HomeMy WebLinkAbout0041 POINT OF PINES AVENUE - Health 41 Point Of Pines Avenue
—Centerville P
A = 210 108003
No. 42101/3 ORA
ESSELTE
10%
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nn TOWN OF BARNSTABLE
LOCH T IQN l'o�1, o P, s v e SEWAGE #
VIIIAGE _ Gn GrJ �rd�e ASSESSOR`S MAP&LOT
INSTALLER'S MAME&PHONE NO.
SEPnC TANK CAPACITY
LEACFHNG FACILITY: (typa) 1 d ; 17'' (size)
NO.OF'BEDROOMS _
BUILDER OR OWNER
OERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted,Groundwater Table to the Bottom of Uaching Facility ------------ _Feet-
Private Water Supply Well and Leaching Fardity (If as,y 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 o leaching facility) Feet
Furnished by 44, 14 4_5 -07 t,
C-:3
1-1 IF I H. Ll
A 10- 30 !g 0- l9'
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
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.
A. General Information JI t
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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 It
//z/
3-24-12
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 Yinal should be sent to the office=of the,:DEP.,,Tt a/on9 system owner
and copies sent to the buyer, if applicable, and the ap rroving authority.
****This report only describes condi,}ipns at the time of inspection and under the conditions of use
at that time.This inspection doesrh6liaddress.how the system will perform in the future under
the same or different conditions of use. 1-9
_ r
at I , 0 iv
`5, 4
t t5ins•11/10 Title 5 Official Inspection Form: u rface Sewage Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
L W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is Centerville MA 02632 3-23-12
required for every
page. Cityfrown 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:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
S
t
Commonwealth of Massachusetts
. Title 5 .Official Inspection- Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is Centerville MA 02632 3-23-12
required for 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
1
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave ,r ,
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12 Y page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is.within 50 feet of a private water
supply well
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
a
S
t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�M s 41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® " Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or Ono" 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 (f any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms). 440
t5ins-11/10 Title 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
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 3-2012
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•11/10 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 r 41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. Cityrrown 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: Owner—pumped 2yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
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-11/10 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
,M 41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
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:
2001
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
22"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 14"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Cerfifcate,of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth:
12"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection' Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 20
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. Cityfrown 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) Qocate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date �
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from infiltrators.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 6-Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Infiltrator leach field in good condition with no sign of back-up into d-box or surrounding stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. CityfTown 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•11/10 Tltle 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
,M 41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. Cityfrown 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
ea
0 0
Lk
IF
c- 3(' -c-
A D- 30 ' 8 p- 9•
,Q
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t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
�^M 41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope 1
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Original design plans on file show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
.y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Point of Pines Ave
Property Address
Heidi Luciani
Owner Owner's Name
information is required for every Centerville MA 02632 3-23-12
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
i
t5ins•11/10 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
a
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION_
APR 1 2 2005
TOV%N U BAf�NSTABLE
TITLE 5 HEALTH UEPT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION P
Property Address: 41 Point ofPines Avenue
Centerville. MA 02632
Owner's Name: John O'Brien
Owner's Address:
Date of Inspection: April 1, 2005
Name of Inspector: (Please Print) Janes M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Ostervft MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Ne s Further Evaluation by the Local Approving Authority
Fa' s
Inspector's Signature: Date: April3. 2005
The system inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
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• Page 2 of 11
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OFFICIAL INSPECTION FORM-NOT IiFOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
I
Property Address: 41 Point of Pines Avenue
Centerville, AM
Owner: John O'Brien
Date of Inspection: April 1. 2005
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 an�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: j
i
B. System Conditionally Passes:
I
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the oll fowing statements. If"not determined",please
explain.
i
I
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.
i
i
ND explain:
Observation of sewage backup or break out or high static iwater 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 I
obstruction is removed
distribution box is leveled or replaced
I
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
i
broken pipe(s)are replaced ';
obstruction is removed
ND explain:
i
i
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2 j
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 41 Point of Pines Avenue
Centerville, MA
Owner: John O'Brien
Date of Inspection: April 1. 2005
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if an determines that the
PP Y)
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
f
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 41 Point orPines Avenue
Centerville, MA
Owner: John O'Brien
Date of Inspection: April 1, 2005
D. System Failure Criteria applicable to all systems:
You must indicate either"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''/z 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 well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 41 Point of Pines Avenue
Centerville, MA
Owner: John O'Brien
Date of Inspection: April 1. 2005
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:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
i
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 41 Point of Pines Avenue
Centerville, MA
Owner: John O'Brien
Date of Inspection: April 1, 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: New systenz-never pumped
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed on 2122102-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
I
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Point of Pines Avenue
Centerville,MA
Owner: John O'Brien
Date of Inspection: April 1, 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 16"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 7"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measurinz stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage
Recornniend pumping.
.GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Point ofPines Avenue
Centerville, MA
Owner: John O'Brien
Date of Inspection: April 1. 2005
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
I
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Point of Pines Avenue
Centerville, MA
Owner: John O'Brien
Date of Inspection: April 1. 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 6 infiltrators-41'x 10'(per as built card)
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The infiltrators were dry and clean. There did not appear to be any si ns offailure
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
LA
1
Page 10 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Point of Pines Avenue
Centerville, MA
Owner: John O'Brien
Date of Inspection: April 1. 2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 41 Point ofPines Avenue
Centerville, MA
Owner: John O'Brien
Date of Inspection: April 1. 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 15+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps, the maps were showing approximately 15'+/-to ground water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report.
11
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FIRST FLOOR FRAMING PLAN 10i17ro1 508-Tr1-0491
2X8s 16"OC
ROOF FRAMING
3-1 3/4"X 16"LVLs
BELOW JOISTS
3-1 3/4".X 16"LVLs
FLUSH AT FIRST'
FLOOR OEILING':
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2 X 10s 16"OC THROUGHOUT
2XSs;Q 16"CMG
ROOF FRAMING
SECOND. FLOOR FRAMING PLAN DATE SWAINE 9
/ 10/17/01 608-771-0491
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2 X'10s @ 16,.'OC
RAFTERSTHROUGHOUT
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ROOF FRAMING PLAN 10/710, SWAINE� O
508-771-0491
2 X 12 RIDGE
12/5 12/12 PITCH MAIN ROOF,
R 30INSULATION
ASPHALT ROOFING ON FELT
PAPER.ON 5/8 PLYWOOD,
ON 2 X 10s @ 16"OC
BEDROOM
2`X 10s =;16"OC
FLUSH FRAME 3- 1 3/4"X 91/2" 2 X 6 EXTERIOR WALLS
LVLs R 16 INSULATION
1/2 PLYWOOD
LIVINGRQOM SHEATHING
WHITE CEDAR
SHINGLES
2 X;11 @ fe".QC -
BASEMENT 3=2 x 12 GIRT
8"PC WALLS ON CONTINU"S_
8"X 16"FOOTING
4"PC FLOOR
TYPICAL BUILDING SECTION DATE SWAINSeafto
10/17/01 508-771-0491
T WN OF BARNSTABLE �
n _ P 9 g
LOCATION �� 1'�l�l OT" P14" AVE, SEWAGE # �s
VILLAGE �✓►T rv� ASSESSOR'S MAP & LOTINSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY S
LEACHING FACILITY: (type) 6 1 A QbAol1 (size) y/ X /d �
NO. OF.BEDROOMS y / /�
BUILDER OR OWNER J 04A Q / L&1 ell
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac�'ng facility) Feet
Furnished by �/1SQt�''On
A Q
P70
/ 3 (1
a 30 iq Q
Ig' 33 yo y3g
3 y
TOWN OF BARNSTABLE
or r
J,OCATION V
�
SEWAGE.#
VILLAGE ��� % > ASSESSOR'S MAP & LOT /®
INSTALLER'S-NAME&PHONE NO. ,4 0/dK 4 , Z Z-,
SEPTIC TANK CAPACITY Z .
LEACHING:FACILITY: (type) � �' (size)
NO. Ol~BEDROOMS
BUILDER OR OWNER ,C
PERMIT DATE:TTY f Z't _COMPLIANCE DATE:
Separation Distance Between the: ll
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility — 3 �cy' Feet
Private Water Supply Well and_Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) i �/�r�I Feet
Edge of Wetland and Leaching-Facility (If any wetland3 exist
within 300'feet o leaching facility) Feet
Furnished by
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No.. Fee
. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE, MASSACHUSETTS
21pprication for Migpozal bpgtem Construction permit
Application for a Permit to Construct(X)Repair( )Upgrade( )Abandon( ) Complete System O Individual Components
Location Addreas,or Lot No. L.pr Gl Owner's Name,Address and Tel.No.
411 Yot waT of t,Eg 7�-� /. G X_,,j E s
Assessor's Map/Parcel �/r+l
Installer's Name,Ad resss and T No./ '`j(� Z 2 f Designer's Name,Address and Tel.No.
G ,rr y /'// - < (/� �� G�r,O� ,�.�EC.r/i����•�r�cl�,
�U �!c� S�Ct �vF G►e.7. 3y .wrni.�. S/ -,,G 7 J�
Type of Building:
Dwelling No.of Bedrooms Lot Size IV D 17sq.ft. Garbage Grinder( )
Other. Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `�`f�� gallons per day. Calculated daily flow `��' gallons.
Plan Date 9 S Number of sheets Revision Date
Title �J�?�E S�wr¢GrE .��4.-< o,' 1-,p T ��,.�r �f i.✓�
Size of Septic Tank /SLO Type of S.A.S. /N�-7H 2�Tytis /S7b. 9-
Description of Soil S ��
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 tho Environme tail C de and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this d,of37ealt '
Signed ` Date
Application Approved by Date ,1—
Application Disapproved for the following reasons
Permit No. Date Issued 12
�« No' ..i 'r"� ✓ G� Fee
a` 4�
{- i Entered in comp uteri
flflflfl /
THE COONlNEALTH OF.flflASSACHUSETTS 1/
� PUBLIC (HEALTH DIV SION -,,.TOWN OIL BARNSTABLE, MASSACHUSETTS
..- 2pplication for M"i!9P0!6a[ *p4tem Construction Permit
Q ' Application for a Permit to Construct(x )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components
Location Addreor Lot No. �T i ^ '•\� Owner's Name,Address and Tel.No.
L// ,"J�,
tikq c r
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. 3(l 2 2 j Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size�sq. ft. Garbage Grinder( )
w;y Other Type of Building f G1 r� No.of Persons �r Showers( ) Cafeteria( )
Other Fixtures �.
\`-Design)Flow gallons per d y.Calculated daily flow `]� gallons.
Plan Date_ /5 y Number of sheets / Revision Date
Title 5�?� F ' S�wAC�f ,J o� L o i %/,�I i�ve g
Size of Septic Tank /SUO Type?of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
i Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
s%
in accordance with the provisions of Title 5 of tbo Environmeptal de and not to place the system in operation until a%Certifi-.
' Cate of Compliance has been issued by this d o?ea
R� Signed Date
Applicati `n Approved by tr f n Date
Application Disapproved for the following reasons
' t N
Permit No. f Date Issued" Z-
r
——,————————————————————————————---——— ——.
j>j(F THEiCOMMONWEALTH OF MASSACHUSETTS
EARN8;TAELE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired ( )Upgraded ( )
Abandoned( y
at z f h
,. as een constructed in accordance
with the provisions of Title 5 an • e for Disposal System Construction Permit No. 2 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the systik will function a d signed. "``'
Date lnspectorT a `
--------------------------------------- --
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
�N.5po al *pgtem Construction Permit
Permission is hereby granted to Cons ct(y R air( )U de( )Abandon( )
System located at t
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 t •s permit.
Date: ° Approved by , A,,, -
t..
r _
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE C� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. Glyd sr [� � �J 7 Z C..
SEPTIC TANK CAPACITY
LEACHING FACII..I'I'Y: (type) / (size
NO. OF BEDROOMS
s
BUILDER OR OWNER C
PERMIT DATE: Z Z/Y Z!t ,CO.MPLIANCE DATE: Z
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) . i Feet
Edge of Wetland and Leaching Facility (If any wetland3 exist
within 300 feet o leaching facility) ,, OZ Feet
Furnished by �r
� 3 �
o
ile1.
;90 ` TOWN OF BARNSTABLE
LOCATION SEWAGE # SrZ
YMLAGE ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. Giidi/4,,,�a��v> 3 G Z L®� 7�
SEPTIC TANK CAPACITY Z
LEACHING-FACILITY: (type) / (size) /
NO. OF BEDROOMS
_ P
BUILDER OR OWNER e
PERMIT DATE: / Z ZZY � COMPLIANCE DATE: `7
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 4q,! S y ' 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 o leaching facility) /�� --L Feet
Furnished by �- /C/,
•O 321
V 97at l
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IVo ' z
r-
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rr"
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A
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ypN 0
N
✓GG Z G W 3 - �'
w fined 3t
u
f4
122
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_ poor rkan
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20
14
II
711
ILIA _..--- -
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2'6°
Public Hea th Division
Town of Barn table
& PO Box 534
- I � - v
10or 'I 3 n u I ro ; i Hyannis,Mal c useds 02601
►w�"= i'o� -— --� 144Fax(508)77 3344
U 8 s 4 �' lq j
a ,�t~_ Phone(50 ) ' I�
--- -- =•--�
71-lk-- -,7�
.......... 71
7
S
ILE -TEST�
,:,SYSTEM ljl�OF.
At EL 51-�O (NOT TO SCALE)
ER TO WITHIN 6" OF. FIN.�.GRADE
HT
S R RTIC� TO N M PARIA, SE
ACCES COVE WATE ENGI EER:
WITHIN
6 , Or FIN. GRADE
'EQ, OARRY
49.5*
MINIMUM . 5' 'OF COVER OVER PRECAST" 14� 27. SLOPE REOUIRED OVER SYSTEM WITNESS:
48.0'
-4 99 '
L
RUN PIPE LEVEL
< 5 MIN/INCH
FOR'FIRST 2'
\�4�80' PERC.
DATE,
J, 'PEASTONE
2" DOUBLEWASHED
46.0' RATE
1500
�SEPTIC 9575
CALLON 7. P#
CLASS SO1ILS
47.50
:10
TANK GAS 5' AT SIDES 4 5.7 5'
r7l
ROAD
BAFFLE , 45.92' �;REA T'A#A
1.5' AT
ENDS� ,
'(-!-% SLOPE), M MANi�AL
5 � CRVSHED STONE OR EC
ELEV. 46.8'
on
COMPACTION. (15.221 21)'
I I I I . I . . 14
4 1 . & r I . 4 6,7'
- 'i�� 43.5'�
DEPM OF FLOW' 5
SLOPE)
O/A
O/A LOCATIO A O�SCALE
�TEE SIZES-* I - 1 11 1 1 �I . . i, - I', . . I I� I
STON F M P
3/4" TO 1 1/2", DOUBLE 'WASHED
SL
10"
JNLET.DEPTH. -3/3
1 OYRr 1 Y 3 3
D p 1 4
OUTLET E TH -
B
B 8.5'r
LEACHING
'PARCEL�1-
SEPTIC TANK LS ASSESSOR MAP 210 ..r
ON
D' E30X
26' ' LS
FACILITY,
I OYR 4/6 ZONING r
4
') , 44�7' 1 24,
1 OYR 4/ DISTRICT: �RD
YAR KS',
D 'SETBA�C
FRONT
�HIGHEST WATER LAKE EL. 35,0'
'10'
4 4.5 8 4 9
C �EAR
.55
PLAN RE
C F MED/
M
.00 COS'
-FLOOD
ED/COS
ZONE�
�'2-5Y 6/4'
2.5Y 6/4
4.5
A
.35
+47'.67
33.8'
32.7'
68"
N
NO: WATER ENCOUNTERED
BENCHMARK
NOT ALLOWE 'LAKE� DATUM SYSTEM',
D r r
CONCRETE BOUND (GARBAGE DISPOSER IS I DATUM is -
SEPTIC DESIGN:
ELEV 46.08' 4, 4'8,16
TH1 AVAiLARLE.
z T - IS
DESIGN FLOW: -L BEDROOMS (-LiO-GPD) 44C) GPDr' 2. MUNICIPAL WAiER
7
-3. MINIMUM PITCH TO -BE '1/87 P.ER ,,FOOT. 1,C),
USE A 440 GPD DESIGN FLOW PIPE-
'FOR ALL.'PRECAST ,UNITS';TO 'BE�,AASHO. H-
440 GPD, 2 BO 4. DESIGN LOADING,
SEPTIC TANK:
43-82
44.99 PIPE JOINTS 'TO BEr
+ 'MADE-WATERTIG
HT
USE A 1 aQ- GALLON SEPTIC TANK BE� ',WITH
6... tONSTRUCTION DETAILS TO
.47 LEACHING: _'ENVIRONMENTAL", CODEJITLE V.
+ r 9.83) 2 (.74) 148.9 7. THIS PLAN IS-FOR PROPOSED j,VOW:ONLY. AND IN
49 2(40.51 OTf0 BE
SIDES: USED �FOR-'LOT LINE r
= , 294.6(74)
40.5 x 9.83
PVC.
. 8. 'PIPE FOR SE T -SYSTEM TO SCH. :40.
BOTTOM: p I c
ONCtA
9. COMPON C LE V1
TOTAL, 599.4 S.F 443.5 GpD .:BE :BACKFILLED OR'- T
ENTS NOT TO HOOT
AND -P-EP M I S SION ORTAINEV
+1 4 .31 INSPECTION B`Y� BOAn 1717
USE 6 HIGH CAPACITY INFILTRATORS WTH ' 3.5' STONE r
FROM BOAPD OF HEALTH,
AT SIDES 'UNDER
PROP. 4 BR' 1.5' AT ENDS �AND 14".1
DWELLING
44.41 0
TF 51.0
47,05
LEGEND
46
OF p 011
'0 T . 9 F I N E S'r, AVEN U E
PROPOSED SPOT, ELEVATION
45.94
DECIt L N'T OF
4 . 001) EXISTING SPOT,r ELEVATION
OWN OF-,.
-THE T
00
0 PROPOSED CONTOUR
-(CEW TE* V1.LLE)`,`B
EXISTING
00 CONTOU"r P'REPARED,.FOR:
-CRONES
46.73
+'4' 7.52' >
20 r ''20r � I 1 .1 - 60 lFeet
0
46
45-89
BOARD OF HEALTH
LOT 10
�LOT
NOVEMBER 13, 1999
----:�-�20,01 7. 20'
DATE:.�
MA.- SCALE:
D DATE
Off 508-362-454 t
fcx 508 362
43,58
45
k
qape engii e ering,
down I inc.
LA
44
4
CIVIL ENGINEERS
'left-
'!LA
44.26
0
47- 0'
�45 J92 1 5. -Al
939 main st. �,.yarmouth,',ma,-02675
S �:DA TE
H, JAJ
'99 310�--9'1: