HomeMy WebLinkAbout0077 PADLOCK LANE - Health 77 Padlock Lane
193-186 Centerville
No. 4210 1/3 ORA
Pendaflex'
10%
"0 '04'BtNSTABLE 1' C. �°
LOCATION^ r�-y�-im� , SEWAGE #
VILLAGE EiN) �1 V'l.l.t ASSESSOR'S MAP & LOT��7 J�o
INSTALLER'S NAME&PHONE NO. To M Il AWE T-1
SEPTIC TANK CAPACITY DO Llo N
i
LEACHING FACILITY: (type) �-(SUv G L 1)rt "ELuS (size) I3 A a'
NO.OF BEDROOMS
BUILDER OR OWNER 6 t &� , D W 6 I NC.
PERMTTDATE: - COMPLIANCE DATE: j
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
� 2
1J
a�
s
3o
J
,
No. q J7 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
• Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Migozal 6potem Con5truction 3dCrmit
Application for a Permit to Construct(e/)Repair( )Upgrade( )Abandon( ) 2/complete System ❑Individual Components
Location Address or Lot No. 6 J!�Oyfl.vT MA./dE Owner's Name,Address and Tel.No. W4_— 6 6
Assessor's Map/Parcel /f3 /I ® b U lgo ov T
Installer's Name,Ad s,and Tel.No. O Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(AV)
Other Type of Building4bo /G44/i 4 No. of Persons 2. Showers( ) Cafeteria( )
Other Fixtures
Design Flow 660 gallons per day. Calculated daily flow 3130 gallons.
Plan Date 1 Number of sheets Revision Date
Title 6 rdIVAIVI— p,o_ A17_fAV 1 U-9
Size of Septic Tank /5-06 ,^,6A-�A/ S Type of S.A.S � ®0 6fYC 11.2�/C¢� LCS
�� /Description of Soil, -a-
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been�' suey
rs Board e
Si Date
Application Approved by Date MAN
Application Disapproved for the following reasons
Permit No. Date Issued
Fee
THE COMMONWEALTH OF MASSACHUSETTS _"Entered in computer:
Yes
,PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
Zlpprication for Mi!gpogar *pgtem Congtruction Permit
�,-Application for a Permit to Construct(V)Repair( )Upgrade( )Abandon( ) /complete System ❑Individual Components
Location Address or Lot No. 6 CdAl J,vT 1A Owner's Name,Address and Tel.No. 6 C/
Assessor'sMap/Parcel
b �
Installer's Name,Address,and Tel.No. .� �. Designer's Name,Address and Tel.No. 7?5 — D 7 3 S
rA
�A,R ✓�. . ��,�
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(A10)
Other Type of Building�L nA F2f1 AM No.of Persons ''Z Showers( ) Cafeteria( )
Other Fixtures \
DesignYlow 660 gallons per day. Calculated daily flow 330 gallons.
Plan Date ~l Number of sheets Revision Date
?° ' Title 4 <'d/IW 7 4AI. ('CAI rg it I LLS
Size of Septic Tank /S-061 o9AL4 Al 5 Type of S.A.S._ Z-) S60 6fiC A ` (o1�CLs
Description of Soil d o /LP.t 4
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
i" Cate of Compliance has been i sue'by ffiisBoardyf e"alh�
Signed / Date
Application Approved by C Date
Application Disapproved for the following reasons
Permit No. Date Issued
--------------------------------------- -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
J THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(✓)Repaired( )Upgraded( )
Abandoned( )by
at CDNf1 /-�'�"' ..._ C�'�T�� /�C.�z has been constructed in accordance
with the provisio�n of Title 5'an the fo Disposal ,ystem Construction Permit No. dated
Installer IJO/',f'- Designer
The issuance of this permit shall not be construed as a guarantee that the sy tem willrfunction *sedesigne
Date Inspector "
No. iW� �� ` � -------------------------Fee
—�—�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
.s,
lwigpogal *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at f, 0,V4AIT L/V• C 6 /jam✓1 LJ1JE
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit. -
Date:_ Approved by
r,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
wM 77 Padlock Lane aka 6 Conant Lane(Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is Centerville MA 02632 May 14 2010
required for Y
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your David D. Coughanowr
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental
Company Name
VkA 43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364 0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
,�.4 Q) I/
C '�---- P—S May 14, 2010
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is y
required for Centerville MA 02632 May 14, 2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is Y required for Centerville MA 02632 May 14 2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
❑ P P Y 9 9
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is y
required for Centerville MA 02632 May 14, 2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is Centerville MA 02632 May 14 2010
required for Y
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is required for Centerville MA 02632 May 14, 2010
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 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 gpd
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is Centerville MA 02632 May 14 2010
required for Y
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 112 gpd
9 ( Y 9 (gpd))
Detail:
2008-2009
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ . No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is y
required for Centerville MA 02632 May 14 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is required for Y
Centerville MA 02632 May 14 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Age: 6+ years. Certificate of compliance issued 12/17/2003 (Board of Health permit#2003-371)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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.):
No evidence of leakage or backup into dwelling was observed.
Septic Tank (locate on site plan):
Depth below grade: 1
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: 10.5 ft x 6 ft x 5 ft(1500 gallon)
Sludge depth: 2 in
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is y
required for Centerville MA 02632 May 14, 2010
every 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 32 in
Scum thickness 1 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design Plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 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
77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is Centerville MA 02632 May 14, 2010
required for Y
every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is y required for Centerville MA 02632 May 14, 2010
every 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
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was not located where shown on as built card, nor was it found by probing extensively in the
general area indicated. Mechanical excavation is not recommended due to potential damage to
subsurface utility and irrigation lines. System has been evaluated on the condition of the leaching
gallery instead (see page13 ).
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 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 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is required for CentervilleY
MA 02632 May 14, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 1
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils.
No standing effluent was observed to a depth of 1 foot below the top of the peastone layer.
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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form e Not for Voluntary Assessments
;M 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is y
required for Centerville MA 02632 May 14 2010
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is Y Centerville MA 02632 May 14 2010
required for ,
every 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
cc
n - o
o
171
3c�
?AD LOCK LNNL
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is Y
required for Centerville MA 02632 May 14, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 30+
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: Permit issued 8/8/03
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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows no groundwater mottling was observed
to a depth of 5.6 feet in a witnessed test pit on 9/26/02. Town of Barnstable GIS Department records
indicate that the property is over 30 feet above groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M ,. 77 Padlock Lane aka 6 Conant Lane (Assessor's map 193 parcel 186)
Property Address
Roger and Diane DuPont
Owner Owner's Name
information is Y Centerville MA 02632 May 14 2010
required for ,
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE ( C,
LOCATION �9 ( ,6N JA/ .. L�AIE SEWAGE# ® 2
VILLAGE �,�N)�11v�L1,� ASSESSOR'S MAP & LOT-_`I'
INSTALLER'S NAME&PHONE NO. TOP �1 EN�✓�D 7� ���- ����
SEPTIC TANK CAPACITY I S off LLo N
LEACHING FACILITY: (type) �- Svv G L. DIL -0, (size)
NO. OF BEDROOMS
BUILDER OR OWNER �i t �Jv� (, I N L.
PERMITDATE: COMPLIANCE DATE: I 0 3
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
l
GC
{ .f
a
3o
i
v
MT ® . Town of Barnstable P# L
Department of Regulatory Services
BARNBIABL& "'Public Health.Division. Date
MA9a
i619'
piEo��► 2110 Mein Street,Hyannis MA 02601
Date Scheduled 026 a' Time �.dv/f m Tee Pd.
Soil Suitability Assessment for Sewage Disposal
J
A1
Performed By: o ut.1 Vl Gl�ti1 @SL,'C 'Witnessed By:
,
1
Own
Location Address / er's Name 0��� , �VQpt.1`f
(, Go►1n,a� �-AtJG y3 ,NRE� �Por�oS �a\vs✓
Address
Assessor'sMapTarcel: /93 6 Engineer's Name C op51A\_
NEW CONSTRUCTION _ REPAIR Telephone H '_2�/-`��
Land Use
1GS\ �F- �i I Slopes(%) 3 ' Surface Stones N
Distances from: Open Water Body o b 4r ft Possible Wet Area l ft Drinking Water Well Zen} ft
Drainage Way 1 D b + ft Property Line 2�_ft Other ft
SI{ETCH:(Street name,dimensions of lot,exact locations of test(roles&perc tests,locate wetlands In proximity to holes)
I
0
c-
>
� s �
VD ,
�3 - -301
— —��C>
y
Parent material(geologic) kRO
LrAC kAL 031W Ai Depth to Bedrock
�gl1l✓
Depth to Groundwater: Standing Water In Hale: F.1 O��! Weeping from Pit Face
Estimated Seasonal High Groundwater I
4
Method Used: "ir- S oV A 1 P ;l. I
Depth Observed standing In obs:hole, 4� in Depth to soil mottles. ' ft
Depth to weeping from side of obs.hole: in. Groundwater Adjustment
Index Well# Reading Date: Index Well level Adj.factor 'Adj.Groundwater Level_
Observation
Hole N Time at 9"
u / t4
Depth of Pere w a `o Time at 6"
Start Pre-soak Time Q 'l7() !Time(9"-6'1
End Pre-soak S� %ODD` q�'� QV WP��
Rate MinAnch
Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(YM)
original: Public Health Division Observation Hole Data To Be Completed on Back
® '-'
Depth from t Soil Horizon' Soil Texture Soil Color I Soil Other
Surface(in.) (USDA) (Munsell) Mottling 'Structure,Stones,Boulders.
Consistency..%Gravel)
-oram`�SAUO p R 5 1
. � —3c� � �eA�� ►��.� IaY�yl�,
3b 13Z G SA,,o Z.SY - 1 Uen1� LCnse ,.rn�v,vr�.
`ram t: a� sati,o
Depth from Soil Horizon Soil Texture -:Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistent %Gravel
� -Z Q
III,
b -33 8 Lopm�{ S�u9 IaYr� w�
L••5� en.6ow�^
�j3 - �3 G SA'�p Z,rj� ��� �D►JG� `Ce �t�t. Sr►N.fl
q __ ..a N
Depth from Soil Horizon Soil Texture Soil Color Soil Otlrer
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consisten %Gravel
tr _
------------
Depth from Soil Horizon Soil Texture Soil Color Sol Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistency.%Gravel)
Flood Insurance Itate Map: V
Above 500 year flood boundary No_ Yes ✓�
Within 500 year boundary No X Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? S
If not,what is the depth of naturally occurring pervious material?
Certification •
I certify that on 5 q jjqc�_Jdate)lhavep sed Ire s it evaluator examination approved by the
Department of Environmental Protection at th bo analysis was performed by me consistent with
the required t lung Vxpertise and exper c d cr d 10 CMR 15.017.
Z.G(O
Signature Date Z
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'll DAILY FLOW: (3)>�EDRODMS x 10 C�PD=330 6PD
�b C��'f' Q-� 4: AS 6EPT6 TANK: 33O C�PD x200%=660 OPP
(P Go g USE: I200 GALLON PRECAST SEPT G TANK
it \ �' ✓� ( 511 LEA(,M1N0 FAGLFY:
U5E: (2)500 CvAL.PRECAST DRYWELLS LI NED WITH A'OF
DOUBLE WA5HE9 STONE ON 51DE5&END5
ICAPACITY:
/ ! 51DEWALL: 76 x 2 x 0.74 _ , 112.5 p ^ ?�
-
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:TOTAL
353 0 C�PD
CONTRACTOR TO pE RCSPON5pLE FOR THE LOGATONOF ALL UTLTE5,
ABOVE AND UNDERC�ROUND,PRt�R TO ANY EXGAVATtiN OR GON51-R
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2. SEPTG 5Y5TEM TO YE NSTALLED N GOMPLVINGE Wlf i i 3O GMR >f�0:TffLE V j
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A. ALL P6TURlt)ED AREAS TO reE LOAMED AND SLEPED II
` e�• 5. CONTRACTOR TO PROVDE 24 HOUR NOTCE[-OR ANY REQUfZED NSPE6TON5
D MEN�5ONA! RCQU REMENT3 II
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LOCATION: (�,- C' IVAV/l" Z,, .I/ G
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PREPARED FOR: f5AY6PE �)U LPINO INC.
of S��NOrltgS rtV / y— a
TMW
8 CIVIL I+ JOB NUMrCR: DATE: /-av
No. 32666C
Gin
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k'✓ ,�• ►i ZONAL
TD3
VVELLF;,
1645 FALMOUTM RD N 5UITE GFNTERVILLE, MA 07-65?
TEL.: (505) 775-035 N FAX: (508) 775--075�
PROf�E5510NAL ENCVINEERS & LAND 6URVEYOR5