property Address:
O jAW A u.. r... -
.Owner:
Date of Inspection: 43/
Inspection Summary: Check AAC,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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
Observation of sewage backup or break out or hicih static water level in:the distribution box due to broken or
obstructed pipe(s)or due to a broken;settled or uneven distribution box. System•will-pass inspection if(with
approval of Board of Health):
broken pipe(s.)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):.
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 11 of l l r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address:
L4
Owner:
Date of Inspection: V/4&/01
SITE EXAM.
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check).all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: Jir/djllj �r� .
II
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-PART C
SYSTEM INFOA MATION(continued)
Property Address:
a
Owner: 4 AA
Date of Ins ection: 21 p/9�
SKETCH OFSEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet.:Locate where public water supply enters the building.
tA
0.
0
1�
10
Page 9 of I 1
OFFICIAL INSPECTION DORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 30 _ FA 2640�
Owner: �/Cc-QC3o
Date of spection:
SOIL ABSORPTION SYSTEM (SAS):._(locate on site plan,excavation not required)
If SAS not located.explain why:
Type �,�,p/, ��C►aie2
Isleaching.pits,number: /Uoo
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,
etcate 02
):
rye,
y o
v%
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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIV (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.):
9
Page 8•of 71
'OFFICIAL:INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS
SUBSURFACE°SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION(continued)
Property Address:
Owner••
Date of Inspection: .
TIGHT or HOLDING TANK;zJ( tank must be pumped at time of inspection)(locate on site plan)
..De pth below grade:
Material of construction: concrete metal - fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
`Design Flow: gallons/day
Alarm present(yes or no):
.Alarm level: Alarm in working order(yes or no):
Date of last-pumping:
Comments(condition of alarm.and:float switches, etc.):
DISTRIBUTION BOX,:: f present must be'opened)(locate on site plan)
Depth of liquid level`abbVe outlet invert: '
Comments(note if box is level.and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER•' locate on site plan)
Pumps.in.working'ord'er.(yes or no):._
Alarms in working order(yes or no):.
Comments(note condition of pump chamber,condition-of pumps and appurtenances,etc.):
8
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM.INFO.RMATION(continued)
Property Address: e� 1
Owner' '
Date,of Inspection:
BUILDING SEWER(locate on site plan),44&
Depth below grade;
Materials of construction:_cast iron _40 PVC_other(explain):-. .
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC.TANK: locate on site plan)
Depth below grade:
Material of construetion: _metal_fiberglass polyethylene
other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions:�• X L
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: Q
Distance from top of scum to top of outlet tee or baffle: l�
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommend tions, thlet and outlet tee or baffle condition,structural integrity, liquid levels
s related to.outlet invert,evidence of leakage,etc.) / ,
p,
!fa/nlf
r� r�
v T
GREASE TR` YX (ocate.on.site.plan) .
Depth below grade:_
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:
Comments(on.pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to.outlet invert,evidence of leakage,etc.):
Page 6 of l 1
OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 20 V -
Owner:
Date of Inspection: U
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):.
DESIGN"flow based on 310 C1v1 15.2.03 (for example: 110 gpd x#of bedrooms): .
Number of current residents:
Does residence have a garbage grinder(yes or no);/
Is laundry on a separate sewage system(yes or no) -{if yes separate inspection required]
Laundry system inspected(yes or no);,�- -
Seasonal use: (yes or no)./�
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: oC_ .1LfU'1%d. 1260_e6Q ,
COMMERCIA`L/INDUSTRIAL��-'
Type of establishment-...
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):—
Industriaf waste holding tank,present.(yes or no):—
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe): .
GENERAL INFORMATION
Pumping Records
Source of information' �( L ��► /n�
Was system pumped as.part of the inspectio (yes or�no)-.
If yes, volume pumped: - .;" gallons-7 How,was quantitypumped determined?
Reason'for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank —.Attach a copy of the DEP approval
Other(describe):
A proximate age of all components,date insta led(if known)and source of information:
4iU?A!eW 7h 3,19V
Were sewage odors detected when arriving at the site(yes or no):ek.6---
6
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM
PART B.
CHECKLI
ST
Property Address:
Owner:
609
Date of Inspect►on: Sh//P_/y
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
c �IWere.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 breakout?
— 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-
Yes no
f_ Existing information.For example,a plan.at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue.approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)J
5
y
Page 4 of l l
OFFICIAL:INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property.Addressi Q fa
Owner
Date of I spection: 94,4101
D. System.Failure Criteria applicable to all systems:
You.must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
Backup of sewage into facility or system component due to overloaded or clogged'SAS or cesspool
Discharge'or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
. cesspool
_ Liquid depth in cesspool is less than 6"below invert.or available volume is less than '/2 day flow
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 I of a public well.
Any portion of a cesspool or privy is within 50.feet of a private water supply well.
Any portion of a cesspool or.privy is less than 100:feet but greater than.50 feet from a private water
supply well-with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organ ic.compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,the 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'systemahe system must serve a facility with a-design flow of 10,000:gpd to:15,600
gPd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
Page 3 of l'l '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address Q _
Owner: "
Date of I spection: !
k;
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)(6)that:the
system is not functioning in a mariner 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
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
su_rface 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 160,feet.but 50 feet or more from a .
private water supply well".Method used to determine.,distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that.facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A;copy.of the analysis must be.attached.to this form.
3. Other:
3
(/ TOWN OF BARNSTABLE
LOCATION 30 4!:)k /VE<L �Zs SEWAGE # 3�5�
VILLAGE -� 7 'fA t// Af ASSESSOR'S MAP dz LOT z ..- —/—/
INSTALLER'S NAME & PHONE NO. �0^ DL t ill a"aoJ �S
SEPTIC TANK CAPACITY /G' D 45LAI Cg-X 1 s 7)
p
LEACHING FACILITY:(type) ', ���ST/ l�`- (size) `-1X
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER Jvb llc
l r
BUILDER OR OWNER �/� !f � Iqoe G -i D/ '9
DATE PERMIT ISSUED: 7 1/3 / Sp
DATE COMPLIANCE ISSUED: /, �' •�
VARIANCE GRANTED: Yes No
f � -
-
V
I S
r
��CJu
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for 11iji-poml Wnrkii Tomitrnrthin rrrmit
Application is hereby made for a Permit to Cotistruct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
30 Oxner Rd Centerville
..........................•-----....-------••-----•---•----•--------------------.........•..------ ------------•-•--•-•-•----.....--•------••-.....--------•••----•-•----•----•-••---•-..........----
Location-Address or Lot No.
D. Archibald
..................--------------------------------------.................................... ----•--------------=--------•--------•-•-••-•----------•...-•-•----.........------••-••.......----
W W.E. Robinson SepVic Service P.O. ' Box 1089 8eriterville
IustalIer Address
d Type of Building Size Lot.----------_--------------Sq. feet
Dwelling—No. of Bedrooms-------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.------------.-------------- Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------------------------------------------------------------...............................................................
W Design. Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length_------------- Width.......--------- Diameter---------------- Depth......------....
x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter---------------.-.-. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank .( )
aPercolation Test Results Performed by.......................................................................... Date......................................
Test Pit No. 1................minutes per inch Depth of Test Pit.-.----.------------ Depth to ground water.......---..............
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit..............----.- Depth to ground water...---..................
a .......................................................................................•---•-------..........................----............................
0 Description of Soil............sand--...............................................................................................................................................
V ----------------------------------------------------------------------------------------------••-----------•----------------------....---------------
W
•------------------------- -----------------------------------------------------------------.................-.........................................................................................
U Nature of Repairs or Alterations—Answer when applicable....-install a precast stonepacked
leachpit
----------------------- -----------••----------------------------------------------------------....-----•-----------------------------------------------------------------------------........••--..----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—.Th ndersigned further agrees not to place the
system in operation until a Certificate of Complianc has bee su by tlla board of h t
Signed ..-�j-- ------ - ----- '------ ..... -- - ...... - / -
Date
Application Approved BY �............. -- ............................... ....-�F
Dace
Application Disapproved for the following reasons- --------------------------- --- ------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------ ------------- --------------------- ---------------------------------------------------------------------- -------------- --- -------------
Date
/
Permit No. ..r :. ................ Issued ......... ''% •., -®.. ........
Dace
t
s. H — // 7
-
No.. FEs..3kt 2...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
App iratiun for Uitj-Vn!3tt1 Wurk,i Tunutrnr#inn 1Prmit
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
30 Oxner Rd Centerville
....•-----. ..................................••-•----------•----------..............-- -----------------------------------•------------------------------•---------------------•---------
Location-Address or Lot No.
D. Archibald
......................_.......................................................................... ----•----------------------------------••-------------.....--------..........---............------
W W.E. Robinson Septic Service P.O. Box 1089 &err`ferville
,-1 ---- - -•--.....
Installer Address
d Type g ____..•.............-••---Sq. feet
T e o Building Size Lot
Dwelling— No. of Bedrooms__________________3
--------..__-_-___-.._--Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons_----_-_____________-_..___ Showers ( ) — Cafeteria ( )
QI Other fixtures -------------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length________________ Width---------------- Diameter__.--_.._.-__.._ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- -------------------------------------------------•-------...------ Date........................................
Test Pit No. 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........................
a ----------------------------------••----•----------------------•--------••----------........._------.........................................................
0 Description of Soil............ and....------•-----------------------------------------•--------------------------------------------------------------------------------------------
V .----------------------------------------------------•--•-•-----.....--•------------------------------------------------------------------------...-----------•---------•-----------.....----•-••--------
W
U Nature of Repairs or Alterations—Answer when applicable.___install a precast stonepacked
1 eachp i t ------------------------------------------------------------------------------
----•-----------------------•-------------------•----------•------•---------------------------------------------....------. ----...--------------------•--------------------------------•••--.......----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—TheAndersigned further agrees not to place the
system in operation until a Certificate of Compliant has bee su dby thfe- board of
Signed .... ... - = ---------------------------- ------.t ...
Dace
Application Approved By . :-:...... .-.............................. ---' l'[-/lam---a= ... . ........................ -- -7- J- ----" ---------
/ Dace
' Application Disapproved for the following reasons- ------------------------------------------/ . -- ............................ .........................
----------------------------------------------------------------------------------- - --------------------------------------. ---------------------------------------
�
/ �. Date
Permit No. / -- -- - --- f�/ Issued .......-. .-... -�...��t�
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(ILlEll'ttftrate of QlIIz/ latianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (x )
by W.E. Robinson Septic Service
-----------------------------------------------------......------....._---------------------------------------------------------------------
In.--her
30 Oxner Rd Centerville
at -------------------------------------------------------------------------------------------------- ---------------...-------------_------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE�of The State n_IronmentaI Code as described in
the application for Disposal Works Construction Permit No. . ...__ ....._".._:51k •�.. dated .��.-...,f...7----_�_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU.EA AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ���
./— ..
DATE........��...... (�_� - _....... - - Inspector ... -- ..... ...._- -�- _. .................
---------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 30.00
No. '_T".. FEE........................
�is�nu�t1 Turku �nnutr�rtinn �rrmit
W E. Robinson Septic Service
Permission is hereby granted ------- - -- -- ------• --. ----- -- ---- ---- ----
to Construct j )-o eeTai ,( ) an Individual
Vlllgewage Disposal System
atNo. -- •----------- -- -------------- -••----...
Street �}
as shown on the application for Disposal Works Construction Permit I\j � $Dated......
--•-------------•---••--. ------................................`
Board of Health
DATE f% (---
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
LO3� V.-
AT ION SEWAGE jl`E!,M4YNO.
r
VILLAGE
Ae
I N S T A LLER'S NAME & ADDIRESS
c e.p � ''
Ll�
_.. ;
B UILDE R OR OWNER d '
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
� � 33
No.............`�•? FEs...... !S.. ....
THE COMMONWEALTH OF MASSACHUSETTS
�}. BOARD F HEALTH...... Y -itii/.i'_.....o j......... ....... .. ... ..... ......................
, pptiration or Uispwi al Workti Toutitrurfiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (; ) an Individual Sewage Disposal
System at:�
Owner � -•----.....-
_.. .. _..
ocation e or
r2-� � � /A Address
. -- .................................................... ..................................................................................................
Installer Address
d Type of Building Size Lot..."'AX4:tKY...Sq. feet
Dwelling—No. of Bedrooms___.__ ....................................Expansiof Attic ( ) Garbage Grinder QL�v
P4 Other—Type T e of Building No. of ersons___--te Showers
a YP g ---------•-•-----------•-•-- P --•-•-•----.-•..•-•- ( ) — Cafeteria ( )
Q' Other fixt es
W Design Flow..........................:....:.. gallons per person per day. Total daily flow.._........_ ............._......gallons.
WSeptic Tank—Liquid capacity./....._.._gallons Length.............•.. Width................ Diameter---------------- Depth................
xDisposal Trench— No- -------------------- Width__.____ .......... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit 'No---------I......... Diameter./o __. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
' Percolation Test Results Performed by .... ./ ..........`-_�._. re ................. Date----•- y a .
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.•.__.___... _ ...... ....... . ..............................................................................................................
O Description of Soil......... . - ��� .!�! !�!*^*'""'�
x ............ _.% ............ r ...................................................
�....................••......--•------••....A.....••-•-•-•-•............--•----•••••.......
U Nature of Repairs or Alterations—Answer when applicable....................................................•........._.........__..._..................
..-•-•-•-••-•••-••---•••-•••------•---•••••--••--•••--••----•--•------•----•---•---•-•--•-••-----•--•-----••---•--------------------••••----•-----•--•••-•••-•--•••••----•••-•-••--•---•.............._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
x the provisions of iITl 5 of-the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu(Fd by he board of health.
aigned.���` ��� �. ............
-------------f `•' f. D to ......
Application Approved By...-•••• r- ---
Date
Application Disapproved for the following reasons-..............................................-----------------------------•---•••--• . ••-•-•--••••-•--•-.
-----••------•-----•---•---.....-•----•---.......-•-•-•-••----------•-•......-•---•----......•••••-•----•----••......•••-•••----••••------••-----•••-••--•------•---•----------•----••-•--••---••-------
Date
Permit No......................................................... Issued----- , ! �-----1�.............
Date
No.. .....%.s.... ....
THE COMMONWEALTH,OF MASSACHUSETTS
BOAR® OF HEALTH
.......OF....... ..............................
Appliration for Rspatial Works Tomitrurtion Prruat
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
ocatio,, dress For Iwt
.._........�.!._.._fr _s ,/ ,a�Fy 1 /� �''e r i [ ..a;' I',+'e✓ �`�
. ...•^ •--•-7-•-- ------------- 1,40
"+_..---'Address --
Owner
01
-�.
p Installer Address
Type of Building §:, Size Lot.... -�_��_.__-•...Sq. feet.,
Dwelling—No. of Bedrooms._.... ..................................Expansion Attic ( ) Garbage Grinder MO
p4 Other—Type of Buildiig ............................ No. of persons-----(._______•____-__--___ Showers ( ) — Cafeteria ( )
O.I Other fixtyres :-•-•-•--••-•---------•-•--•-•
----••-•------.....---•--••-•--•----•-•--------•----........•.............
W Design Flow................ ..6............_.._...gallons per person per day. Total daily flow............3.1 ...................gallons.
WSeptic Tank—Liquid capacityl gGOgallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width....______..___.___ Total Length.................... Total leaching area........._..........sq. ft.
Seepage Pit No---------/.......... Diameteryo. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by........ P !r' �....•................. Date......
14 Test Pit No. I................minutes per inch Depth of Test Pit____-_-_••-__•--__•• Depth to ground water------------------------
/ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil ..••-••-.7....•-•-• ......•-•-•• -------------------------------------------------
----------••-----------^-_-•-•---••-----------•----_-•---
D •P ""..........Ie'/, 1 _ ------------------------------------------------•------- ---------------------------------
1.
----
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 iITL is 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss d by he board of hea th ,
Signed' _ �_�......... !'� `r
Application Approved BY .._4 /,1. '� 1•�ll !................•.. / ----=�-......7.
`'- -'---�.
Date
Application Disapproved for the following reasons-------------•-••-------•----•------------•-----•------•---------------•-----------------------------...••_-•••--
^••-••••••••••-••-•-•••-•-••-•••-••-••-•••••••••••••-••••••••••--••••••••--••-•••••----••--•-••-•-•-•-••-••••••-••..._...----••••••-•••••-•-••--••••••-•••••••••••••-•••••-•••••-•---
--- ----------
Date
PermitNo.......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
HEALTH./...✓ � s�z�l�.. ............................
F
( ntifirFatr of TomptiFaurr
Tj.IIS IS TO CERTI Y, That the Individual Sewage Disposal System constructed ( 4'�`or Repaired ( )
by..... ..... _.. 'P . -•-------------- •---------- ----- .......
` U Instal /
/ . . ... t 1' ---'�-----F-=-------�--...{r �F- .-�1
has been installed in accordance with the provisions of TI/"'��'r--'• 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No: ='___�`�.....•....__...__. .....................
THE ISSUANCE OF•TINS CERTIFICATE SHALL NOT BE /,TWEDVVR
ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........................................................--____------.......--- Inspector• ••.-•• -=-----•••--•-•--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
-, A; ................................
/ FEE....2__5...
ti.
Disposal Work pan�posal.
a#ra ion rrnmit
Permission is hereby granted..... _:._.:.r............:..�(
• •••••••-•••••---•-•.............•••-•--......................_..
to Construgr(�y(' ) or Repair ( ) an I, ividual S,e)wage ystem
at No._"_. /•••.7_/ � ' �.� rl. f (�(•C�-`' � _.._.... Gi ------ - •.............
_ T.�-----...-^_-.,.... _.. Street '-
as shown on the application for Disposal Works Construction Permit .o..__ . Dated.__ — 7�
' ° 1 . ..............................
3 C —7 Board of Heath/
DATE. -- ...- /-••• .... --- ................••••.
FORM 1.255 HOBBS & WARREN. INC., PUBLISHERS
2-723,±
43 I+
-•_ �- 25� AST#
oT 2 3 M�
L
�-0
Q� a 1�.1
N VQ
LOT 23s\ _
28
0
V OF MASS
THOMAS
LLE
I 3L3 31.2 T�
I;� 31c7 Fcrs/fie
L oT 3 0 I �0 s u FN
THOMAS E.KELLEY-CO.
ENGINEERS—SURVEYORS
346 LONG POND DRIVE
r)TV•4E -VOP ot= SOUTH YARMOUTH,MAS&
IS Co.7 F=tEV A�3oVC T-+E - ��
c�UT Eet.►i� 01` E READ CERTIFIED PLOT . PLAN
oPt'o5.'rz-_ Tu E SovT�E2Ly LOCATION CE-KD -_Rv�Lb_: . ...
��NbaT►oN v�/ALL, SCALE .( ��- .3�.�. . . DATEM! !�
Z) E PLAN REFERENCES-Au.�F. - .'.J 1►�?
CEOyTE2v�("("E_�3A2►.�Sr.l,_'B E .55,
4v4Te2 Avg &.-wg 6. �4'.I��: ?►, 1��3 ,.L_ . . . . . .
1uc_ S�2vEYo2
P_r%,&J S 2--77
I CERTIFY THAT THE
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
S TBACK REQUIREMENTS OF THE TOWN OF
L-EY 1
t�.LrXA . . WHEN CONSTRUCTED.
�c�LL i�G iT�-F� (2o�tj
C EtJT--f---2 C.C"E. 1'1 A5S• DATE /�
1 �
PETITIONER: 02.cp3Z EGISTERED LA D SUR YOR
L.31.�7. .. .. ... w
TOP OF FOUNDATION
1 CONCRETE COVER
CONCRETE COVERS
411 CAST IRON 12��MAX. � r f '
12"MAX.
PIPE (OR 4IORANGEBURG(OR EQUIV.)
° EQUIV.)— MIN. PIPE- MIN. LEACH
PITCH I/4"PER. PITCH I/4"PER.FT.
o PIT PRECAST
ol� NVERT Q ';�:: LEACHING
` e EL.44•37. ... V PIT OR
IN T INVERT ? w q.�
SEPTIC TANK �� DIST.
EL....�.. E228:13 _ EQUIV.
�.0 INVERT • ' BOX ,. °•
GAL. INVERT F-�" „ ..
28 INVERT " va- :�, 3/4 TO II/2
EL.... w w 0-
�2�8g WASHED
w r: STONE
10 ...
o, � , ., _ IA� ►lo
PROFI LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
SOIL LOG WITNESSED BY :
DATE �.34'"9"... TIME.3..�. ?S. PSI• Cr v BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 hlpmA-:;. U-LP _3I�.)
ELEV.. .''`':". . . . ELEV. .. .. . . . . . . e •&NGINEER
.,✓ooOlopr.^ W G37DLOA�1
DESIGN DATA :
gesso,1. Suasart_ NUMBER OF BEDROOMS 3
Zq" 24„ TOTAL ESTIMATED FLOW . . 3Q. . . GALLONS/DAY
BOTTOM LEACHING AREA ?8'S� . SO-'FT. /PIT
h`tp. SA�fl
mEDISAI�O SIDE LEACHING AREA . . .� �. SQ.FT./ PIT
GARBAGE DISPOSAL (50% AREA INCREASE)
Cv
2A1Ct_
TOTAL LEACHING AREA . '�� SQ.FT
i*j E. -j 4,TL _
144" I ,� PERCOLATION RATE . . . �G`�.�. MIN/INCH
LEACHING AREA PER PERCOLATION RATE SQ.FT.
.�O.WATER ENCOUNTERED
NUMBER OF LEACHING PITS r14
APPROVED- .'BOARD OF HEALTH
DATE. . . . . . . . . . . . . . . . . .
AGENT OR INSPECTOR
�filL�/ZL6S �C�Tiq�v�!� ���P���DF MAss90
THOMAS yG
t/TGf/ Zv¢ E. r'^„
CE.UTL��di�� Ufa�S THOMAS E.KELLEY CO. � KEUEY co
•_4• . . . ENGINEERS—SURVEYORS .A No.24260 O
026103 Z 346 LONG POND DRIVE o9o�F.G/STEa���a``
PETITIONER
• SOUTH YARMOUTH,MASS. FSS�ONALEaG
. 02664