HomeMy WebLinkAbout0524 PRINCE HINCKLEY ROAD - Health ol
524 PRINCE HINKLEY RD., CENTERVILLE
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TOWN OF BARNSTABLE
LOCATION,5�dl �!A".,fG `- I- ''.cc e-- yla SEWAGE # �q"lj
VILLAGE �G�n-% 11 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 1 Z
SEPTIC TANK CAPACITY
LEACHING FAC1LnY: (type) r_ s��-�Z L'C (size)
NO.OF BEDROOMS
BUILDER OR OWNER �V ti•,c�
PERMITDATE: ,5—/3 1 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching F t ity Feet
Private Water Supply Welland Leaching Facility (1f any we exist r
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any well s exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
-- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
524 Prince Hinckley Road 3�
Property Address Iw
Catherine Tomkinson
Owner Owner's Name
information is
required for every Centerville V MA 02632 March 14, 2016
page. City/Town State Zip Code Date of Inspection
.11
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Patrick T. Sullivan
use the return Name of Inspector
key.
Ready Rooter Excavating
�y Company Name
P.O. Box 89
Company Address
ro Forestdale MA 02644
City/Town State Zip Code
508-888-6055 SI 12843
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
March 16, 2016
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�o VS
e
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
=- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.4 524 Prince Hinckley Road
Property Address
Catherine Tomkinson
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
page. Citylrown 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:
Old leach pit still connected to system.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
•y'�r 524 Prince Hinckley Road __
Property Address
Catherine Tomkinson
Owner Owner's Name
information is Centerville MA 02632 March 14, 2016
required for every --
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a Oroken, settled or uneven distribution box. System will
pass inspection if(with approval of Board/of Health):
i
❑ broken pipe(s) are replaced i ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
i
i
❑ 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):
r
❑ obstruction is removed ❑ /Y ❑ N ❑ ND (Explain below):
i
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.
i
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:
j
❑ 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
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
524 Prince Hinckley Road _
Property Address
Catherine Tomkinson
Owner Owner's Name
information is Centerville MA 02632 March 14, 2016
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary"to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well/,Water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other: jf
i
r`
i
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 1h day flow _
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M _ 524 Prince Hinckley Road
Property Address
Catherine Tomkinson _
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
- -
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No /
I .
❑ ❑ 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
El ❑ the sy'stem 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
524 Prince Hinckley_Road_____
Property Address
Catherine Tomkinson
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
524 Prince Hinckley Road
Property Address
Catherine_T_o_mki_n_so_n____ _
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
—
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ No
9 GPD
Water meter readings, if available (last 2 years usage (gpd)): 2014=2015- 11 11 GPD
Detail:
Property used during summer months and holidays for past three years.
Sump pump? ❑ Yes ® No
Last date of occu anc : December 2015
P Y 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.):
i
Grease trap present? ;� ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
I
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 524 Prince Hinckley Road
Property Address
Catherine Tomkinson
Owner Owner's Name
information is
required for every Centerville MA 02632 March 14, 2016
page. Cityfrown 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: Owners records: Pumed 2013
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
4 Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
524 Prince Hinckley Road
Property Address
Catherine Tomkinson
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Septic tank installed 1985. Leach chambers installed 08/25/1999. D-box replaced 11/20/2015.
Certificates of Compliance on file at Health Dept.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18
p g feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: n/a
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
8"
Depth below grade: 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: 8.6' x 5' x 4.5' 1000 gallons
2„
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• age 9 of 17
f
Commonwealth of Massachusetts
q -( Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
524 Prince Hinckley Road
Property Address
Catherine Tomkinson
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
page. CitylTown 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 33"
Scum thickness 1" at inlet<1" at outlet
Distance from top of scum to top of outlet tee or baffle 8" to PVC tee. 10"to concrete top
of baffle.
Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined? Tape measure and dip tube.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet PVC tees in place. Liquid level at outlet invert of old leach pit which is still connected
to system; not inspected. Covers are 8" below grade. Pumping is not needed at this time. Property
has seen seasonal use over the last three years.
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
(Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
<,� o 524 Prince Hinckley Road
Property Address
Catherine Tomkinson
Owner Owner's Name
information is MA 02632 March 14, 2016
required for every Centerville
page. City/Town _ State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm'and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forme Not for Voluntary Assessments
524 Prince Hinckley Road
Property Address
Catherine Tomkinson
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
- -
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
011
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
One inlet, one outlet. H-20. No solids carry over. Installed in November. Riser brings cover within 4"
of grade.
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.):
r'
i
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
524 Prince Hinckle r_Road
Property Address
Catherine Tomkinson
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 gal ea. w/
4' of stone.
❑ 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.):
Camera used to locate and inspect chambers. Dry at time of inspection. Light staining 8"+-from base
of chamber. No sign of past hydralic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
i
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
r'
Materials of construction -
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
wM 524 Prince Hinckley Road
Property Address
Catherine Tomkinson _
Owner Owner's Name
information is Centerville MA 02632 March 14, 2016
required for every --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
i
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
524 Prince Hinckley Road
Property Address
Catherine Tomkinson
Owner Owners Name
information is Centerville MA 02632 March 14, 2016
required for every
page. Citylrown 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
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t5hm-3M 3 TM9 5 onloo kwpecbon Font&MmUce Sewage Disposal System•Page 15 of 17
a T
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forme Not for Voluntary Assessments
� 524 Prince Hinckley Road
Property Address
Catherine Tomkinson
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: >5
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: 1999
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:
maps.mass is.state.ma.us/oliver.php
You must describe how you established the high ground water elevation:
Test hole in 1999 found no ground water at 120". Base of chambers at 60" below grade. Accessed
local ground water contours and topo mapping. No high ground water in area of system.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 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
524 Prince Hinckley� y Road
Property Address
Catherine Tomkinson
Owner Owner's Name
information is required for every Centerville MA 02632 March 14, 2016
—
page. CityrFown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. Z6/5_L" o Fee k1ho 1100
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Misposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(V/�pgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. fir;��c�-�`w�ea � Owner's Name,Address,and Tel.No. (4{`97 o7S`C'�7
Assessors Map/Parcel O f j ` S,14cQ cgv
Installer's Name,Address,and Tel.No.9Z)"g` Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms s Lot Size d L{l ` :-bP6 sq ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ' Ahqgpd Design flow provided /i/ gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) .A
" 0(n 3
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o
gne / Date',` 1
r
Application Approved by n_w Date /
Application Disapproved b, Date
for the following reasons
Permit No. J ti Date Issued
I
/ 00
No. — Fee kl
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: e
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
21pplication for disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(Upgrade Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. Sa Qr�,hc�-�,v� n� Owner's Name,Address,and Tel.
Assessor's Map/Parcel
mr
Installer's Name,Address,and Te.No.S-Z�"Q- Designer's Name,Address,and Tel.No.
0 a� o>`�srS�la
Type of Building:
Dwelling No.of Bedrooms Lot Size d L{3 '�Cb�S sq<ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) )UVgpd Design flow provided 4 Jf gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
-aa
Nature of Repairs or Alterations(Answer when applicable) ��
Date last inspected:
Agreement:
Th�-� e�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 Codeind not to place the system in operation until a Certificate of
.w Compliance has been issued by this Board-peal�k''
e Date
Application Approved by Date
Application Disapproved b. Date
for the following reasons
Permit No. ,J.'; - y 17 Cj Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded
Abandoned( )by � � �•a�� �— '�J��'�,( �,�i�,
at `el&Ohas been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 0 dated )/ I
Installerl�___QZ � V o, Designer
#bedrooms Approved dest n flaw I{ /� i4' gpd
The issuance of is pe it shall not be construed as a guarantee that the system wil�fun t)i as desig d.
Date I-[ � Inspector v �, i ,
I
----- -- --------------------------------------------------
No. 006 - 409 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
;Disposal 6pstem (Construction Permit
Permission is hereby granted to Construct( ) Repair(�)� Upgrade( ) Aband(o�( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date �l 7Approved by r�
s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
information is
required for every Centerville MA 02632 4-24-13
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:outA.When A General Information filling out forms ���lutn11111u1��i�
on the computer, ����` 1}1 OF
use only the tab
1. Inspector: _0�� •''` ��
key to move your Off;' y
cursor-do not314 ��; JANIES N
use the return
James D. Sears m=
_
key. Name of Inspector c -Sy
Capewide Enterprises LLC - �'•.n o;
�I�y 11 Company Name �yi� Y�� ��
ICI 153 Commercial St.
Company Address - — -
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
1 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 ❑ F ils ==
C>
~art
❑ Needs Further Evaluation by the Local Approving Authority ICPO
, -- 4-24-13 N
I actor's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
v
d �� 3
l5 ns•3/13 Title 5 Offiaal 1 'on Fo rrc Subsurface Sep ge Disposal System•Page 1 d 17
i
Apr 26 13 07:23a p.2
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
524 Prince Hinckley Rd.
IW-I
Property Address
Diane Zani
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
page. City(rown State Zip Code Date of Inspection
B. Certification (cunt.)
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:
❑ 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)`
15ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Apr 26 13 07:24a p,3
Y
Commonwealth of Massachusetts
U
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
ion is
requirequiredd for every Centerville MA 02632 4-24-13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cons.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Apr 26 13 07:24a p.4
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
page. City/Town State Zip Code Date of Inspection
S. 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
ry.
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 UsisM is less than 6" below invert or available volume is less
than day flow),F,9 CIII v G
t5ins.3113 Title 5 Official hv"clion Form:Subsurface Sewage Disposal System•Page 4 of 17
Apr 26 13 07:24a p.5
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owners Name
information is required for every Centerville MA 02632 4-24-13
page. Cityrrown State Tap Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year MOTdue to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS,cesspool or privy is below high ground water elevation_
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis_ [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10.000gpd.
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 20C 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 I I 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.
151ns•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Apr 2613 07:25a p,6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y 524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or."no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection.>
® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NA Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15203 (for example: 110 gpd x#of bedrooms): 330
Mrs-N13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 d 17
Apr 26 13 07:25a p.7
Commonwealth of Massachusetts
Title 5 official Inspection Form
R' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
page. CitylTown state Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal.tank D Box and two 500 Gal_ dry well chambers.
Number of current residents:
1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2011-108,000Gal
9 ( Y 9 (gPd)) 2012-128,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present.
Date
Commercial/lndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/personslsq.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:
Wins-3113 Title 5 Official I rupedion Form:Subsurface Sewage Disposal System•Page 7 or 17
Apr 2613 07:25a p,g
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zan!
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
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: Every 2 Years
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: . ------ - —
Type of System.
® Septic tank, distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑• Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
15ins•3113 Title 5 Official hnspedion Form:Subsurface Sewage Disposal Syslem-Page 8 of 17
Apr 26 13 07:26a p.9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Tank Na 1 New D Box and leaching 1999 permit#99-138
Were sewage odors detected when arriving at the sine? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"
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.):
Pipeing is 4" PVC SCH 40
Septic Tank(locate on site plan):
1'
Depth below grade: 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
1000 Gal Precast
Sludge depth:
2"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Apr 26 13 07:26a p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
information is Centerville required for every MA 02632 4-24-13
page. cltyrrov►m State Zip Code Date of Inspection
D. System Information (coat_)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness 1.1._
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 17"
How were dimensions determined? Asbuilt=Tape
Sludge Judge
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. Tank and cover's at 1' below grade w/in and outlet tees. No sign of
leakage or over loading.
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
15rns-3113
Title 5 Official Inspection Fenn:Subsurface Selvage Disposal System.Page 10 or 17
Apr 26 13.07:26a p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
IWO`
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions: -
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins•3l;3 Title 5 Official hisipecton Farm:Subsurface SPHage Disposal System•Page 11 of 17
Apr 26 13 07:27a p.12
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's flame
information is required for every Centerville MA 02632 4-24-13
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth ofliquid 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.):
Camera out to D Box, Box at 26"below grade, Box looks good. No sign of over loading or solid
carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Apr 26 13 07:27a p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ti
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number.
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovaEive/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 two 500 Gal.Dry Well Chambers. Chambers are 30"below grade wet on bottom. Wall's
are clean like new. No sign of over loading solid carry over or stain line
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•3113 Title 5 Official Inspection Forrtc Subsurface Sewage Disposal System•Page 13 of 17
Apr 26 13 07:27a p.14
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
page. Cityffown 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.)-.
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Apr 26 13 07:28a p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zan
Owner Owner's Name
information is required for every Centerville MA 02632 4-24-13
page. CitylTown State Zip Code Date of fnsper#ion
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:
j ® hand-sketch in the area below
❑ drawing attached separately
-/ 3
�+ £A 2 /
y .
Lo
®,r
Ny'
U i
t51rs•W13 Tille 5 Official trspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Apr 26 13 07:28a p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owner's Name
requir nform ation is Centerville MA 02632 4-24-13
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
46'
Estimated depth to high ground water: 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:
USGS Well SOW 252 46' ADJ 4'
You must describe how you established the high ground water elevation:
USGS Well SOW 252 at 46' Bottom of leaching at 5' below grade. Bottom of leaching at
404 above well depth.
Before filing this Inspection Report, please see. Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 16 of 17
Apr 26 13 07:28a p.17
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
524 Prince Hinckley Rd.
Property Address
Diane Zani
Owner Owners Name
information is
required for every Centerville MA 02632 4-24-13
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
y ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•all Title 5 Official Inspection Form:Subsurface Sewage Disposal Sysfam•Page 17 or 17
is CO.1 O.N7 'E ALTH OF MASSACHU SETTS
EXECli TILT OFFICE OF E:,'VIRONME:v TAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON b4A 02108 (617) 292-5600
TRUDY CONE
Secretan-
ARGEO PAUL CELLUCCI DAI'ID B. STRUHS
Governor Conunissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 524 Prince Hinkley Rd.. Name of Owner J im Dunn
C-p me r i f l e , MA Address of Owner:
Date of Inspection: l� 9
Name of Inspector: ease Print) Wm. E . Robinson Sr .
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
company Name: Wm. E . Robinson Septic Service
Mailing Address: P.O . Box 1089, Centerville , MA
Telephone Number: T 7 K_R'7'7 H
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site
sea disposal systems. The system:
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: �i(/ ,,/ � �" Date: 7
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (301 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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
9 IO
Iv�6
...1 s
2 1999
TOWN OF BARNSTABLE
HEALTH DEPT.
revised 9/2/98 Page Iof11
t� Primed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �✓
PART A
CERTIFICATION (continued)
'ropenyAddress524 Prince Hinkley Rd.. , Centerville , MA
awner: J im Dunn
Date of Inspection:
INSPECTION MMARY: Check A, A C, of D:
A. Y PASSES:
1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMM TS:
B. SYS M CONDITIONALLY P' SSES:
ne or more system omponents as described in the "Conditional Pass" section need to,be replaced or repaired. The system, upon
ompletion of the re6lacement or repair, as approved by the Board of Health, will pass. ,
Indicate yes, no, or not det rmined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The se tic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Com�iance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
/Health).
eptic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
e is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
oved by the Board of Health.
age backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
e to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
ystem required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
ction if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
4,f'r
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop"Ad&.tress: 524 Prince Hinkley Rd . , Centerville , MA
Owner: Jim Dunn ,
Date of Inspection: 3-a,f^'9
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 the
public health, safety and the environment.
111 YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
17V
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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3 OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
a
CERTIFICATION (continued)
t ,
Property Address: 524 Prince Hinkley Rd.. , Centerville. , MA
Owner: Jim Dunn
Date of Inspection: �s pCJ
D. SYSTEM FAILS:
You mu t indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes N
Backup of sewage into facility-or system component due to an overloaded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
_ 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE YSTEM FAILS:
You must ind cate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
heal h and safety and the environment because one or more of the following conditions exist:
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)
The owner or perator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the apartment for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
4 PART B
CHECKLIST
Prop"Address: 524 Prince Hinkley Rd.. , Centerville , MA
Owner: J im Dunn
Date of Inspection: p Q
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and-the system has been receivingtrormal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
J _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
t1l _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b))
_ The facility owner (and occupants,if different from owner) were provided with information on the proper-Mai ntenan"-of
Subsurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION }
Orop"Address: 524 Prince Hinkley Rd.. , Centerville , MA
Owner: J im Dunn
Date of Inspection:3 A�
FLOW CONDITIONS
RESIDENTIAL:
Design flow:. /�g.p.d./bedroom.
Number of bedrooms(desi n):_-3_ Number of bedrooms (actual):,
Total DESIGN flow G�j
Number of current residents:
Garbage grinder lyes or no1:J
Laundry(separate system) (yes or no),,i if If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):A, 0
Water meter readings, if available (last two year's usage (gpd): 1998 91 , 000 gal.
Sump Pump(yes or no):k d 1997 92, 000 gal.
Last date of occupancy:
COMMER IALIINDUSTRIAL:
Type of es t blishment:
Design flFne
d ( Based on 15.203)
Basis of dw
Grease trt: (yes or no)_
Industrialolding Tank present: (yes or no)_
Non-sanite discharged to the Title 5 system: (yes or no)_
Water mengs,if available:
Last dateancy:OTHER:) )Last dateancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
3. /- 7 C/
System pumped as part of inspection: (yes or no)LL.d
If yes, volume pumped:/D d-d gallons
Reason for pumping:
TYPE01 YSTEM
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)
1/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other /
APPROXIMATE AGE of all components, date installed(if known)and source of information: .1 d d- 7 1 9
Sewage odors detected when arriving at the site: (yes or no)Ti d
revised 9/2/98 Page 6of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontinued)
'rop"Address: 524 prince Hinkley Rd.. , Centerville , MA
Owner: Jim Dunn
Date of Inspection: 3 a �e
BUILDI G SEWER: `7
(Locate site plan)
Depth bel w grade:_
Material construction:_cast iron_40 PVC_ other(explain)
Distance rom private water supply well or suction line
Diameter
Comme s: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is.age confirmed by Certificate of,Compliance_ (Yes/No)
le
Dimensions: 4e q
Sludge depth: ,
Distance from top of sludge to bottom of outlet tee or.baffle:4-"5�
Scum thickness:_ 1 1
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle-Z
How dimensions were determined: 6 PZ — 7--4
'omments:
(recommendation for pumping, condition of inlet,and oqllet tees or baffles, depth f liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) o
v
GREA E TRAP:
(locate o site plan)
Depth belo grade:_
Material of onstruction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions
Scum thick ess:
Distance fr m top of scum to top of outlet tee or baffle:
Distance fr m bottom of scum to bottom of outlet tee or baffle:
Date of la pumping:
Commen :
(recom ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidenc of leakage,etc.)
revised 9/2/98 Page 7oftt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C �.
SYSTEM INFORMATION(continued)
'rop"Address: 524 prince Hinkley Rd.. , Centerville , MA
Owner: J im Dunn n
Date of Inspection: 3,aa s! cl
TIG TOR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(loca Leon site plan)
Depth elow grade:_
Materi of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensi ns:
Capacity gallons
Design fl w: gallons/day
Alarm pr sent
Alarm le el: Alarm in working order: Yes_ No_
Date of revious pumping:
Comm nts:
Icon ' ion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_V
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal er}ce of Aolids carryover, evidence of leakage into or out of box, etc.) -
PUMP CHAMB _
(locate on site pla )
Pumps in working order: (Yes or No)
Alarms in workin order(Yes or No)
Comments:
(note condition o pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ropertyAddress: 524 Prince Hinkley Rd.. , Centerville , MA
Owner: J im Dunn
Date of Inspection: .3•as-y r
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:L
leaching chambers,number:
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failur level of ponding, damp soil, condition of a tion, etc.)
CESSP OLS:_
(locate o site plan)
Number an configuration:
Depth-top o liquid to inlet invert:
Depth of soli s layer:
)epth of scu layer:
Dimensions o cesspool:
Materials of c nstruction:
Indication of g oundwater:
inflo (cesspool must be pumped as part of inspection)
Comments:
(note conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on si a plan)
Materials of onstruction: Dimensions:
Depth of soli s:
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9ofII
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———————————————— 9 d N
———————————————— ~' m
THE COMMONWEALTH OF MASSACHUSETTS 0
D y
Dunn BARNSTABLE, MASSACHUSETTS " m
Certificate of Compliance z
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired C- ) Upgraded ( ) o
Abandoned ( ) by Wm, E . Robinsor, Septic S rvicP
• at 524 Prince Hinckley Rd � , Centerville , MA has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9� dated
Installer Designer
The issuance of this pe sh O n n ued as a guarantee that the srste O1 functio as med.
Date Inspector {'—
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(coat need)
rop"Address: 524 Prince Hinkley Rd.. , Centerville , MA
Owner: Jim Dunn
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
del
Estimated Depth to Groundwater/S Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11
F.Hic................
r THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
`C� w N.................oF........! �-+ P�-t�---..._..............
ApplirFativat for Elispoii al Workii Tomitraurtluat fautit
Application is hereby made for a Permit to Construct (/) or Repair ( ) an Individual Sewage Disposal
System at:
......_. h 627... J. ...�-4!w _ � .P- Mom:.._....--
Location-Address Lot No.
-t?.. ..`:�......................4 ..... �" 132 r�h/ °� tit
...� °r1�`��rr� "ip ---------- .........1,rf�...... ..........................................
Installer Address
dType of Building Size ]Lot_._..t..._ _ (O_..Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic- ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fi,�tures -------------------------------------------
-.�✓W Design Flow........... ... ..........................gallons per person per day. Total daily flow........... ..........0.......gallons.
WSeptic Tank—Liquid capacity.Pv�gallons Length._`' __ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No....._.1------------- Diameter------------t4?.. Depth below inlet......... Total leaching areau?7_.d..sq. ft.
Z Other Distribution box (�/) Dosing tank ( )
a _._
Percolation Test Results Performed byWPc! ?!G T-_-A+:`ii�.lr.............................. Date.... .�._�_�P..' ._.....
a Test Pit No. 1. `'L Depth to ground water.._Ia_1� __.
GL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •-----•-----••-••---•-•-•...------•••••-•-•---•---••---•--------------•......------------•----.........-•-••---•--------•-•------•-•------------••-----..----
O Description of Soil............ �........55.......-�....
x
W
x --••---•-•-------------------------------------•--•••----•-•--.....-----•------:-----------••-•-•-•-----------------------•----...---•••-----------------..............................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-----------------------------------------------------------•------------------------........---•--------------------------------------•--------------------------------...........•.......-•••-.........
Agreement:
The undersigned agrees to install the aforedescribed Individ al Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Co e— The un rs.gned further agrees not to place the system in
operationuntil a Certificate of Compliance has bee * s y f health.
� �LA_4� Signed..... • . --- -- ..........................................
A roved B Xp<plicati�onPP y----- --e ------ --- -----• ............
Date
Application Disapproved for the following reason .---------•-•--------------------------------------------------•---------------------.-----•-•-------•••--••----
•--------•--•....-•--.......---•---------------------•-------------•-••---------------••---•----•-----••-I-••---------------------------•-•--•---•--------------••-•--•-----------------......-----....--
Date
Permit No.. y .... 1� -------------------------- Issued-...
Date
r
No............ - �...� �.. Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Allpfiratioo for Uiipoiia1 Workg Too,itrortioo .rra it
Application is hereby made for a Permit to Construct ( V) or Repair ( } an Individual Sewage Disposal
System at:
Lvrrz-7 pp2 { I�L f,1t�CG li1<IIJi VIL- /� 1 .
...... _....5. ...........................................................1 lU 1 G,...... ..... _......_._...� .._......_._... .....__.. ...c.._._-------------------------
Location-Address or Lot ti o.
_ - -a•.o Ly_uJ..�1.............. :t... 13�- �.../ r�?n�.........................................................M
- -..... • --••
Own r s
r-=
Installer Address
Type of Building Size Lot.... ?;�_ _ ___Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa4 Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Gl•l Other_fixtures ...............................................- ---------------------------------
W Design Flow............ `l________________________gallons per person per day. Total daily flow............ .................gallons.
WSeptic Tank—Liquid capacity__.!'/ gallons Length__`�? 1_.-P__ Width---------------- Diameter---------------- Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No........I............ Diameter............ _. Depth below irdet.......... Total leaching area__9A!,._�-2____sq. it.
Z Other Distribution box ( %/) Dosing tank ( )
aPercolation Test Results Performed by! A. _.n'S7�. .____________________________ Date.... ........
�4 Test Pit No. 1-------------minutes per inch Depth of est Pit_____( .......... Depth to ground water____tN4`!J�-:.
0�4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94 ••-•••••-•-.........................................................................................--••---•-•---••••••----••••••-•••-•.......----••---_..._.
D Description of Soil------------ !"- -. _..__ P. .S •l�•• j C
V -•--•------•----••--•----•••••••-----.....-••-••--•....----•--••---._...----••••--•••----------------•--••-•-••••--------••----•••••-----•-•-•-•••••----••----•---•-•-•••••.......-....=`....vk>L
W
----------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------••--
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
-------------------------------------------•----------------------------------_._-••-•--•-..........-•••--••••••---...----------------------•----------•------------------------------------...--•__••••
Agreement:
The undersigned agrees to install the aforedescribed Individ al Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Co —The un s• ned further agrees not to place the system in
operation until a Certificate of Compliance has bee } u y th f health.
Signed .s -'st" F�
PPlication Approved By................. ...... -='........................................... ..... �
Date
Application Disapproved for the following reasons...................______.........................................................................................
--------------------------------------------•--------------------•---•----•------------•-•-•-------------•--•••--•-----••=-•-----•••----•••••--•-••-•-------•••--••••-•--------••••-------•••••••-----•-
Date
PermitNo......................................................... Issued_.......................................................
Date
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEAL_TH
ds.....OF.......... ..... �.. 1 �,1` . ... .....
(9rdifirtttr of (toutpit inre
Y, That th,�e'�dividual Sew, e Disposal System constructed (t-7 or Repaired ( )
by...THIS T_O�R--._ ...... ---------------------------------
----- -•------•----------
f f� Ihsta a�rf I✓/
has been installed in accordance with the provisions,_of TIT T' 5 of The State Sanitary Code as,described in the
application for Disposal Works Construction P.ermtt jNo.__.____1f'" `/- .......... dated...............:
-- ------------- ••--•••-
THE ISSUANCE OF THIS CERTIFICATE:'SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL. FUN9TION SATISFACTORY.,AZ
�
DATE--------.... . ------------------...................... Inspecio_,r- .._.__��.
1,
a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTHY
..........OF..--..� ... f` ��. -G�`e..................
No._..... ..t��.....__ ------_....
Permission is h y granted...- �?" � ,_r_�_'"/.__^_�
�___ �'' :
to Construct �r Re air ( n Individual SewageDisposal ystem
Street v ✓" /
as shown on the application for Disposal Works Construction Permit N .l.. {'Dated__.._2tf.?.11 `-
--••.........-••-•-•••- -9!:Z�....--- ..........................................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 1
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S/TE PLAN sNEET /of z
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REGISTERED LAND SURVEYOR
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BENCH MARK DATUM WM. M. WARW/CK B ASSOC., INC.
DOMESTIC WATER SOURCE \A—JA-r R-
90X, 801 , - NOR TH FA L MOUTH
FLOOD ZONE o a*.F - MASS. 02556 . (6/7J 563-,?6 39
LEACHING 8A.SIli SECTION NOT TO SCALE shces/ V e/ z
24 C.L MH COVER
EAR:H F/LL BR/CAK.ANO MORTAR COURSES AS RE00• TO BRING
1 4 COVER TO GRADE
r
INLET a8. FLOW LINE 2'�yp'TO "WASHED PEASTONE.FREE OF IRO NS,
P/PE FINES,AND DUST /N PLACE
` 414 To'/%p"WASHED CRUSHED STONE FREE OF
OPENING W/TH 4PB"71 OUTER DIAMETER ' IRONS FINES .AND DI/ST /N PLACE
'
AND IJ14"INSIDE w: �,
DIAblfrER I. CONCRETE TO BE 4000 PSI 28 DAYS
2. REINFORCED WITH 6"x6 NO. 6'GA. W.W.M.
3. 2'AND 4�. SECTIONS ARE AVAILABLE .FOR
• GREATER, DEPTH REQUIREMENTS
4,0,, �-- 2 ---r— s'o" ---z�-:.� 4.' NUMBER OF PITS REQUIRED o 9- '
M/N {-.- NOrE::EXCAVATE TO ELEVATION 3�•o OR
EFFECTIVE DIAMETER
(NOT ro EXCEED rIN£s EFFEcr/vE p£PTH1 LOWER AS REQUIRED TO REMOVE ALL
ow
WATER TABU - LOAM AND CLAY BENEATH PIT. REPLACE
EXCAVATED MATERIAL WITH CLEAN '
rYP/CAL .PROF/LE : GRAVEL TO LDESIGNED GRADE. R
---lB"STD LT WGT. C.L MN COVER -
,4 y `�•O A%O !J
'i
4"C.1.PIPE 4"BIT.FlefRL PIPE OUTLFT LEVfL
DWELLING FLOW ZINE TIGHT JOIC TO FIRST ✓DINT
,I w , 14 OO 110 000 ►
70� C./. TEE ' glv.ly 1i0 I00 1 !
i_1 0 0 0 0.0 1 1 I
41&,6 'qTD. PRfcAST CONC. /ST. OX TO Be 1 I i 0 0 0 00 1 t , I
WaGAL.S6'PT/C TAN �Oi 0 1 1100
d 0 0 0 0 0 1 I I
INS ALT LEp O/Y LEVEL, 1 0 0 0 O 0 0
.. ' 0 0 O O r....: •..... I I f Q
---�—�--8 STABLE BASE
\SfPr1C UNK TO BE 1 0 0 0 b 0
INS7444ED ON LEVEL, I I f 100100 1 ►
STABL E BASE. I ,t 0 0 0 O 0 1 / ,
00
, tt0 0011 „
4FACHIN17 BASIN 0
BASE TO BE L fVEL 0 0
5014 AND PERC. DATA
PERC. RATE% MIN. /IN. TEST PIT NO gal TEST PIT NO. 2
0�� O„
s".>ra,s o L_
TEST BY
WITNESSED BY i?orJ �, FF p' M ER. saw p
TEST.PIT GR. EL.
'4 7. $
DATE: Is
Nv rwr-N wATEF- 3 ,$
DES'/GN DArA c£NERA4 `NOr£s
BEDROOMS 3 NO HEAVY. EQUIPMENT TO RUN OVER SYSTEM: :
DISPOSAL SEPTIC 'TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD
EST. TOTAL DAILY EFFLt!"GPD. PRECAST, REINFORCED CONCRETE UNITS.
SEPTIC TANK tbvo GAL _ALL .SYSTEM COMPONENTS',SHALL BE INSTALLED IN ACCORDANCE
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE
SIDEWALL AREAZ SGAL./SQ FT MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF
BOTTOM AREA GAL./SQ FT. SANITARY.. SEWAGE EFFECTIVE ON JULY I , 1977.
LEACHING REQUIRED I�SQ FT ANY. CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
ACTUAL LEACHING AREA OF HEALTH. '
�� Q F� AT CAMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE
BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
PITCH ALL SEWER LINES `' I/4" / FT, UNLESS INDICATED OTHERWISE.
Ili OF
� '
SEWAZ ®/SPO.5A L SY.S TEM
moo`' MARTIN
E.
w MORAN v
.e '0► "T
11 23417 �2'7�' l.o �
ti-r -V t I t E AA 0.
SS1QUA4
SCALE .AS /NO1C,4i'ED DATE i 2 �•1�,�g'4
Os>i'X M. WARW1CK 8 ASSOC., INC.
BOX 80/ - ie/ORTtJ FAQ A'OflTH
IASS. 0?556 (�'lT1 5 6.3-26.�8
PROFESSIONAL ENGINEER
TOWN OF BA RNSTABLE aq
'6-7' 0
LOCATIONsi,� � � 4 L r)ck L SEWAGE
VILLAGE LLII v ��•� ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PNONE NO. "kc-LE-1( coax r t.2-�
SEPTIC TANK CAPACITY 11 O 0 0
LEACHING FACILI'TY:(type) (size)_ �'� Z�
NO. OF BEDROOMS . FRIVATE WF.I,I. C LI�.._WATE`-
;BUILDER O1CJIER i)
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED;�:��=U_�__-
VARIANCE GRANTED:
tf
�� Ll �,
LOCATION SEWAGE PERMIT NO.
Ct
VILLAGE
Las��Llllus
INSTALLER'S NAME A ADDRESS
B U I L D E R OR OWNER
(� DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
® river
RIO
No... �.�...... t Fmc................��.............
r THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.... 0F........0,
Appliratiun for Biipuual Wurkii Cnuuitrur#ion Urrmi#
Application is hereby made for a Permit to Construct (.-<or Repair ( ) an Individual Sewage Disposal
System at: 0-
64;y.......k0k.J ar,.f .1.n._.-. - ----.1.::.. --e------•---------- ....... S�Xk-.+.!.k-JA (....--�'e A...-----------�6.....✓�7--
�^ ocation Add `� or Lot No.
---... � � .......--•--•----------------
O<w�r ^�- ^ Address /�. 7
X`-�4/i._ p Y- ` ,�,,�� X__J�.� .......
Installer Address
Type of Building Size Lot..., (e.....Sq. feet
Dwelling—No. of Bedrooms.........�..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................. No. of persons..................--........ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------••----•--•--------•-----•• .
W Design Flow.............................. . ........gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity W_Algallons Length................ Width---------------- Diameter----............ Depth................
xDisposal Trench—No- --------------...... Width.................... Total Length.:.................. Total leaching area....................sq. ft.
Seepage Pit No-----_-------------- Diameter.---.--..-.-.---.--. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by...................................•-•-----------•--------------•----•.... Date.......................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water............1-----.----
(i, Test Pit No. 2................minutes per inch Depth of Test Pit------.------------- Depth to round water---------.--------------
Descriptionof Soil........................................................................................................................................................................
x
W ••---------•----------------•------•------------•------•-•-•-----------------•------------------•----•-•---•----•----•------------••----••-•-----•-•-----•-•-•--•-------••----.........................
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
f^
the provisions of TT�•7 IE 5 of the State Sanitary Code— The undersi ed further agrees not to place the system in
operation until a Certificate of Compliance has been sued by•h bo of health.
r
Signed--- . ............... -- lfflf� _.....
• �----•---•----•-•---•- J__ Date
Application Approved By.....------. > :.. _�..... --••-• .• .• ...
Date
Application Disapproved for the following reason.....------------------------------------------------------------------=------•--•----.....-----•--•..........._._
--------------------•--------........---------------------------------------------------------------•--....---•-----------------------------------------------------------------------------------....-•-
_ // /Date
Permit No--- �-�� -- Issued._/ _d-_..�7 .�t��J................
No.._47cA�....... Id FnE ......
THE COMMONWEALTH OF MASSACHUSETTS
�^ `J `�BOAR® OF HEALTH
.........................................OF........
(+�'.. -
Apptira#ion for Disposal Works Tonstrurtinn Vrrutit
Application is hereby Trade for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at
,.--- •-•-,,Location-Add s ( , or Lot No. ••--- -
WOwner Address
�:F_. �•j 11..a1-C. :..:).,e-I................... z oaZ.[•e 1 Y.� '... r
Installer — Address
UType of Building Size Lot---/ .L.(e.0_w__-___Sq. feet
�-, Dwelling—No. of Bedrooms.........l/..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures .........................................
-------------
W Design Flow............................................gallons per person per day. Total daily flow-------_....................................gallons.
WSeptic Tank—Liquid capacity-!,-�?s2.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—NTo. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (. ) Dosing tank ( )
0-.4 Percolation Test Results Performed by........................................................................... Date........................................
W
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water___-_----_--_-__--._.-_
Ps Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------------------
a --••---I------••---/ro.,D--•-- t-•-- - ..........................CS.l t
Description of Soil...............................................................................................................................................
----------
x
U -------•-•-------------------------------------•---•-----------------------------•-------------------------•---------•-•-----------------•----•----•---•---------------.......---•-----••---•--------•.
W
-------------------------- ---------•------------------------...---------------------------------•-------------------------------------------------•-------------------------------------------••-•-...
V Nature of Repairs or Alterations—Answer when applicable.____________________________________________________________________________________•.-.-.----.
------------•-----------------------------------------------------------------------•--....._..-----------------------------------------------------------------------------------------........--••----
Agreement:
`. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TILE 5 of the State Sanitary Code—The undersi ed furt'l:er agrees not to place the system in
operation until a Certificate of Compliance has been 'ssued by h bo of health.
Signed-- r ^.. i./l.'',.. '
- ---•-- - Zy-----•---•----------•--- ---------
Date
Application Approved By--••------- .... 1 1------. ------ ........ --------------------------------------
Date
Application Disapproved for the following reason '--------•-••-••-----•-----------•••--•••-----•-----•-----•-•-----------------••-••------------•--------.......--
.......................................-----•--••------•-.....•-----------••-•-••---••------------------•--------------•---•••-...-------------•------•-•-----•--•-------•••----•-----•---•---•......_.
• Date
PermitNo. -_�r_-- .��`--------------------------------- Issued.-•------------•----------------------•------•--------
D,=_-
THE COMMONWEALTH OF MASSACHUSETTS
�._ BOARD—Q,F HEALTH
........................Y:?..............OF......z f s- jI '...'........:.......................
Trrfifirate of Tompliaure ,�y��, , IZ
THIS IS TO CERTLFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b ....................
..... .7'�r' /C�-�'- --.....
• ------ - . .. ---- ..---- ....
at .h_>_....G( d .. ==-J it t- -fr' /. (f..�.J{_r_�rrr -•--------------------------
has been installed in accordance with the provisions of rITE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........... _' . .:............... dated__..__............._...._..__........._.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............1----f; ^19...--•-----------------•----------...---. Inspector .. ---:�..............................................
ram( . THE COMMONWEALTH OF MASSACHUSETTS
0 0 BOARD---OF HEALTH
No_,;'L. .F.t-1... 1''EE...w � ....:.
Disposal arks ,/Tonptr iott rrutit
Permission is hereby granted.-- -/�"/:'rJ (_O 541il�f r ...
¢ .-- --•-•- - •-- ...........
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No..... - ------A:_[_��.c lhre_3.1.�°1.. �..•.t_!. -!�_
Srreet
as shown on the application for Disposal Works Construction Permit--No..__._..../A.-•_ Dated.._ l --•_f--� .4'_
— .. ...............
DATE... `� ---•-- Board of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - 56