HomeMy WebLinkAbout0071 POWDERHORN WAY - Health 71 Powderhorni Way
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190 171
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No.2163LOR � �`
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments ` qy Sr
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form. Inspection forms may not be altered in any way.
A. General Information
1. Property Information: MAP 190—PARC 171
71 POWDERHORN WAY- CENTERVILLE, MA 02632
Property Address
DESROSIERS, DON
Owner's Name
71 POWDERHORN WAY
Owner's Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
J U LY 9, 2007
Date l r-
2. Inspector:
JAMES D. SEARS
Name of Inspector c:r
A & B CANCOj -:
Company Name
350 MAIN STREET cn
Company Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
508-775-2800
Telephone 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
El N ends Evaluation by the L cal Approving Authority
ir6dctors 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
a` Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. Certification (cont.)
71 POWDERHORN WAY
Owner's Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
DESROSIERS, DON
Owner's Name
JULY 9, 2007
Date of inspection
Inspection Summary: Check A, B, C, D or E/always complete all of Section D
A) System Passes: ✓
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B) System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or
Repaired. The system, upon completion of the replacement or repair, as approved by the Board of
Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
compliance indicating that the tank is less than 20 years old is available.
ND Explain:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
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Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
71 POWDERHORN WAY
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
DESROSIERS, DON
Owner's Name
JULY 9, 2007
Date of inspection
B) System Conditionally Passes (cont.): NIA
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):
Elbroken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND Explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced.
obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health: N/A
® 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
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
71 POWDERHORN WAY
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
DESROSIERS, DON
Owner's Name
J U LY 9, 2007
Date of inspection
C) Further evaluation is required by the Board of Health (cont.): N/A
2.System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public
health,safety and environment:
The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public
water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*
Method used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria
indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
� ~ Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
71 POWDERHORN WAY
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
DESROSIERS, DON
Owner's Name
J U LY 9, 2007
Date of inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
✓� Backup of sewage into facility or system component due to overloaded or clogged SAS
or cesspool
0 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
0 Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
0 Liquid depth in leaching is less than 6"below invert or available volume is less than
'/day flow
® ✓� Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped:
Q 0 Any portion of the SAS,cesspool or privy is below high ground surface water elevation.
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary
to a surface water supply.
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
® N/A 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.]
YES No
The system is a cesspool serving a facility with a design flow of 2000 gpd—10,000 gpd.
Yes No
0 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
DESROSIERS, DON
Owner's Name
J U LY 9, 2007
Date of inspection
E) NIA-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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments
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Subsurface Sewage Disposal System Form
C. Checklist
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
DESROSIERS, DON
Owner's Name
JULY 9, 2007
Date of inspection
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
Q ✓� 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, including 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)].
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
DESROSIERS, DON
Owner's Name
J U LY 9, 2007
Date of inspection
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
Number of current residents: 4
Does residence have a garbage grinder? Yes 0 No
Is laundry on a separate sewage system?[if yes separate inspection is required] ® Yes ® No
Laundry system inspected? 0 Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): N/A
Sump pump? Yes No
Last date of occupancy: PRESENT
Commercial/Industrial Flow Conditions: N/A
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:
Last date of occupancy/use:
Date
Other(describe):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
u Title 5 Official Inspection Form
Not for Voluntary Assessments
a yew•
Subsurface Sewage Disposal System Form
D. System Information (cont.)
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
DESROSIERS, DON
Owner's Name
J U LY 9, 2007
Date of inspection
General Information
Pumping Records:
Source of Information: N/A
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:
0 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:
1999 PERMIT 98-786A
Were sewage odors detected when arriving at the site? ® Yes ❑ No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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Title 5 Official Inspection Form
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Subsurface Sewage Disposal System Form
D. System Information (cont.)
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
DESROSIERS, DON
Owner's Name
J U LY 9, 2007
Date of inspection
Building Sewer(locate on site plan): ✓
Depth below grade: 1'
feet
Material of construction:
❑ cast iron 0 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
Septic Tank(locate on site plan): ✓
Depth below grade: 28"
feet
Material of construction:
�✓ concrete metal ❑ fiberglass ❑ polyethylene other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) Yes ❑ No
Dimensions: 1500-GALLON PRE CAST
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle 27"
Scum Thickness 3"
Distance from top of scum to top of outlet tee or baffle 8"
Distance from bottom of scum to bottom of outlet tee or baffle 15"
How were dimensions determined? . ASBUILT-TAPE-SLUDGE JUDGE
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
r Title 5 Official Inspection Form
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Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
DESROSIERS, DON
Owner's Name
JULY 9, 2007
Date of inspection
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 AT WORKING LEVEL.
NO SIGN OF LEAKAGE OR OVERLOADING.
Grease Trap (locate on site plan): N/A
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A
Depth below grade:
Material of construction:
concrete M metal ❑ fiberglass polyethylene other(explain)
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
CitylTown State Zip Code
DESROSIERS, DON
Owner's Name
JULY 9, 2007
Date of inspection
Tight or Holding Tank(cont.) N/A
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 a copy of current pumping contract(required). Is copy attached? ❑ Yes No
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.):
D-BOX IS 16" X 16" —33" BELOW GRADE. BOX IS CLEAN & SOLID.
(1) LINE IN — (2) LINES OUT. NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
Pump Chamber locate on site plan): N/A
Pumps in working order: ❑ Yes ® No
Alarms in working order: ® Yes ❑ No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
DESROSIERS, DON
Owner's Name
JULY 9, 2007
Date of inspection
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:
Type:
❑ leaching pits number:
® leaching chambers number: 2
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.):
LEACHING IS (2) 500-GALLON DRY WELLS. LEACHING AT 4' BELOW GRADE
WITH 6"WATER. NO HIGH STAIN LINE, NO SIGN OF OVERLOADING OR SOLID
CARRY OVER.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
71 POWDERHORN WAY
Property Address .
CENTERVILLE MA 02632
City/Town State Zip Code
DESROSIERS, DON
Owner's Name
JULY 9, 2007
Date of inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A
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, damp soil,condition of vegetation,
etc.):
Privy(locate on site plan): N/A
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
DESROSIERS, DON
Owner's Name
JULY 9, 2007
Date of inspection
Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at
least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where
public water supply enters the building.
35 t
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COMMONWEALTH OF MASSACHUSETTS
T Title 5 Official Inspection Form
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Jew.
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
71 POWDERHORN WAY
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
DESROSIERS, DON
Owner's Name
JULY 9, 2007
Date of inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to NO ground water: 10
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:
TEST HOLE OFF PAST REPORT 10' NO WATER.
TEST HOLE AT 4' BELOW BOTTOM OF LEACHING.
G`
a M 14 1'tr
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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TOWN OF BARNSTABLE
-.J,7CATION 9 / h4o^*✓ 111•4S" SEWAGE#
`r VILLAGE _ f/-1/- ASSESSOR'S MAP&PARCEL
W&BkhbERS NAME&PHONE NO. 1§ Od xl
SEPTIC TANK CAPACITY '�' �� / /1J j B�-C 7-10.A-
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER Sw��S £ �S
PERMIT DATE: GQMP�, CE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
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COMMONWEALTH OF MASSACH;U891' 'S
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RONMENTAL EXECUTIVE OFFICE OF ENVIIRS
o DEPARTMENT OF ENVIRONMENTAL r�ROTECTION
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RECEIVED
350 MAIN STREET
WESTYARMOUTH,MA AUG 2 4 Z004
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508-775-2800
KM BAR
TOWN O NTH DEPT NSTABLE
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
I 1
MAP—190 PARC-171 CERTIFICATION iOAP
Property Address: 71 POWDER HORN WAY PARCEL
CENTERVILLE,MA 02632 �y
Owner's Name: ,LAMES FOW ,ER
Owner's Address: 71 POWDER HORN WAY
CENTERVILLE,MA 02632
Date of Inspection 08-05-06
Name of Inspector:(please print) .TAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarniouth,MA 02673
Telephone Number: 508-775-2800
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: DDate: 08-05-04
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 tot he buyer,if applicable,and the approving authority.
Notes and Continents
.***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 I
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: TAMES FOWLER
Date of Inspection: 08-05-04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
I have not found any information which indicates that any of the failure criteria described in 310 CUR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer_yes,no or not determined(Y..N, ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: JAMES FOWLER
Date of Inspection: 08-05-04
C. Further Evaluation is Required by the Board of Health:N/A
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(l)(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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of 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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: JAMES FOWLER
Date of Inspection: 08-05-04
D. System Failure Criteria applicable to all systems: N/A
You must indicate'`yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in leaching is less than 6"below invert or available volume is less than''/y day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pmuped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 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 Systems: N/A
To be considered a large system the system must service 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(hnterim Wellhead Protection Area—1WPA)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 is 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 CNIR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/I5/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: TAMES FOWLER
Date of Inspection: 08-05-04
Check if the following have been done. You must indicate"yes" or"no"as to each of the following
Yes No
X Pumping infonnation was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
X Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
I
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: JAMES FOWLER
Date of Inspection: 08-05-04
FLOW CONDITIONS
RESIDENTIAL X
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 4 of bedrooms: 330
Number of current residents: 4
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): X
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIALANDUS TRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
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: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—HoNv was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1999 PERMIT#98-786A
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: JAMES FOWLER
Date of Inspection: 08-05-04
BUILDING SEWER(locate on site plan): X
Depth below grade: 12
Materials of construction: Cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Coinments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 28"
Material of constriction: X concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confinued by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 GALLON PRE CAST
Sludge depth: 12"
Distance from top of sludge to the bottom of outlet tee or baffle: 18"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: AS BUILT AND TAPE
Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL,OUT LET TEE TANK 28"BELOW GRADE,COVER AT 1'.
NO SIGN OF LEAKAGE OR OVER LOADING.
GREASE TRAP(located on site plan) N/A
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:
Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: JAMES FOWLER
Date of Inspection: 08-05-04
TIGHT or HOLDING TANK: N/A (tank must be puunped 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)
Alain level: Alarm in working order(yes or no):
Date of last pumping
Cotmnents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Continents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
D BOX IS 16"X16"-33"BELOW GRADE,ONE LINE IN,ONE LINE OUT.
BOX IS CLEAN—NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Connuents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: JAMES FOWLER
Date of Inspection: 08-05-04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
X leaching chambers,number: 2
leaching galleries,number
leaching trenches, number,length
leaching fields,number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Continents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS TWO(2)500-GALLON DRY WELLS. LEACHING IS 37"BELOW GRADE,WET.
NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionX 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):
Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Constriction:
Dimensions:
Depth of solids:
Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: JAMES FOWLER
Date of Inspection: 08-05-04
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.
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 POWDER HORN WAY
CENTERVILLE, MA 02632
Owner: JAMES FOWLER
Date of Inspection: 08-05-04
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 10 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:
X Observation 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:
HAND UDG TEST HOLE— 10'NO WATER.
TEST HOLE 4' BELOW BOTTOM OF LEACHING.
Title 5 Inspection Form 6/15/2000 11
ci TOWN OF BARNSTABLE
LOCATION / � AoA-�-rle ° OR/' A-14)` SEWAGE #
VELLAGS £ti'r ASSESSOR'S MAP & LOT
DfSTAlk�gR'S NAME&PHONE NO.
SEPTIC TANK CAPAC= —5,Z 0 7/ G iN 71-16
LEACHING FACILITY: (type) (size)
°NO.OF BEDROOMS
BUILDER OR OWNER o °4 F 4
ERMI'I DATE: : CONS DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
r
3 v.�
� o .
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
11 Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppficatiori for Di,5pont *p5tem Cow5truction Permit
Application for a Permit to Construct,(. )Repair(c—)-Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot NO—V Powde-i- !llol-n cci,4y, Owner's Name,Address and Tel.No. 7-q4 g
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. y•77-03 y f Designer's Name,Address and Tel.No.
J0,fep6l 0, &4 S
o1 1,44,i/s S ,
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S�n
Nature of Repairs or Alterations(Answer when applicable) F,Jl %Xis/"is9CZ 1S'_a%55pools 611111 r� C� �
T_k7.5 r"1/ P;-00 Ge;l. S 7, 2 S90 fsa/ &-y«c,l /'4.4.Wl�" cry, r4
-1 r .SPo w e_ j4f a y;J d 2" P_al'a .STOG/e_
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.
Signed 1 4.15 A ® r, Date /2-17 y N
Application Approved by Date
IF 'Application Disapproved for the ollowing reasons
Permit No. Y Date Issued
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Migpozal *paem Construction Vermit
Application for a Permit to Construct( )Repair(Z,4-Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot N nowcler W o Owner's Name,Address and Tel.No.7%/— a-N(i?
Assessor's Map/Parcel GSHT/_Nt/i//i: J401`s Poall-ee
4 /7/
Installers Name,Address,and Tel.No. '117_p 3 409 Designer's Name,Address and Tel.No.
Jascpti rI., 13pwvs
s
pe of Building: !
Dwelling No.of Bedrooms _� Lot Size sq.ft. Garbage Grinder('� )
Other Type of Building T No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date NLOber of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil <, �� tom.
Natu a of Repairs or Alterations(Answer when ap; icable) F%Z/-X1sr/e�z di=S P00/S w/T�i
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. /
Signed a Date''. /.2
v� Application Approved by Date
Application Disapproved for the ollowing reasons
Permit No. w Date Issued -~--M
THE COMMONWEALTH OF MASSACHUSETTS f
BARNSTABLE, MASSACHUSETTS
(Certificate of (otnpriance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( y"
Abandoned( )by
at I ben nstructed in accordance
with the provisions of Title 5 and•the for Disposal System Construction Permit No. ed
Installer .%r=* —6 613,w ft-a;S Designer /i NoS
The issuance of this ermit shall not construed as a guarantee that the system w function as designed.
Date "' Inspector
.�.
/%/ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Digpogaf *pztem Construction VerM-' it
Permission is hereby granted to Construct( )Repair( ,�_jlpgrade( )Abandon( )
System located at
41izro l<C/mLX
a04 tw�se 144//e
and as described in the above Application for Disposal System Construction Permit. The applicant recognize his/her duty to
comply with Title 5 and the following local.provisions or special conditions.
Provided: Construction must b complet d wit 'n three years of the date of tl s rmit.
Date: Approved by /I/
I
r
TOWN OF BARNSTABLE °
LOCATION CA .ss`' C?m SEWAGE # 7L 12?6 A
VILLAGE A#)-a ti A,0 ASSESSOR'S MAP & LOT/f0 17/
INSTALLER'S NAME&PHONE NO. `7'7 0.3 y q c%5 z P�i 0� ��i�irNroS
SEPTIC TANK CAPACITY nn /
LEACHING FACILITY: (type) '1^Sos 6.411�y k/i Af (size)
t
,40.OF BEDROOMS -3
;BUILDER OR OWNER
PERMTTDATE: /�- �`7'Q� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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�fac�it )) Feet
Furnished by
�Q a
.t6-
10/9197
NOTICE: This Form Is To Be Used For the; Repair Of Failed
Sceptic Systems Only:
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, ogrras , hereby certify that the application for disposal works
construction pemlit signed by me dated 12— /7 — LF ,concerning the
property located st 7/ Poavc r wkyky z meets all of the
following criteria.;:
(/There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
t/There is no increase in flow and/or change in use proposed
There are no variiances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will LWt be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete ithe following:
A)Tap of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map) _
SIGNED:
DATE: /2 —1 7— 9�
-�
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER f 9
(Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cent
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a
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