HomeMy WebLinkAbout0033 OXNER ROAD - Health 1,33-Oxner,R6ad,44�",
Centerville
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UPC 12534 '
ILO.2�153_LO�R
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LOC'kTION SEWAGE PERMIT N.O.
V LIL A G E F
I N S T A LLER'S #, NAME i ADDRESS
-`B-U-1-L,DhE-R OR OWNER r
J
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED 17 --29,
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No....................... .... ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD RF HE
........ ------------*OF......... �............................
Appliration for Disposal Works Tonstrartion 11nmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewa isposal
System at: /(?w-aVJ - - ..
.... ......................4----- ....... -----------------------------------------------------------------------------------------
-L-.cal'.n-Address.......... r Lot.No.
. .................
..........I..._.._.._. ......._._.................
ner Address
..............
------in----- --------------------------------------- ...---- ----- --------------------*------------------------- -----------
--- ------inst ler Address
Type of Building Size Lot_ ........................Sq. feet
r. Dwelling—No. of Bedrooms.......tv..................................Expansion Attic-(—)-. Garbage Grinder-�—)-
P4 Other—Type of Building ............................ No. of persons.......:.........__..__.____..................... Showers Cafeteria
04
Other fixtures ....................................................................................................................................0...............
Design Flow.......�,.r a.............00.......gallons per person Rer day. Total daily flow......%1,0.0.........................gallons.
WSeptic Tank—Liquid capaci"ey............gallons Length-_-4�.......... Width..G.......... Diameter................ Depth..............._
Disposal Trench—No........... ... Width.................... Total Length........
...... Total leaching area....................sq. ft.
Seepage Pit 2 No....6?9!� AA.eter.........P--- Depth below inlet......;K..... . Totaf leaching area..�....4.k..sq. ft.
Z Other Distribution box Do i tank W_ -
Percolation Test Results Performed ........ ................................................ Date.../.,2--YP....7.t.......
Test Pit No. I................minutes per i;nh Depth of est.Pit.................... Depth to ground water.___.._..............__.
Test Pit No. 2................minutes per inch Depth of Test Pit.__........_.......... Depth to ground water........................
---------------- ................ ...
0 Description of S il..............0-1-------'t X
-- ------
... ........
,
/P
.............................................................................................................
................. ....................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable........................:.........:............................................................
............................................................................................................................................................................I...........................
Agreement;
: 1 1
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system,in
operation until a Certificate of Compliance has bee issuedb the b • • l health.
11 t h.
Sign ................... .... . ....•----....-•----....--•---
......
Application Approved By....... ................ ..../-2 -- *.... ......7�.l.........
Date
Application Disapproved for the following reasons:....................... ............7........................................................................
................................0.......................................0...........................0.................................................................................................
Date
7,
Permit No........................... Issued_ ............................
..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD qF HE
OF.........
.. . ..... .. ..... .. ...............................
Appliration for 13haposal Works Tonstrurtion ramit
Application is hereby made for 'a Permit to,Construct or Repair an Individual Sewage Disposal
System at:
........ .
. .................. ....... ........................................................................................
oc /"o r Lot No.
Adner
dress
................. ....... ' --------------------4- -- --------------------- ..................................................................................................
Insta le-Z .11-
r Address
Type of Building Size Lot.266......Sq. feet
Dwelling—No. of Bedrooms_ ................................Expansion Attic-4--+ Garbage Grinder
04 Other—Type of Building ............................ No, of persons............................ Showers Cafeteria
Other fixtures .................i...................................................................................
�p---------------------*-----------
Design Flow............Iro........ ...........gallons per person per day. Total daily flow....._ ..............................gallons.
WSeptic Tank—Liquid capa 711r� 'V gallons Length._.i?�......... Width...6�......... Diameter'*... ................ Depth......_......._.
Disposal Trench—No.......... Width.................... Total Length........ ...... Total leaching area.----------- sq. ft.
Seepage Pit ameter..........1-4--- Depth below inlet.._,.._......... Total leaching area--- ft.
Z Other Distribution box Dosi/n tat(4 ;t _» /F — *7,d—
Percolation Test Results Performed ........... . . ............................................. Date...42..-A/�,P_�7 .....
f
Test Pit No. I_-------------minutes per inZ Depth of �est Pit........_........... Depth to ground water._....................__
Test Pit No. 2................minutes per inch' Depth of Test Pit._.......::...:_:;.; Depth to ground water.........................
,'
0 .. .... VNX. & I - ----------------
. ..-------------/----
Description of SPil.... ..... ......... -------------------------------------------------------------------.....-..-.-.-.-.-.-.-.-.-
.........
.................
............... ......................................................................................................................................-.................................................
U Nature of Repairs or Alterations 2—Answer when applicable..............................................................................................
.............................................................................;......................... .....................................-- I........................................................
Agreement:
The undersigned agrees to i install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TTLIZ 5 of the'State Sanitary Code The undersigned further agrees not to lace the system in
A.— i p
operation until a Certificate of Compliance has'bee�s tied bD,,the bo healt
h.
_qlth
. .. .......Sign .....................
Date
7--
.. .........
Application Approved By........7......• . .. ..........
Date
Application Disapproved for the following reasons:..................... . ..................................................................................
......................................................... ----------------------------------------------------------------------------7................................................................
Date
PermitNo........................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... n*h.............OF......... ... ...................................................
.�-�-
Tntifiratr of Toutpliatta
THI IS TO_g 'y
.&YT I �'
/7hat the Individual Sewage Disposal System constructed /Oo Repaired
by. X.......4_17. jW/..... .............................. ....7........ ........
Nstaller
------------* j
9A...... . ...... ..........................................at....;�.....
has been installed in a* with the provisions o T ;rl_ of The State Sanitary Code as d c 'b d ' the
application for Disposal Works Construction Permit No---- ----------:2, ................... dated-.-..--/..............!��.. ..................
THE ISSUANCE OF THIS CERTIFICATE: SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................................4............................................. Inspector---------------------------------------------I..................................7....
THE COMMONWEALTH OF MASS*CT-iUSETTS
OF HEALTH
r'7 .......... .. .... -.4-W...................................................
FEE...
a .._.
Displisa rhv rjXdialt prrufit
n �, J�
Per'mission q hereby granted.........6.!�! Agnll�!1141 -
1� i--------------- ...................................................
to Constru9t)( 41r_r Repair n Indi idu "KS,R 0 )/a v I Sewage Disp
atNo.fn.... w ....................................
Sheet
as shown on the application for Disposal Works Construction?Perif m 1"N o... ated..... ..............
a
...Viie-W-V ...................
Board o ;-a'
DATE... A'Frj-------
V
............................................. ..
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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THOMAS E.KELLEY CO.
ENGINEERS—SURVEYORSi,� v��
346 LONG POND DRIVE :J
SOUTH YARMdiJTH,MASS. CERTIFIED PLOT PLAN
02664
LOCATION
tw of �,o:i ot•tfgss�� SCALE . DATE
i�o THOGP. g TH01" PLAN REFERENCE}E.
�l�?
r .o
ON
,.98. gw.3/�i.
I- RTI E .. DcJ�47
SHOW S PLAN IS LOCATED ON THE GROUND
AS SHO HEREON AND THAT IT CONFORMS TO THE
jl SETBAJ,C jUIRME�iI OF�THE TOWN OF
G� .1 f/G. HEN CONSTRUCTED.
C/:J77::na.�<' �s fib//ij1 DATE
'
PETITIONER:
REGI TERED LAND SURVEYOR
I > .J
f
EL. So.off
OP OF FOUNDA ,ON � �� CONCRETE COVER
CONCRETE COVERS
CAST IRON PE (OR 12"MAX. ` ' 12"MAXUIV.)— MIN. 4"ORANGEBURG(OR EQUIV)CH 1/4"PER. PIPE- MIN. -T LEACH
PITCH 1/4"PER.FT. PIT PRECAST
--INVERT Q LEACHING
o EL.. '/.00.. INV T INV PIT OR '
SEPTIC TANK SZ DIST. w EQUIV.
�QD� EL... c. . EL
INVERT BOX
•
GAL. INVEj2 T �~ Q: °•
ELY T4 INVERT ww 3/4°TOIIli'
� LL o
WASHED
. EL....r.... .. W
STONE
j
l0� DIA N v
PROR LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
03r-R E L
I FA A R"Tw;
SOIL LOG WITNESSED BY :
DATE /2.•ltB,78.. TI ME. 9,', �� T��U�/��l�2�Z�f•! .��•� . BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 �-
ELEV. .. .. . . . . . /,�D/�J/�5 �•/�E� Rc•. ENGINEER
�q woo9Loqn1
8 _ DESIGN DATA
-�-
NUMBER OF BEDROOMS .T'��r�� . . . . ,
TOTAL ESTIMATED FLOW . . �.0, . GALLONS/DAY
BOTTOM LEACHING AREA . . 9,5.�. SQ.FT. /PIT
►�li�T�j2`� SIDE LEACHING AREA ,.�/�1��✓`0 . SQ.FT./ PIT
GARBAGE DISPOSAL - AA1 . .(50% AREA INCREASE)
MED.S�,v� TOTAL LEACHING AREA . SQ.FT
PERCOLATION RATE . . . T�/o . . MIN/INCH
LEACHING AREA PER PERCOLATION RATE. Q. SQ.FT.
A�d WATER ENCOUNTERED
NUMBER OF LEACHING PITS
APPROVED . . . . . . . . . . . . . BOARD OF HEALTH •/.����/��lQ/1�c�� �'241�i�Q�lJT���� D/-
DATE . . . . . . . . . . . . . . . . . . . rp�GGtl'1„1 ��`/��Ci� �„��/Cif G•'��
AGENT OR INSPECTOR
THOMAS E.KELLEY CO: '
ENGINEERS
LONG PONDR VE S OFM9s 346 DR
C S. z �� THOMAS yG
SOUTH YARMOUTH,MASS.
E.
02664 o KEILEY
No.24460�� �
q0 G/STEQ
FSS/ON L Eat
PETITIONER ��%F����/.'f�i`�� /Z•ZO•�O �!U✓ler✓'L I�
a
5 TOWN OF BARNSTABLE
LC CATION 3 / 36 V e-, SEWAGE#
.VILLAGE � ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. Ste Z 6,15 J c�
SEPTIC TANK CAPACITY ) QD� -
LEACHING FACILITY.(type) 'S size)
NO. OF BEDROOMS ��
OWNER
PERMIT DATE: !9 /3'a COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
f �
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i°i`�
c� ``-'fie.�
��
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TOWN OF BARNSTABLE
LOCATION )Q09 SEWAGE #
VILIykGE ASSESSOR'S MAP & LOTIg�'�a•�
1 v'n
Jd
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)
� ze
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COIvY1,� CE DATE:
Separation Distance Between the: e�
a
Maximum Adjusted Groundwater Table to tkiottom 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
No. Fee �z
,THE COMMONWEALTH OF MASSACHUS'ETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZppYicatton for 3uoogal *pgtem Con0tructton Permit
� I
Application for a Permit to Coyruct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 12 C)MC Owner's N A ddress;and Tel.No.
Assessor's MapTarcel 3 P (la—
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of B ilding:
Dwelling No.of Bedrooms 2-- Lot Size 60 sq.ft. Garbage Grinder ( �
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 'LID — gpd Design flow provided gpd
Plan Date "S,IM9 Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this and of Health.
Sig d Date -09
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
No. / t Fee
r
;i 4E''°C.OMMONWEALTH OF MASSACHt1SETT Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplication for )Bigpogal *pgtem Con.5truction 30ermit
Application for a Permit to Coneruct( ) ,Repair of ( ) Abandon( ) ❑.Complete System ❑Individual Components
t
Location Address or Lot No. 33 � � Owner's Nam ,Address,and Tel.No.
Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer'sNamdAd'djess and Tel.No.
_ w
%I l i $ 2a �. v�ct e e ..h 3 61--16y 1
Type of B ilding:
i Dwelling No.of Bedrooms Z Lot Size 6 sq.ft. Garbage Grinder (No
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ILZO gpd Design flow provided -�j 7 gpd
Plan Date 2S,7ooq Number of sheets Revision Date_ /V
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this 44eard of Health.
j
Sig Date '�� I 0
Application Approved by_")&'1 is Date g
Application Disapproved by: Date
i
for the following reasons
Permit No. Date Issued
--------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliattce
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( )
{ Abandoned( )by N o t
t1u at ,ner t�.. (`(,o ,� � has been,constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No . .. /w�. dated
Installer \ ek r.iUe Designer �. �3n�►, � A,Jf_,r
#bedrooms Z.. Approved design flow gpd
The issuance of this permit shall not a con tr fed as a guarantee that the system if�i] cti as design m
Date Inspector
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS
=igpoga16pgtem C o truction i3ermit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( )
System located at `!Z MAer
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction ust be om leted within three years of the date f tf t pe
Date Approved
Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
BAAS&"J= Public Real& Division
Mse Thomas McKean,Director
200 Main Street,Hyannis. MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer d: DesiQner-Certification Form
Date: �' l� Sem,age Permitf4L2—3Y9 Assessor's Map\Parcel�
Designer. U vJ ^- 2 Installer: / C(
q c /
Address: /39 ��^ Address: ��
U WA_ nJ-
On was issued a permit to install a
(date) (installer)
septic system at (�l`�N- based on a design dra-,Am by
(address)
LQ. dated
(deslk r)
I ce:an° gnat the septic system referenced above was installed substantially according to
file design; u�nich may include minor approved changes such as lateral relocation of the
distribution box andlor septic tanh.
I certify that the septic system referenced above was installed with major changes (i.e-
Rreater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance Aith State & Local Regulations. Plan revision or
v
cerifled as-built by designer to follo-W.
F H OF NSSq
ARNE H. oyGN
OJALA
(Installer's Signature) CIVIL cn
NO. 30792
FG I S T O'� �Cr�
-8/GNAL EaG\
(Designer's Signature) (.affix Desi` is Stamp Here)
PLEASE. RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q: HeaUdSeptic/Designer Cenification Form 3-26-04.doc
Town of Barnstable
Op 1HE T°�
Regulatory Services
BnxxsrnaiE. ; 'Thomas F. Geiler, Director
y MASS. g
1639o. Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
FINAL ORDER
July 18, 2007
Mr. John Cosby
33 Oxner Road
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 33 Oxner Road, Centerville,MA was last inspected on
April 271h, 2007,by Ronald Burlingame, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 ( 310 CMR 15.00) due to the following:
System is in hydraulic failure
You were given 60 days from the date of the system failure May 16th, 2007 to bring the
system into compliance.
Any person who shall fail to comply shall abe fined not less than $10.00 nor more
than $500.00. Each day's failure to comply with an order shall constitute a separate
violation.
You may request a hearing before the Board of Health, a written petition requesting
a hearing on the matter,within seven (7) days after the day this order was served.
4omas
RNSTABLE HEA H DEPARTMENT
A. McKean, R.S., C.H.O. 1
Agent of the Board of Health 17 --1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ae
-TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 33 Oxner Rod
Centerville,MA 02632
Owner's Name: John Cosby
Owner's Address: 33 Oxner Road,Centerville,MA
Date of Inspection: April 27,2007
Name of Inspector: (please print) Ron Burlingame
Company Name: Ron Burlingame
Mailing Address: 58 Oak Street
West Barnstable,MA 02668
Telephone Number: 508420-2050
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 DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
.�i.
Passes , `
Conditionally Passes
Needs Further Evaluation by the Local Approving Auth
X Fails
Inspector's Signature: Date:
nJ >
The system inspector shall submit a copy of this inspection report to the Approving Authority(Boar of He4or co
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design Qw of 1000rri
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regio 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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CNM
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 high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria 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:
r
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than`h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
YES (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
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.
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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X — Were as built plans of the system obtained and examined?(if they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS,located on site?
X _ 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?
X _ 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
X _ Existing information.For example,a plan at the Board of Health.
X _ 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)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no):No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use: (yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2005/81,000 2006/67000
Sump pump(yes or no):No
Last date of occupancy: Current
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CUR 15.203): gpd
Basis of design flow(seats/persons/sgketc.):
Grease trap present(yes or no):_
Industrial 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: N/A
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: ggallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information: 1978
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
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: X (locate on site plan)
Depth below grade: 1'
Material of construction: X concrete_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: 1000 gallon
Sludge depth: 12"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement baffles are in poor condition. No cement tee on outlet end of tank
GREASE TRAP:_(locate 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 8 of 11
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: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explam):
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: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: At working level at time of inspection.
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.): Yes,evidence of soil carryover.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
1 leaching pits,number: 1000 galilon pit with stone.
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.): Signs of hydraulic failure. Heavy soil staining and soil waste at bottom of pit.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
• Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
l
• Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 14 feet
Pl 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:
TO
Z
-o
1 Z,
l�
SYSTEM PROF LE NOTES
TOP FNDN. AT EL. 76.0'
ACCESS COVERS TO WITHIN 6» OF FIN. GRADE (NOT TO 1. DATUM IS APPROXIMATE NGVD
ACCESS COVER (WATERTIGHT) TO ACCESS COVER TO WITHIN 3 OF FIN. GRAD
75,0' MINIMUM .75' OF COVER OVER PRECAST WITHIN 60 OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING
2% SLOPE REQUIRED OVER SYSTEMice Rd•
ger
74.5' RUN PIPE LEVEL 2» DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. = CrosbyaCap' a
\_*EMTING FOR FIRST 2 OR GEOTEXTILE FABRIC ,�
**EXISTING 1000
3' MAX. H_DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO Rood JQcs
10 pak Street
*EXISTING GALLON SEPTIC TANK 73.1 tt GAS s` SUP 73.52'
boo
6 72.79' 5. PIPE JOINTS TO BE MADE WATERTIGHT.
.. _. .. BAFFLE 72.96' � 0 L=1 0 �
r72.72' p p p p. Q p E3 Q p ° 6. CONSTRUCTION DETAILS TO- BE IN ACCORDANCE WITH LOCUS a
6" CRUSHED STONE OR MECHANICAL 10 � C] m ED G 0
COMPACTION. (15.221 [2]) 2' O 0 Q 0 CJ CI O 0 MASS. ENVIRONMENTAL CODE TITLE V. jyg9et
DEPTH OF FLOW = 4' 0 70.72 Rio, Lake .
7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
INLET DEPTH = 10"
Q
OUTLET DEPTH = 14" ( 1 X SLOPE) ( 1 x SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. e�°°d
FOUNDATION EXISTING SEPTIC TANK 14' D' BOX g' LEACHING 5.22' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION LOCUS MAP
OBTAINED FROM BOARD OF HEALTH.
*THE INSTALLER SHALL VERIFY THE VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE SCALE: 1" = 2,000'f
LOCATIONS OF ALL UTILITIES AND IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
ALL BUILDING SEWER OUTLETS AND BY HEALTH INSPECTOR DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION ASSESSORS MAP 193 PARCEL 122
ELEVATIONS PRIOR TO INSTALLING BOTTOM TH-1 EL. 65.5 OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO
ANY PORTION OF SEPTIC SYSTEM PAPERWORK AND HEARING REDUCTION PROPOSALS-APPROVED COMMENCEMENT OF WORK. LOCUS IS WITHIN AP OVERLAY DISTRICT
BY THE BOARD OF HEALTH REVISED DURING A PUBLIC
HEARING HELD ON NOVEMBER 15, 2005 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
**THE INSTALLER SHALL CONFIRM REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
MIN. SEPTIC TANK SIZE AT 1000 2) FAILED SYSTEMS ONLY - SEPTIC SYSTEM COMPONENT TO ,� UTILITY CLUSTER
GALLONS AND ITS SUITABILITY FOR FOUNDATION SETBACK, IF AN IMPERVIOUS LINER IS DESIGNED �4 CATV, TEL RISERS 12. ANY UNSUITABLE MATERIAL ENCOUNTERED. SHALL BE
RE-USE AND INSTALLED. 1 ELEC HANDBOX REMOVED 5' BENEATH AND AROUND THE PROPOSED
LEACHING FACILITY.
i
LEGEND SYSTEM DESIGN:
100.0 PROPOSED SPOT ELEVATION � GARBAGE DISPOSER IS NOT ALLOWED
+100.00 EXISTING SPOT ELEVATION ; r DESIGN FLOW- 2 BEDROOMS 0 110 GPD = 220 GPD
,� �� I9.3S• USE A 330 GPD DESIGN FLOW
100 _p PROPOSED CONTOUR ,
SEPTIC TANK: 330 GPD (2)°= 660
100 EXISTING CONTOUR `� PAVED PAV i
" **If,--i.lSE EXIS; Nr 1000 GALSEPT{v TANS
/fir F�
CAUTION! GAS SERVICE IN AREA ��2, LIGHT ST LEACHING:
TEST HOLE - LOGS (SEE NOTE f10) �, ��� 15�
Q `��., % GARAGE SIDES: 2 (25 + 12:$3) 2 (.74) 112 GPD
SLAB g
ENGINEER: DAVID FLAHERTY, R.S. �,� w BOTTOM 25 x 12.83 (.74) = 237 GPD
5 REMOVAL OF SOIL REQUIRED TO , ���\ i
DONNA MIORAND{ R.S. ACCOMMODATE 60't 40 MIL LINER �� i Olt-
WITNESS. TOTAL: 472 S.F. 349 GPD
; ." w�
(AS SHOWN PER PLAN) DOWN. TO � � �� .�
DATE: MAY 22, 2007 SUITABLE SOIL LAYER. REPLACE �O ,
WITH CLEAN MEDIUM SAND. USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
< 2 MIN/INCH
{NCH TOP-OF LINER EL. 7352' t� i p L, _: �� O T 36 WITH 4' STONE ALL AROUND
PERC.. RATE. - / BOTTOM EL 69.52' SFt
CLASS I SOILS P# 11791 ''
of ,
BENCHMARK
ELEV. ELEV. `' EXISTING 2 BR TOP BRICK LANDING , MA
0" 41 2. i : i O' DWELLING- ELEV = 76.34' APPROVED DATE BOARD OF HEALTH
75.5' 0" 75.5' , : TOP FNDN
, ELEV=76.0'
A A
c�
LS LS `
i t1of
d-
6" 10YR 3/3 75.0' 6" 1 OYR 3/3 _ 75.0' R=120.0 DECK w TITLE. 5 . SITE,E PLAN
V
A=9.95,
OF
LS LS . s 33 OXNER RD.
10YR 5/8 74.2' " 1OYR 5/8 METER
16"
16 74.2 (CENTERVILLE) BARNSTABLE, MA
UTILITY CLUSTER
CATV, TEL RISERS PREPARED FOR
C C
ELEC HANDBOX
PERC HICKEY- CONSTRUCTION
MCS MCS DATE: MAY 25, 2007
2.5Y 6/3 2.5Y 6/3
5% COBBLES 5% COBBLES ��H OF
ass �`� M�� Sc off 508-362-4541
�� q�y Q ARN hl. ARNE yG fan 508 362-9880
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o OJALA OJALA H.
CIVIL A ,26348 dolmen ca e engineering,eerin inc.
No. 3079 � � P 9 9�
120" 65.5' 120" 65.5' Cl U!L ENGINEERS
�'o F ° '�ess\o
Scale: "= 20' sG/S aG` suRV °� LAND SURVEYORS
NO GROUNDWATER ENCOUNTERED y/ y
Wig / 939 Main Street YARMOUTHPORT, MASS.
0 10 20, 30 40 5o. FEET D ARNE H. OJALA, .E:, P.L.S.
DCE #07-116 07-116 HICKEY CONSTRUCTION.DW6 (DDF) }`