HomeMy WebLinkAbout0064 PATRIOT WAY - Health 64 Patriot Way
Centerville P
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IN
UPC 12543 a
No. R
HASTINGS. MN
1
TOWN OF BARNSTABLE
LOCATION la`q SEWAGE #
NULAGE C-��'�� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY SL'rWrn
LEACHING FACILITY: (type) c. (size)
A�t r
NO. OF BEDROOMS >
BUILDER OR OWNER
�Z)
PERMITDATE: ` S � COMPLIANCE DATE: d�
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
S / -T
Commonwealth of Massachusetts �9a - �302�
I?: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville ✓ Ma 02632 2/28/20
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information p/_p
filling out forms I q 3 7 c on the computer, 7
use only the tab Michael DiBuono
key to move your Name of Inspector
cursor-do not DiBuono Sewer And Drain
use the return Company Name
key.
35 Content Lane
;Q Company Address
Cotuit Ma 02635
City/Town State Zip Code
508-364-9587 SI 13522
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
3/2/20
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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
:. p Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is Centerville Ma 02632 2/28/20
required for every _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 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 contains a 1000 Gallon septic tank as well as a concrete distribution box and a leaching
trench of High Cap infultrators 37'x 10'x 1'
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�V
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriot Way
V�
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*'This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/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 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
- ,p Title 5 Official Inspection Form
Flo, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes"or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El 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)): App 213 Gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriot Way
V�
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is Centerville Ma 02632 2/28/20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Not provided
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Patriot Way
v-
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (Yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Tank is original to home. New leaching added 4/26/05
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. 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.):
System is vented through the roof
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
U
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000
Sludge depth:
3
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
30"
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tee's in place at time of inspection
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
,(!A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
1*11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Ile'
� 64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Level with no signs of push back from leach
field
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.):
I insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1 37'x10'x1'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
L15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Functioning as designed
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
3/2/2020 Assessing As-Built Cards
plow. TOWN OF BARIVSTABLE
LOCATION �'" �(�bT SEWAGE N
W.LAGE_L�7�r-T�1 ` ASSESSOR'S MAP&LOT 1 �3�:'-L
INSTALLER'S NAME&PHONE NO, �a
SEPTIC TANK CAPACITY S
LEACHING FACILITY:(type) (size)
NO.OFBEDROOMS 'Lt
BUILDER OR OWNER�/ �Z1 C.�✓L
PERMITDATE: ?—�Z'Q COMPLGINCE DATE: d�
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 3W feet of leaching facility) Feet
Furnished by
3C
A 3>, 2
83, L,17
WC ',ar
https://www.townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=192132&seq=1 1/2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
isrequired for every
Centerville
Ma 02632 2/28/20
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 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: 2005
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:
Test hole data on file
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Patriot Way
Property Address
AHLMAN, JESSICA
Owner Owner's Name
information is required for every Centerville Ma 02632 2/28/20
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑ A. Inspector Information: Complete all fields in this section.
❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
❑ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
❑ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
A� a 64 PatriotKWay r�
Property Address
t�
Doris Welcome P.•
Owner Owner's Name
information is Q1
required for every Centerville Ma 02632 9/8/15
page. City/Town State Zip Code Date of Inspection f w°
f..a
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
J JJ J�
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return — — -
Name of Inspector
key.
DiBuono Sewer and Drain _
rea Company Name
8 Johns path _
Company Address
serum S Yarmouth MA 02664
City/Town State Zip Code
508-364-9587 S113522
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
9/10/15
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.
Vs
15ins•3113 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
64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is Centerville Ma 02632 9/8/15
required for 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:
The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles
are in place. The Distribution box is level and at normal level. The leaching is made up of several
leaching chambers and at time of inspection levels appeared to never have been at abnormal levels.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
\a 64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
El Pump Chamber pumps/alarms s/aIarms not operational. S stem will pass Board of Health approval
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
- 64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is Centerville Ma 02632 9/8/15
required for 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
0 ® 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
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
a 64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
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.-
El ® 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 1.the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
64 Patriots Way
Property Address
Doris Welcome
Owner Owner's'Name
information is required for every Centerville Ma 02632 9/8/15
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
El e Pumping information was provid
ed 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles
are in place. The Distribution box is level and at normal level. The leaching is made up of several
leaching chambers and at time of inspection levels appeared to never have been at abnormal levels.
Number of current residents:
1
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
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available last 2 ears usage d 148 Gpd
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 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•3/13 Title 5 Official Inspection Forms 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
64 Patriots Way _
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
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:
2012
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
. Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
\a 64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
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:
10 years
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 18
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.):
System is vented throught the roof.
Septic Tank (locate on site plan):
Depth below grade: 1 ftfeet
Material of construction:
i
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gallon
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gallon,
Sludge depth: 3
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
64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
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 24 —
Scum thickness 3
Distance from top of scum to top of outlet tee or baffle 42
Distance from bottom of scum to bottom of outlet tee or baffle
1" Sludge stick
How were dimensions determined?
Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No evidence of Ieaking,Tees and or baffles in place at time of inspection.
Grease Trap (locate on site plan):
Depth below grade: NAfeet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
15ins•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
64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
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.):
Tees are in place and levels are normal.
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
Commonwealth of Massachusetts ,
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a, 64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
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
At normal level
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.):
Distribution Box is level and at normal level with no signs of carry over or decay.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ Now
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 4
❑ 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.):
No signs of carry over and no signs of hydraulic failure.
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
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-.
No signs of ponding or hydraulic failure.
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
. Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
aa'°p 64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
page. CityfTown 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Ug"o,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
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: 10 + ft
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: 4/22/05
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:
Test hole data on plan dated 4/22/05
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
9/14/2015 Assessing As-Built Cards
TOWN OF BARNSTABLE
LOCATION 2 66-r _SEWAGE q
VILLAGE —o✓`�GI&` ASSESSOR'S MAP&LOT Nam' L3�
INSTALLER'S NAME&PHONE No. y6
SEPTIC TANK CAPACITY - �+
LEACHING FACILITY: (type) a (size) 7K�0f )c l
NO.OF BEDROOMS 3
BUILDER OR OWNER ��� ✓L
PERMITDATE: .`—Zz_Q_ COMPLIANCE DATE: "r
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 Facibry(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
66
!
83,
1,40 G�ruti Opt'
http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=192132&seq=1 112
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Patriots Way
Property Address
Doris Welcome
Owner Owner's Name
information is required for every Centerville Ma 02632 9/8/15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information— Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable
�TME Regulatory Services
Thomas F. Geiler,Director
w BAMSTABLE, •
9� '. �0� Public Health Division
�Fc +s Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 4/26/05
Designer: Shav Environmental Services, Inc. Installer: Robert Septic Services.
Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street
MA 02536 Yarmouth, MA
On 5/22/05 Robert Septic Service was issued a permit to install a
(date) (installer)
septic system at#64 Patriot Way, Centerville, MA based on a design drawn by
(address)
Shay Environmental Services, Inc. dated 04/19/05
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
�kOF41ASSc
q
CARMEN
� E. � '
Install 's Si re o SHAY
No. 1181
G/STER10
04NITARVP�
(Designer's Signa e) (Affix D esigner''s amp 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:Health/Septic/Designer Certification Form
y
No. 1V � � _ � � ¢ Fee
g
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpplication for MiopaaY bp$tem Con6truction Permit
Application for a Permit to Construct('. )Repair(X Upgrade( )Abandon( ) ❑Complete System );�Itdividual Components
Location Address or Lot No. .}-�4 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel � �N\¢ `Mfl
Installer's Name,Address,and Tel.No. i Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder
Other 'Type of Buildin No.of Persons Showers( v-f Cafeteria( vy",
Other Fixtures
Design Flow 2>` gallons per day. Calculated daily flow 3 2) -gallons.
Plan Date 1 `S Number of sheets Revision Date
Title L}
Size of Septic Tank qY,5T. 1 low6 Type of S.A.S.
Description of Soil; ��� 3 n�� X 3 .;Xs T2i
Nature of Repairs or Alterations(Answer when applicable) Q l`_'91
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued o do Health.
Si ned Date q-,?1-G
Application Approved b Date CJ
Application Disapproved for the following reasons
Permit No. cO 5 , Date Issued .�
NI—,-- S /tCI6 Fee
THE COMMONWEALTH OF MASSACHUSET't.. Entered in computer: /
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2ppfication for Mi5pont *potent c(Cong;truction Permit
Application for a Permit to Construct('. )Repair(�Upgrade( )Abandon( ) ❑Complete System k1tdividual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
�4 ` r',csT t, pr
Assessor's Map/Parcel C�a��\e t M A
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
-PO\QQcks iC SJCs. dsvic4 ' Er,L) � S,3Cs
Co L-1 - 5_�A '9_9 U,
Type of Building:
Dwelling No.of Bedrooms Lot Size I".-; 4 sq.ft. Garbage Grinder(41A
Other Type of Building n\nx--i a No.of Persons_— _ Showers( y,'Cafeteria
Other Fixtures
Design Flow ) gallons per day. Calculated daily flow gallons.'
Plan Date \ a.N�6' Number of sheets � Revision Date
Title A SaD�..c �_ j2p l Dc�,��AD
Size of Septic Tankt z)T. I Ve y -fir nl_— Type of S.A.S. � \mac c�tx5
Description of Soil �b c, -_a .-, F�-,\car. x 3�'°t5 T2.t-1c
Nature of Repairs or Alterations(Answer when applicable) tiRr t�\n 4!r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by-this Board of Health. r,
Si ned _ Date
Application Approved by, __ 1 Date Was f 0 S
Application Disapproved for the following reasons
e
Permit No. Goo t. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate`of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(V-j-
Abandoned( )by
at Q has been constructed ig accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. rgr1 Y- l/..(, dated /)-1 G 5-
Installer--- Design C . <: t1 A-41
The issuance of this permit shall not be construed as a guarantee that the'the w l"unction as designed.
Date 5 /� �`-"� Inspect
_ - ._..... —————————— ----------------------------
No. = I Fee Jda.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigotaf *pgtem Cong;truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( (_LAbandon( )
System located at P 14?u—
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
Date:�'�,-;k,10 5 Approved 1
TOWN OF BARNSTABLE'
LOCATION task VM(X0 +SEWAGE # �'.�
VILLAGE C- �� `� ASSESSOR'S MAP& LOT 1T7-_
INSTALLER'S NAME&PHONE NO. 42
SEPTIC TANK CAPACITY S
LEACHING FACILITY: (type)- (size) 37k ®�?c t
NO. OF BEDROOMS 3
BUILDER OR OWNER
. PERMITDATE:. Al_ COMPLIANCE DATE: Vnlgr-
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
ii
b
3r
PXST 6g�
a
► S
9/16103
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
e C'� �',hereby certify that the engineered plan signed by me
dated concerning the property located at
L. � �• meets all of the
following criteria:
• This failed system is connected to'a residential dwelling only. There.are no commercial or
business uses associated with the dwelling.
• The soil is classified!as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or.may conduct deep
test holes and percolation tests at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will-be located no less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the.
Frimptor method when applicable)
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information).
B) G.W.Elevations +adjustment for high G.W. _ ;
DIFFERENCE BETWEEN A and B ,
SIGNFD DATE:
NOTICE
NA Based upon the above information;a repair permit will be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASepdr\percexemp.doc
r'
Permit Number: Date:
Completed by:
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: tk-4 2/LTII'.\Y�'t Lot No. FO
Owner: �a 2.��� te e'- ;�r-�,s, Address• C'VCy_,Q
Contractor: ,,JCi : Address:
Notes: 1 r A V
STEP i Measure depth to water table
tonearest 1/10 ft. ...............:.............................................................. .Date 4
mont /day year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site:and determine:
OA Appropriate index well........................................
............
OBWater-level range zone ....:................................................ C
STEP 3 Using monthly report "Current
Water Resources Conditions
determine!current depth to
Water level for index well ..................... X
year
STEP 4 Using Table of Water level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
andwater•level zone (STEP 2B)
determine Water-level adjustment ...................................... `
STEP 5 Estimate depth to high water
by subtracting the water•
level adjustment (STEP 4)
from measured depth to water
level at site,,
(STEP 1) .................................................. ..........................................................
h
Figure 13. 'Reproducible computation form.
15
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
► Environmental Protection
VANIM F.Weld Trudy Cox*
oasomw
Arpso Paul Ce#uccl
c.rld B.s1rWu
oonmdaaioc�r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION RECEIVrM
PnPe*ty Add:esa: �y��i� g Addeees of Owner.
Dane of Inspection: _ ! (If different)
Name of Inspector.. 7-jig- 97 AUG 8 1997
Cow!rwy ams„Addresa and Telephone Number. HEALTH DEPT.
✓✓ r!! TOWN OF BARNSTALLE
JWCA1154&41EN_T�
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
asses
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ F .
Inspector's Signature: �t � Date: g
The System Inspector mit a copy cf this inspection report to the Approving Authority within thirty(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
:sport to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Clwk A, B. C,or D:
A) SYSTEM PASSES:
have not found any information which indicates that the system vioLw any of the farm mit"as defined is 310 CNR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon oompletion of the replaceareat or repair,passes
inspection.
Indicate yes,me,or not determined(Y,N,or ND). Describe basis of date mduation in all instances. If*aft determined",explain wby not)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or e>tfiltratioa,-or tank failure is
imminent. The system will pass inspection if the existing septic tank a replaced with a poaforming*aeptim tank as approved
by the Board of Health.
(revised 11/03/95) 1
One VAnter Street o. Boston,kbsaachusetts 02108 a FAX(617)SWIC49 a Telephone(617)292-SSW
Pmed on RecWW Pape.
Lf
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner.
Date of Inspection:
B)SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or out or high static water level observed in the a boa is due to broken or obstructed pipe(s)
or due to a broken, or uneven distribution box. The system will inspection if(with approval of the Board of
Health):
_. broken pipe(s)are replaced
� ction is removed
' bution box is levelled or rep
The system required pumping more four times a year to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the of Health):
broken pi s)are reply
obstruction ' removed
C1 FURTHER EVALUATION IS REQUIRED BY THE BO OF HEALTH:
Conditions exist which require further evaluation the B of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD O HEALTH D INES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT TH PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 t of a surface water
_ Cesspool or privy is within 5 feet of a bordering vegeta wetland or a salt marsh..
2) SYSTEM WILL FAIL UNLESS BOARD OF HEALTH PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SY TEM IS FUNCTIONING IN A THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRO ENT:
The system has a ptic tank and soil absorption system and is 100 feet to a surface water supply or tributary to a
surface water su ply.
_ The system a septic tank and soil absorption system and is a Zone I of a public water supply well.
The system hei a septic tank and soil absorption system and is 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is lea than 100 feet but 50 feet or more from a private water
supply well/unless a well water analysis for eoliform bacteria and volatile organic compounds mdteates that the well is i:te
from po n from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Addraw
Owner.
Date of Inspootion:
DI SYSTEM FAILS:
I have determined that the violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for
this determination is identified be w. The Board of Health should be contacted to determine what will be necessary to correct the
Lfiure.
Bacitup of sewage into facility or in component due to an overloaded or c]ogge�SAS or cesspool.
Discharge or ponding of effluent to surface of the ground or surface rs due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box outlet invert to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"belo invert or a ' ble volume is less than 1/2 day flow.
Required pumping more than 4 times in the NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, 1 or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is a' 100 f of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy within a Zone of a public well.
Any portion of a cesspool or vy is within 50 feet of private water supply well.
Any portion of a cesspoo or privy is leas than 100 feet greater than 50 feet from a private water supply well with no
acceptable water q analysis. If the well has been to be acoeptable,attach copy of well water analysis for
eoliform bacteria, the organic compounds,ammonia n and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following cri apply to large systems in addition to the criteria a e:
The system a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and cty and the environment because one or more of the following conditions east:
the system is within 400 feet of a surface dri:iloag water supply
the system is within 200 feet of a trtbutary to a surface drinlong water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 13 of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into fall aomplianoe with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
p v
S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
l G
PmPsrty Adde.a+eu�t�c
owner..
Date of Inspection: l _� n 7= 7
Cheek if the following have been done:
_Pumping information was requested of the owner,occupant,and Board of Health.
�_ one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
VThe system does not receive non-sanitary or industrial waste flow
_The site was inspected for signs of breakout.
✓All system components, excluding the Soil Absorption System, have been located on the site.
_✓ 'on of bales or
manholes were uncovered,opened,and the interior of the ' tank was ' for condition The septic tank mash red, pe ceps �P��
toss, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: C .
Owner.
Date of Inspection: 7-
! FLOW CONDITIONS
ENTIAI:
Design lbw: 0 ons
Number of be na:
Number of current rasidents:�
Garber grinder(yes or no):_Lycl _
Ivry connected to system(yes or no):- .
Seasonal use(yes or no):fs,6:)
Water meter rwdiaes, if available:
Last date of occupancy: ,
COMM ERCIALANDUSTRIAL
Type of establishment:
Design flow:
Grove trap present: (yes or no)_
Industrial Waste Holding Tank present: (yea o
Non♦anitary waste discharged to the Titl m: (yes or no)_
Water meter readings, if a
da occupancy:
OTHER (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECQPDS and source of informs on:
System pumped as part of inspection: (yes or no i b
If yes,volume pumped: gallons
Reason for pumping:
TYPE OYAMM M
C/ Saptio fl absorption system
Single cesspool
Overflow cesspool
Privy
Shard systam(yes or no) (if yes,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and omme Of information: 7 7'
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Address:
Owner. f n 1
Date of Inspection:
SEPTIC TANK2L--'
Goeste on site plan)
Depth below Vude--ii-
Macerml of construction: 419erete_metal_FRP other(e:pl=)
Dimensions:
Distance from top of sludge to bottom of outlet tee or bafII ,
Seam thickness: _ A/
Distance from top of scum to top of outlet tee or baffle: _4;-
Distance from bottom of scum to bottom of outlet tee or baffle:,��
Comments:
(recommendation for pumping, condition of inlet and cutlet tees or babes,depth of 'd 1 in relation tlet ' rert,structural integrity
evidence of etc.)
w
GREASE TRAP:_
(locate on site plan)
Depth below grade:
]Saterial of construction:_concrete_m FRP_other(explain)
Dimensions:
Seam tbklmssa:
Disumot from top of scum to top of outlet tee e:
Distance from bottom of scum to botto outlet tee or battle:
Comments:
(reeonunendation ping, condition of inlet and outlet tees or baffles,depth of liquid level in relation outlet invert,structural integrity,
evidence etc_)
(revised 11/03/95)
I -
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
// SYSTEM INFORMATION(continued)
Owner rowrty
Addreaw
o r.
�d2� �eAl .
Date of Inspection: F/
F7
TIOUT OR HOLDING TANK_
ODOM*on site plan)
Depth belowVade:
Material of construction:_ metal_FRP_other(e:plain)
Dimensions:
Capacity: Gallons
Design flow: aauon./day
Alarm level:
Comments:
(Condition of' tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX P14
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: Pt 10
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.)
PUMP CHAMB
(locate an site plan��!.
Pampa is working o)
Cosmeatr
(note condition of condition of pumps and ,etc.)
.(revised 11/03/95) 7
1 .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property dro
Owner. -
Date of Inrpe,etioa:
SOIL ABSORPTION SYSTEM
0onte on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,stplain:
2 — Cmz�c7 /rc _
haehiag pits,number:
haehin chambers,number:_
hashing galleries,number:
leaching trenches,number,length:
hashing fields, number,dimensions:
overflow ossspool,number:
Comments: (49w cqtdition of soil,signs of hydraulic ure, level of ponding,condition of vegetation etc
CESSPOOLS:(beate on site pla_n)
Number and configuration: ,
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of owpool:
Materials of construction.
Indication of groundwater•
in"' ( 1 must be pumped as part of inspection)
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:_
(locate an site plan)
Materials of ommtruction. Dims:
Depth of solids:
Comments: (ante signs of bydranlic laslt>:+e,.level of pondw&wit tion of VVIOM on,
(remised 11/03/95) 8
T
t.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
An
Property Address: W
Owner:
Dale of Inspection: 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
lk
\ /
DEPTH TO GROUNDWATER
Depth to groundwater:/ _feet U, n j
method-of determination or approximation: �7
ell- Y9—� 4"
(revised $/1S/951 9
f •
'NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. SECTION A -A
ALL OUTLET PIPES FROM THE %
1-house
10' min. from DISTRIBUTION BO.SHALL BE 12'
Existing Foundation to septic tank o-Box cover must be PROFILE_ VIEW OF ADDITION TO LEACHING SYSTEM SET LEVEL FOR AT LEAST 2 FT. CONCRETE COVER
Septic tank covers must be
TOP OF FOUNDATION ELEV. 100.00 (Assumed) within 6 in. of finished grade t =
within 6 in. of finished grade - _
'. Grade over Septic Tank - 99.00 Grade over D-Box - 98.00 - ode over SAS - 9&00 3" of 1/8' - 1/2" Washed Peastone 3 - S' OUTLET `+ '�-'•' ':'- 2" ' N
\ i ~'� KNOCKOUTS
3/4" to 1 1/2 Washed Crushed Stone / \: , '
r
`-
4" PVC(CAPPED) INSPECTION PORT TO BE
•`, , - 12* INLET
OUTLET
S - 0.07 3 HOLE H-10 6•
ST. BOX 3' Maximum Cover T OF System- Elev. s95.00 .INSTALLED AND TO BE WITHIN 6" OF GRADE .. ,;-� x cy.^ `.l
2 r'; 64 Patti•t Vb
5=0.01 or Greater 15.5"-- r w
ui 10' EXIST. Top rs � .... . . ... �,r 7 �•,
FXICT PIPE "~' 00 04 1,000 GAL. in 15, �` s- 0.01" p,,y root 4 10'• Effective Depth - 4" - SCH. 40 Te L)5'"�
FROM ExisT, FOUNDATION rn SEPTIC TANK n
C1 i
iI H-10 m r, 20 PLAN SECTION CROSS-SECTION _' , Q ;i
UD
CONCRETE FULL FOUNDAriON II _ p 5 Units @ 6.25' = 30'
> <t 0.83' (10 inches) 3 3 4 6 ..
6 n.ot 3/4"-, ,/z `�- 31.25' �--- 3 HOLE H-10 DISTRIBUTION BOX t`;` a
SYSTEM PROFILE compacted Stave " m ,
c > a rn 37,25' NOT TO SCALE +
Not to Scale - 8
> 4' -� I� ( 4' it Effective Length o Ile,Rwhtli&"y9 o pr 8:ae4NA�Tea
c 11 y SOIL ABSORPTION SYSTEM (SAS)
6 in.of 3/4"-1 1/2" o GENERAL NOTES
compacted stone Q EPFective Width
o INP-ILTATROR HIGH CAPACITY (H-20 LOADING)/ GE❑RGE ❑'BRIEN
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE m 1. Contractor is responsible for Digsafe notification
o (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes.
W
Bottom of Test Hole 1 Elev=87.5o NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" ,2. The septic tank and distribution box shall. be set
Groundwater Observed - NONE OBSERVED level On 6" of 3/4"-1 1/2" stone.
........................................
----- -----'---- ------- ---- -- --- .
3. Bockfill should be clean sand or gravel with no
---- - - --- - - stones over 3" in size.
PERCOPe��O�^T�ONf �e�� 4. This system is subect to inspection during installation
LATION I 'V L b Carmen E. Shay - Environmental Services, Inc.
5. The contractor shall install this system in accordance
Date of Percolation Test. APRIL 20, 2005 with Title V of the Massachusetts state code, the approved plan
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations.
Results Witnessed By. WAIVER(per Barnstable B.O.N.) 6. If, during installation the contractor encounters any
EXCAVATOR: Shay Environmental Services, Inc. -� soil conditions or site conditions that are different
Percolation Rate: Less Than 2 MPI ® 30" from those shown on the soil log or in our design
- - - Failed installation must halt & immediate notification be
Test Hole Leach Pi"t made to Carmen E. Shay Environmental Services, Inc.
No. 1 ___----------- _______97 7. No vehicle or heavy machinery shall drive over the
DEPTH saLs ELEV. ----------- 'septic system unless noted as H-20 septic components.
8. Install Tuf-rite as baffles or equals on all outlet tee ends.
0 98.50 124.51 g
Loam - .� 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
Sand y g� 7.25' 10. All solid piping, tees & fittings shall be 4 diameter
,D rR a/z J3" �,.e. .E;;`: .:; ^ SHED Schedule 40 NSF PVC pipes with water tight joints.
0"-12" A 97.50 Box
r_ r s ._ • u. 11. Municipal Water is Connected to ALL OF The Residence and Abutting
Loamy -- --- --D - - --- ------- ---- ---
98
Sand Properties Within 150 Feet.
10 1R 5/6 33.5'
Failed TEST HOLE #1 THE PROPERTY LINES ARE APPROXIMATE AND
12"-30" Br ss.00 9� Leach Pit ELEV.= 98.50 COMPILED FROM THE SURVEY PLAN GENERATED BY
Medium PROJECT BENCH MARK BAXTER & NYE of OSTERVILLE, MA
2eavd7/4 TOP OF FOUNDATION 20'. -0 - CERTIFIED PLOT PLAN OF #64 PATRIOT WAY, CENTERVILLE, MA"
30'-132" G 87.50 ELEV. = 100.00 (Assumed) DATED DATED OCTOBER 20, 1976
O BRICK AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
PATIO/WALK IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
`\ 919 THE SEPTIC SYSTEM INSTALLATION.
EXISTING LEACH PITS TO BE PUMPED OUT AND REMOVED
LOT #A7 g�J EXISTING NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
3 BEDROOM FROM THE EXISTING LEACH PIT TO BE DISPOSED
HOUSE LOT #A5 OF AS PER BOARD OF HEALTH SPECIFICATIONS.
r, THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
Perc #1 #64
Depth to Perc: 42" to 60"
Perc Rate= Less Than 2 MPI _ _-� ASSESSORS MAP 192 PARCEL 132
Observed Groundwater = None Obs. I
LEGEND
I I
DENOTES PROPOSED
2-18" DIAM. ACCESS MANHOLES I I 1 04X 1
SPOT :GRADE
a•
;. X 104.46 DENOTES EXISTING G
g9--- ---------------- --- ------------ ----- --------- SPOT
GRADE
LOT #A6 I I PL PROPERTY LINE
^) a I GRAVEL
INLET i ou Er 15,840 Square Feet t/ I I DRIVEWAY j 9f
I I PROPOSED CONTOUR
THE ACCESS COVERS FOR THE SEP11C TANK, I I I
t DISTRIBUTION BOX AND LEACHING COMPONENT I I I - - -- -' - -97 EXISTING CONTOUR
SET DEEPER THAN 6 INCHES BELOW FINISHED - I
-r GRADE SHALL BE RAISED TO WTHIN 6'! i I
STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. ( 125.00' I
PLAN UIEYY INSTALL TUF-TITE GAS BAFFLES OR EQUALS I I I I DEEP TEST HOLE &
PERCOLATION TEST LOCATION
3-24" RE)AOVABLE COVERS - ------ _----- -
I" I 6 FOOT STOCKADE FENCE
-- i
3' min!clearance • 11111 -
_ INL£T. B min 12_mfi. inlet to outlet. 8q_tT
Its MilEr"T^ �--- ....___----
ff----- ___L�Tu-Id leveF� OUTLET -------_5' 7 5' _7"
z
P LOT P LAN
E I r LlQuid quid min.
".arn, '�
- v o " . �• depth
OF PROPOSED SEPTIC SYSTEM UPGRADE
�.,..,. :-<.r PREPARED FOR
{ `f (40 FOOT RIGHT OF
wA )
CROSS SECTIONEND-SECTION ' MICHELLE MONTGOMERY
AT
TYPICAL 1000 CALLON SEPTIC TANK # 64 PATRIOT WAY
NOT TO SCALE
CENTERVILLE MA -
Design Calculations
OF ssq P PARED BY:
Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gat./Day Min. per Title,V)
C ME
Garbage Grinder: No ;,t
Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per 'Title V) ' �
Septic Tank i - 2 x 330 Gal./Day = 660 USE EXIST.'1,000 GAL. Septic Tank: S Y VIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch No. 1
Bottom Area: , 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons P.O. BOX 627
sideway 0 20 40 jQ Area: 0.74 gal./sq. ft. x 78 sq. ft. 58 gallons sTE�� EAST FALMOUTH+ MA 02536
Providing: = 331.80 gallons NITAR\P
- ----- -- TEL/FAX 508-539-7966
Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH,
SCALE: 1 "=20' DRAWN BY: CES DATE: APRIL-21, 2005
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE
ON THE ENDS. No STONE UNDER x SCALE: 1"=20' PROJECT#SD726 FILENAME: SD726PP,DWG SHEET 1 OF 1