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TOWN OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �X
LEACHING FACILITY.(type) size) 1'� t �oK a
NO.OF BEDROOMS
OWNER im C
PERMIT DATE: ) — COMPLIANCE DATE:
Separation Distance Between the: N 0,V e
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is required for every Centerville Ma 02632 12/9/2020
-
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
Company Address
Centerville _ Ma 02632
CitylTown State Zip Code
> 774-248-4850 smjonestitle5@gmail.com, SI4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system Inspector In full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
12/9/2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is Centerville Ma 02632 12/9/2020
required for every .
page. City/town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The property located at 99 Sheaffer Rd Centerville is served by a Title V septic system consisting of a
1000 gallon septic tank, distribution box and 2 500 gallon precast leach chambers. Although the
system was found to be in proper working condition at the time of inspection this report does not
guarantee future performance under similar or increased usage.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired_The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7Y2612018 Tate 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is required for every Centerville Ma 02632 12/9/2020
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cost.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
16.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.712W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is Centerville Ma 02632 12/9/2020
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
ElDischarge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owners Name
information is Centerville Ma 02632 12/9/2020
required for every
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
t5insp.doc•rev.712612018 Title 5 Official Inspertion Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form_-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owners Name
information is Centerville Ma 02632 12/9/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. 'You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doc•rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 99 Sheaffer Rd _
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
k,
information is Centerville Ma 02632 12/9/2020
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
Description:
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
ent
Last date of occupancy: Date
t5insp_doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is Centerville Ma 02632 12/9/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/262018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I
Commonwealth of Massachusetts
i- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is Centerville Ma 02632 12/9/2020
required for every --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
system repaired 11-6-2018 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: eet
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.):
Joints in good condition, no leakage, vented through roof.
t5insp.doe•rev.7128I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
U- � Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is required for every Centerville Ma 02632 12/9/2020
page. Cityrrown State Zip Code Date of inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth: 5" --"" --
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness 2"
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Opened covers and took
measurements
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 does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
t5insp.doc-rev.7r2WO18 Tale 5 Official inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is required for every Centerville _ Ma 02632 12/9/2020
page. Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle —
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7126/2018 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is required for every Centerville Ma 02632 12/9/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (coat.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.)*
Distribution box was level and in good condition with no rot. Water level was even with outlet invert
with no signs of past backup.
t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is required for every Centerville Ma 02632 12/9/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order. ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
2x500 gals
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: -—--
t5insp.doc•rev.71262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
ofTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
`Jv Property Address
Valdinei&Glaucia Dangelo _
Owner Owner's Name
information is required for every Centerville Ma 02632 12/9/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (coat.)
11. Soil Absorption System (SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
leaching facility was video inspected and found with 2" standing water and no signs of past
overloading.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer —
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-_Not for Voluntary Assessments
�. 99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner owner's Name
information is required for every Centerville Ma 02632 12/9/2020
--
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids ---
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd _
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information.is Centerville Ma 02632 12/9/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
0
a6
Z-3
39
t5insp.doc-rev.7126=18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 18
cry Commonwealth of Massachusetts
�
Title 5 Official Inspection Form p .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is required for every Centerville Ma 02632 12/9/2020
page. Citytrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on,record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc.rev.7f26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd
Property Address
Valdinei&Glaucia Dangelo
Owner Owner's Name
information is required for every Centerville Ma 02632 12/9/2020
page. Cityrrown state Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.MM2018 Trite 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
No. ��/ � � 3 3""? Fee
ll��s
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ae—
PUBLIC HEALTH DIVISION :TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Bispos4l 6pstPm Construction Vffmit
Application for a Permit to Construct( ) Repair(r/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.by 5 h�liC> Owner's Name,Address,and Tel.No.
Assessor s Map/Parce _C)
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures �J
Design Flow(min.required) 3!Z) gpd Design flow provided �q 17 gpd
Plan Date q 1—IF) Number of sheets Revision Date
Title
Size of Septic Tank 141 (N� Type of S.A.S. ;� s G;C���b� �1`lO ��faMb�s
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) i I�SfCa 11 C�, ri e 1 CvJ CD Too G��!(�
.)A-jo cjac,mS�fft rA j'- q 5 FcXv--e
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
igned Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. � — 1 Date Issued Y
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
s
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4 application for 0ispos �����,tem Construction Permit
Application for a Permit to Construct( ) Repair(Z pgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or LotNo.9y Owner's Name,Address,and Tel.No.
Assess�o sl partCe7
f �3 Installer's Name,,A-dddress,and Tel..tNo. Designer's Name,Address,andt Tel.No.
'oe,A 17 CQ )r1 NC t curt `f�✓ �vF�l
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size / �T_sq.ft. Garbage Grinder( )
Other Type of Building CM s��.e. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided :3 q ,7 gpd
»-f-Plan"• -�Z Date R-1 —19 Number of sheets 0- Revision Date
le ,
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
'g e Date jZU
- a
Application Approved by Date /
Application Disapproved by Date
for the following reasons
Permit No.��"�[/ �,,'� Date Issued
V--'-`------------------------------------------------------ ------------------------------------------------
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 r
at !a-_ f r (` p,IT, , � has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NoV 9--3 3-7 dated
Installer--- t�3�G A '�����rs S 4Designer
#bedrooms 2 Approved design flow gpd
The issuance of this permit shall n t be construed as a guarantee that the system wil function si it ed.
Date Fs Inspector '
---------------------------------------------------------------------------------------------------------------------------------,-j------
No. i -- Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
30isposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) J� Repair( �� Upgrade( ) Abandon( )
System located at��� fir.G��°r r,b,�' Zr�t e7
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 thi permit.
Date // /T Approv{ y 41
Town of Barnstable
IKE Regulatory Services
Richard V. Scali, Interim Director
+ BARNSTABLE,
MASS. $ Public Health Division
i639. ♦� r
Thomas McKean, Director
200 Main Street,Hyannis, M:A,02601
Office: 508-862-4644 Fax: 305-790-6304
Installer & Designer Certification Form
Date: if -7 i Se«-age Permit# 13M —31Z Assessor's Map\Parcel 6 Ck
Designer: n�i r�ee ;n wor-CISr 1 o r Installer: At Sy,��
Address: l Z W, C rb s�,e W F-4 Address: Pont I
On P'o 3 1 'i C was issued a permit to install a
(date) (installer)septic system �^at S (moo, er � Vk%,\ = based on a design drawn by
ci-e. (address)
Gig i��e r"nC, LL)b rL4j 14 C , dated
(designer) '
f certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory. n},,4,
I certify that the septic system referenced above was installed with major changes (i.c.
greater than 10' lateral relocation of the SAS or anv vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system, referenced above was constructe nce with the terms
of the I\A approval letters (if applicable) 10OF
PETER r. �,
�1GEWEE I
CIVIL
taller Signature) rvo.s5sos
RFGISTET+
(Designer's Signature) (Affix Designers tamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Scptic.'\Designcr Certification Form Rev 8-14-1+.doc
Town of Barnstable P#
oF�
Department of Regulatory Services
�Y'ub1k Health Division
Date
�ag '. h / 1 :' 1`4u�
Ar a3q �a J00 Main Sheet;Hyannis MA 02601
l.n.i
Date Scheduled Time D. Pee Pd.
1`0
Foil Suitabilio Assessment fog 'ISge Disposal
:PerformedII Y �itnessed.B
Location.Address
LOCATION& GENERAL INFORMATION 1(� 5 ke p-4 Owner's Name S;v s�� iM e L�►Uc��`t
6-,,i-z"i le C mp+ Address q S tie a E' e R- lk
Assessor's Map/Parcel: ��^Z _0 Engineer's Name r v n ewe Sri `�e
NEW CONSTRU17rION REPAIR 7� Telep//hone# SaT_ ?7—$'3 1'�
Land Use /2ej i c'C,1�`Z Slopes(%) %.4 Surface Stones
Distances from: Open Water Body MjA_ ft Possible Wet Are-4A. ft Drinking Water Well
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands fn proximity to holes)
6
EL
Aeq Pd
Parent material(geologic) Depth to Bedrock a
Depth to Groundwater. Standing Water in Hole: U Weeping from Pit P1ceh'�
Estimated Seasonal High Groundwater. >I (1
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in, Depth to loll mottles:
Depth to weeping from side of obs.hole:. it). Groundwater Adjusittietit ft.
Index Well# Reading Date Index Well.level _x>1d1,factnr a— Adf.Clydutidwitterl vel
PERCOLATION TEST Date Tttn+
Observation
Hole# Time at V
Depth of Perc 42- 6o T(me at6"
Start Pre-soak Time @ — Time(9"-6")
End Pre-soak Mt
Rate Min:/Inch Z
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation.Hole Data To Be Completed on Back-----------
***.If percolation test is to be conducted within 100' of wetland;you must first notify the
Barnstable Conservation Division of least one(1) week prior to beginning.
Q:\SEPTIC\PERCFOR.M..DOC
DEEP.OBSERVATION HOLE LOG Hole# t
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consiistcn ravel)
d — v� loq„t o�fL� L
.10 e l C�✓ e Sa.tK (6 y,2
DEEP'OBSERVATION HOLE LOG Hole# 'Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Cor.sisten.c� %Grave!).
3-7
qq -��L� C y f `�S S`�w� k
DEEP OBSERVATION HOLE LOG Hole#
Depth.from Soil Horizon Soil Texture Soil Color Soil Other
Surface(iu.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency, Gray
DEEP OBSERVATION HOLE LOG Mole#
Depth from Soil Horizon Soil Texture Soil Color Soil other
Surface(in) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
ons' ten M
Flood Insurance.Rate 1k1812:
Above 500 year flood boundary No— Yes
Within 500 year boundary No Yes
Within L0l)year flood boundary Nq:�< Yes..
Depth of Naturally occtirringi Pervious Material
Does at least four feet of naturally occurring pervious material exist in'all areas observed throughout the
` area proposed for the soil absorption system? Iia-
If not,what is the depth of naturally occurring pervious material?
Cedifi ation c�4�
I certifythat on (date)I have passed ti:e soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis.was performed by me consistent with .
the required trai rti.se and a perience described in 10 CMR 15,017.
Date
Signature
Cif
Q:CS,EPTIC�PERCFORM.DOC'
i
THE Town of Barnstable Barnstable
°^ Regulatory Services Department MWWI
i639� erlcac 1
sARNSPABL&
MASS& Public Health Division
1��`
Fc " 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4988 0152
March 2, 2018
MCLAUGHLIN, SUSAN D
99 SHEAFFER ROAD
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 99 Sheaffer Road, Centerville, MA was inspected on
02/26/2018 by Thomas Roux, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching pit or cesspool with high liquid level,<12" below inlet (pert Town
Code 360-9.1).
• It was determined that both leaching pit structures were full of water and no
longer draining. This indicates a hydraulic failure.
You are ordered to repair or replace the septic system component within two (2)years
from the date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\99 Sheaffer Road Centerville.doc
Town of Barnstable
A a pNCTAm r, � .
' AM
�,bg Regulatory Services Department
Public Health Division
200 Main Street,FAyannis MA-02601
Office: 508-862-4644 Richard Scab,Director
FAX: 508-790-6304 Thomas A McKean,CEO
Feb 6, 2007
Rev. 5111116
DEADLINES T O REPAIR FAILED.SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15,000) _
An`Y'marked in the ❑is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑Discharge or ponding of effluent to the surface of the ground
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe. :.
❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE(1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an Overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollutio
TWO (2)YEAR DEADLINE CRITERIA
Mn e. O0
❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code
§360-9.1)
❑Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
WSEPTCDEADLINES TO REPAIR FAILED SYSTEMS.doo
1.
Commonwealth of Massachusetts �707"0(0q
Toros 5 Off oc'W MapecUan Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9
M 99 Sheaffer Rd.
Property Address P7
Susan McLaughlin
Owner Owner's Name
required for
is every
Centerville
required for eve Ma. 02632 February 26, 2018
page. City/Town State Zip Code Date of Inspection r
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General InformationQ
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Thomas Roux
use the return Name of Inspector
key.
r� Company Name
89 Mayflower Lane
Company Address
East Wareham Ma. 02538
City/Town State Zip Code
774-678-9066 S14531
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 16.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
T409m.-tf-4 L7, �2 D T
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 hove the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�Oy��d vs
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is required for every Centerville Ma. 02632 February 26, 2018
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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form-
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is Centerville Ma. 02632 February 26 2018
required for every ry
page. Citylrown 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 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 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is Centerville Ma. 02632 February 26, 2018
required for every ry
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 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
w 99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner owners Name
information is required for every Centerville Ma. 02632 February 26, 2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
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 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•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
M 99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is Centerville Ma. 02632 February 26, 2018
required for every
page. CityfTown 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): No design Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): +330 gpd
t5ins•3113 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
u at 99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is required for every Centerville Ma. 02632 February 26, 2018
page. Cityfrown State Zip Code Daespection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Tide 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
w 'r 99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is required for every Centerville Ma. 02632 February 26, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner
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):
Septic tank with two pits in series.
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is Centerville Ma. 02632 February 26, 2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
46 years, assessors records indicate that the house was built in 1972.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.3
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: +10'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.3'
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: 81 x 52W x 5.3'H
Sludge depth: N/A
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is Centerville Ma. 02632 February 26, 2018
required for every
page. CityrFown 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 N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? N/A
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The pit structue was dug up before the septic tank was inspected. The pit was in hydraulic failure,
which triggers a failure. There was no need to go back and look at the septic tank, since it was
already deemed a hydraulic failure.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•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
99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is Centerville Ma. 02632 February 26, 2018
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is required for every Centerville Ma. 02632 February 26, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
There is no D-Box.
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:
It was determined that both pit structures were full of water and no longer draining. This indicates a
hydraulic failure. The pit structure(s)are made of blocks.
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
M ' 99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is required for every Centerville Ma. 02632 February 26, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ 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.):
It was determined that both pit structures were full of water and no longer draining. This indicates a
hydraulic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
N• Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is required for every Centerville Ma. 02632 February 26, 2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,e�''• 99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is required for every Centerville Ma. 02632 February 26, 2018
page. Cityrrown 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
4
r 4e v i C)L)
P �
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: "/',' iQ�/T!� �a G✓?�QLSO�/
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
� prick � � •
(revised 04/35/97) Page 9 of 10
Commonwealth of Massachusetts
a Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is required for every Centerville Ma. 02632 February 26 2018
page. Cityfrown 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: +24'
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:
Checked with Jim Benoit from G.I.S.
You must describe how you established the high ground water elevation:
Checked with Jim Benoit from G.I.S.
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
• r �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 99 Sheaffer Rd.
Property Address
Susan McLaughlin
Owner Owner's Name
information is required for every Centerville Ma. 02632 February 26, 2018
page. Citylrown 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not use the return Name of Inspector
key. Septic Inspection Services Co.
Company Name
r� 189 Cammett Road
Company Address
Marstons Mills MA 02648
City/Town State Zip Code
508.428.1779 S1 12855
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
�j -�C✓ �
l=J` October 19, 2010 Job# 10-260
spector'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.
' � l0
ISins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disp a Sp .z,n Page t of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every page. Cityrrown 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:
® 1 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:
Tank is not in need of pumping at this time, overflow leaching pit was empty at time of inspection.
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-09108 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
,M r 99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N. ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety.and the environment:
❑ Cesspool or privy is within 501feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of-Massachusetts
4 Title 5 Official Inspection Form
a>
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
99 Shaeffer Road
` Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every 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 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�., 99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every page. City/town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 96,000 gal. _
9 ( Y 9 (gpd)): 132 gpd.
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: CurrentlyOccupied.
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09108 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
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every 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: Tank pumped two years ago.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan): 5
Depth below grade: 6"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: 8.5' long x 5.2'wide- 1000 gal.
Sludge depth:
4"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is Centerville
required for MA 02632 October 19, 2010
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cost.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 26
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 10"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was found at bottom of outlet invert, baffles were intact. Tank is not in need of pumping at
this time.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is
required for Centerville MA 02632 October 19, 2010
every page. Clty/rown 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: 1
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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 October 19, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: Two 6x6 pits inseries.
❑ leaching chambers number:
❑ 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.):
Overflow pit was found empty at time of inspection with a high stain line 18"from bottom of pit
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
15ins•09/08 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
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is Centerville
required for MA 02632 October 19, 2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is required for Centerville MA 02632 _ October 19, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
Sheaffer Road
44 22
//�
J
as9:
66
28
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is
required for Centerville MA 02632 October 19, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers -(attach documentation)
® Accessed USGS database-explain:
USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el 35 and topo map shows property above el 60
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins-09/08 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
99 Shaeffer Road
Property Address
Richard Lamonte
Owner Owner's Name
information is Centerville
required for MA 02632 October 19, 2010
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN
{OF ARNSTABLE
LOCATION Q s==E P
VILLAGE ASSESSOR'S je&PARCEL
�S NAME&PHONE NO. ` Rn-00C�/6n a I 1-1 11
SEPTIC TANK CAPACITY 1003
LEACHING FACILITY:(type) 1�`� (size) /000
NO.OF BEDROOMS 3
OWNER LdLmon+e
PERMIT DATE: C DATE:- loi n IIO
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility; Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY 0OA6
\ 4 4 \ \ 4 4 \ 4 4 k \ \ 4 4 4 k 4 4 4 \ • � '�
\ 4 t 4 \'4 4 \ \ t • • • \ t • .t • t t \ k
\ 4 \ 4 t 4 \ 4 4 \ \ t 4 4 \ \ t t 4 t t t \ \ t 4 \ \ 4 4 4
f f r f J ! ! ! r ! r ! !
t t \ \ \ 4 4 \ \ t 4 t t. \ \ 4 4 4 t • 4 \ 4 ...
F
f
t t t • • \ 4 4 t • • 4 t • \ \ t t • • 1 \ 4 4
r J
\ k 4 \ \ \ 1 4 4 \ \ \ 4 4 \ \ \ \ 4 4 t \ \ \ 4 k \ \ \ \ 4
k • \ 4 \ t \ 1 \ t • • 4 \ t t \ \ 4 4 t t t 1 \ 4 \ 1 4 \ •
44
22
66 ;
28
TOWN OF BARNSTABLE
Rc� Shee,�
.�A'T--JN (1� � � SEWAGE #
VII;LAGE `SUl 1 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist ,
within 300 feet of leaching facility) Feet
Furnished by �U
ec�
�y
FO
�a6 C)
� 33
THE COMMONWEALTH OF MASSACHUSETTs
BOARD OFHEALTH
...._�`C/ ....OF........\•_?_tom V. sN c�C. ...................................
Appliration for Disposal Works Tonstrur#iun Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-Location-Address or Lot No.
...................... a L.�: -r�......... .. ............................ .'� ..............................................
Owne�r� Address
................. ------------...............................
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms.•...�.................. .Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—Type of Building No. of persons............................ Showers —
YP g .....................£_..... ----•-(----)-------Cafeteria ( )
d Other fixtures ............. _----_-._.-----.__-•-•------------------------- ---
W Design Flow........ ___ ...................gallons per person per.day. Total daily flow........... �_ ?.................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No_______f____________ Diameter.____ __ ....... Depth below inlet.___��..._.___.__. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
�+ -------------------------------------•----------------------........-----•-------•-•-----•--------.....-----._........-----................•----...----......
ODescription of Soil.........................................................................................................................................................................
x
W
VNature of Repairs or Alterations—Answer when applicable........il V.Q_....._..__ .....................V e1..... _ ...._..
E=f......... ........... .��` -..... .......................................................c'.- S
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of rL"I711-L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the bo of
Signed.. • ...... ..........:` .�
f
Application Approved B -' ....... ----•................................•----.....-•---•------. -----------1
Date
Application Disapproved for the following reasons:-------•-----------------------•----.......---•-------------...---------------------------•••-•-.............._
..---•-•----•-•..............•---•---........----------------.................--------------•----------------•----------...--------------------------------.............................................
ate
Permit No......................................................... Issued...................1.......clC� /
Date
No:2E4 . ...... Fim........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ter".... ...........OF... ..N 7 ...................................
.................. .........
Appliration for 11isposal Works Tonstrurtion j1prmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
............4:On _�_......
Location-Address or Lot No.
..................... ......... L<
............................$1A "t.. 2, ....................................................
Owner Address
................................... ..................... ..............................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.....::::5...............................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers — Cafeteria
Otherfixtures .....................................A................................................................................................................
WW Design Flow..__.___s__....................gallons periperson per day. Total daily flow_.__.___. __ .................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width____.__._._...__ Diameter...__.___._.____ Depth_.__._........_.
Disposal Trench—No_ .................... Width_._.__.__._.__.___.. Total Length.____.._.___._.:... Total leaching area....................sq. ft.
Seepage Pit N I o....../............. Diameter..... ....... Depth below inlet....1�.l......... T6tal leaching area..................sq. f t.
Z Other Distribution box ( ) Dosing tank ( )
*..4 Performed by..............................................Percolation Test Results ..................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit___.._.....___.____. Depth to ground water.._______.___._______...
44 Test Pit No. 2................minutes per inch Depth of Test Pit___.._.....________. Depth to ground water.._________.____.__.___.
M -----------------------------*-*--**-----------------------*-------------*................*------------------*------**------------------*------**...*
0 Description of Soil........................................................................................................................................................................
W
----------*-----------------------------------------------------------------------------------------*--------------------------------------------------- --------------------------*-----------
......................................................................................................................................................................................;------ ----
U Nature of Repairs or Alterations—Answer when applicable._______AVI?...........Q.w`�...... ...... 7v!2......
..........4.9 _74........& ............
A ..... ......... ...................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T 1L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance.has been issued b the bo o_iealtl.
I I - ' ;y
rn-T-7 - -----
Sig ed--------I--- ...................
D
r1k,4�4--_-, �_� - - �.— 0— � - - . -
Application Approved ..........C.................................. 10/ 7-1/97
Ap .................. ........................................
Date
Application Disapproved for the following reasons:...............................................................................................................
.......................................................................................................................................................................................................
( � -7
Permit No.....................................7 Issued..............D..........2 9.....4� Date....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........OF.........�.2,.l�.n.....r k �1c,l ......... .......................
(Irrtifirate of Timplittnrr
THIS IS TO CERTIFY, T�at-the Individual Sewage Disposal System constructed or Repaired
by--------------- .......... ...........................................................................................................
Installer
atRje�....... `�'T. ............I...4f/e ......................r_��.IfaL...............................................................
.................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit ......... dated_...____./L)I ol. 7..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. ............... 4- _7 Q\ -,
............................4............................ Inspector....................................................................................
———————————————————————————————————————————————————---————————
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
\'A' "— '__: .............................
7 .............................. ........._OF....... :2 0
N ....U-0 FEE ..................
Disposal Works Tonstrurtion "pamit
Permission is hereby granted--------.. ............................................................................
to Construct or Repair an Individual Sewage Disp Ll System
......... _el -.... /T.........
at No............... ........ et.�-__r --- .....................................................
Street
as shown on the application for Disposal Works Construction Permit N ............ Dated..________(_b')
o......... .......................
.........................................................................................................
DATE------ ....................................... Board of Health
TOWN OF BARNSTABLE
LOA 1r!N If < SEWAGE # 7/6
VILLAGE ASSESSOR'S MAP & LOT 122,
. 'S NAME&PHONE NO. P. /21/LC11iIZ 7
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) f T 5<��L� Z�- e)
NO.OF BEDROOMS 3
ILUSMR OR OWNER ^g.
PERMTTDATE: A4�4/ 17 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility /� ® Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin facili Feet
Furnished by
, s
� t
�3�1G� �I
A��- ; i
� ���] i
�I
ddOO
r�� �y I
h
f� � I
i
I
V
.S'� 4°WN OF BARNSTTABLE
Y.d SEWAGE # O 7- 7t 6
VILLAGE r�/P kkI7�&SSOR'S MAP & LOT 06
INSTALLER'S NAME PHONE NO. rlJ ✓�`'l b��(�
SEPTIC TANK CAPACITY a WOE) Gt'UMCA ,
LEACHING FACILITY:(type) Vt (W-A V1 W(p (size) tV ge
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: I cu
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No L/
�eaL
C�CSSS�-11 CHZU)
t`1 ec v (Q K Ce
EXISTING CONTOUR
x 60.98 EXISTING SPOT GRADE p N
—W— EXISTING WATER SVC. ea cPor� !Q
EXISTING GAS SERVICE Gear` 6°of s�9
-r3 H.W OVERHEAD WIRES �a 9S4�P �o cF
�a
TEST PIT J�a'�° ° �e 'Qp9
BENCHMARK
LEGEND
�c
LOCUS Pcee� Q pa
LOCUS MAP
NOT TO SCALE
QG
0�
2a1/
a
S 39119'00" W
100.00'
x 101.67 LO
SHED ..
LOT 153 ��'
15,255±S.F. TP-1 102,31
0 lot12_ $ x 0
0EXISTING LEACH PITS FIREPIT� TP-2 C 0a
102.18 �
(FROM RECORD AS-BUILT) �
TO BE PUMPED, FILLED
t;.. 0
WITH SAND & ABANDONED
:fp A
102.22 +; f ` �t;•:;. 15' BENCHMARK
1 1 0�21 1� x ORANGE DOT/STEP
�- 102.49 EL.=103.71
0
N O BM p
103.71 N
o x 102.60 NLn _
"-O
U
tTl A -DECK
rm e C
®� _ 103� x 1,02.- .
EXISTING SEPTIC TANK 1/
(TO REMAIN) 102,93
TOP OF TANK, EL.=101.60t
INV.(OUT)=100.27t 102,90 ' 'EXISTING
, 'HOUSE(#99), �GARAGEJ
i T.O.F—103 7f
4'`
102.84 103 80! .
• iO x --
x 102.34 3 103.24 103.25 If 102,80
....
103
• 3
I 10 7
Al +102.05 x 102.38 102-
•
702 DRIVEWAY;
• 100.00' • ,
101._..... _.. __ N 39'19'00" E
100.22 10032 edge 100.57 of pavement 100.74 100.80
SHEAFFER ' ROAD
��P��� of Mgss9cyG PARCEL ID: 172-069
o PETER T. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
McENTEE
o CIVIL
No. 35109 99 SHEAFFER ROAD, CENTERVILLE, MA
O�rF S1 Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
A
OWNER OF RECOED Engineering by: SCALE DRAWN JOB. NO.
McLAUGHLIN, SUSAN J Engineering Works, Inc. 1"=20' P.T.M. 236-18
99 SHEAFFER ROAD
12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET N0.
CENTERVILLE, MA 02632 (508) 477-5313 9/1/18 P.T.M. 1 Of 2
e
NOTE: TO PREVENT BREAKOUT, FINAL GRADE
SHALL NOT BE AT, OR BELOW, EL.=99.5
SEPTIC TANK PROPOSED D-BOX FOR A DISTANCE OF 15' FROM THE EDGE
INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT OF THE PROPOSED S.A.S.
PROPOSED S.A.S.
OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE
INSTALL RISER & COVER OVER ONE CHAMBER AND
T.O.F.=103.7t SET TO 3" OF F.G. TO SERV AS INSPECTION PORT
F.G. EL.=102.9t F.G. EL.=102.9t F.G. EL.=102.3t F.G. EL.=102.3t
vEN
MAINTAIN 2% SLOP R S.A.S.
L = 20' L = 5'
S=1% (MIN.) ® S=1% (MIN.) ' LAYER OF 1
4'SCH40 PVC 4"SCH40 PVC 2 /8- TO 1/2"
6*1
DOUBLE WASHED STONE
to"I . 6 ®aaEa®® (OR APPROVED FILTER FABRIC)
t 4' 96aaa®�
EXISTING 48" LIQUID aaaaaa ---3/4' TO 1-1/2' DOUBLE
LEVEL 4' 4.8' 4' WASHED STONE
ADD INV.=99.22 PROPOSED INV.=99.05 GAS BAFFLE
INV.=100.27t D-BOX EFFECTIVE WIDTH = 12.8,
EXISTING INV.=99.00
FLn EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBER
SURROUNDED WITH STONE AS SHOWN
NOTES: H-10 RATED
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP CONIC. ELEV.=99.8t
INVERTS, PRIOR TO INSTALLATION. BREAKOUT ELEV.=99.50
00=99 ELEV. . ease
2) D-BOX SHALL BE SET LEVEL AND TRUE TO INV. a ease®®®
GRADE ON A MECHANICALLY COMPACTED SIX a�i�ecealaaaaaaa
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.=97.00
310 CMR 15.221(2). 4' 2 x 8.5' = 17.0' 4'
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0'
5' (MIN.) ABOVE G.W.
4) GAS BAFFLE TO BE I PERVIOUS MATERIAL
��
AS MANUFACTURE Y TUF-TITE, ZABEL OR EQUAL. BEACHING SYSTEM SECTION
NO G.W., EL=90.8 -
SEPTIC SYSTEM PROFILE
N.T.S.
GENERAL NOTES: -
/ BACK fOF
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL / �x
BOARD OF HEALTH AND THE DESIGN ENGINEER. "" r s& '�~
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DECK
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
LOCAL RULES AND REGULATIONS. ND
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR �.
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE r�
DESIGN ENGINEER. �O
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN Ln
ENGINEER BEFORE CONSTRUCTION CONTINUES. c71
5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. iV
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF '0
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF ; 3 ; 1-
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. Nam, N
8:THERE-ARE-NO`'WEL'L"S'WITHIN 150' OF THE PROPOSED S.A.S.
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
DIRECTED BY THE APPROVING AUTHORITIES.
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
CONSTRUCTION.
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS SEPTIC LAYOUT
IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. SOIL LOG
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. DATE: AUGUST 30, 2017 (REF#15,767
14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC SOIL EVALUATOR: PETER McENTEE PE(SE�1542)
SYSTEM COMPONENTS NOT SHOWN ON THE PLAN WITNESS: DONALD DESMARAIS R.S.HEALTH AGENT
ELEv. TP-1 DEPTH ELEV. TP-2 DEPTH
102.3 A 0 102.3 A 0"
SANDY LOAM SANDY LOAM
10YR 4/2 10YR 4/2
DESIGN CRITERIA 1017 B . 1018 B 6"
SANDY LOAM SANDY LOAM
10YR 5/4 10YR 5/4
NUMBER OF BEDROOMS: 3 BEDROOMS 99.3 36" 99.2 37"
C1 C1
SOIL TEXTURAL CLASS: CLASS I COARSE SAND PERC COARSE SAND
DESIGN PERCOLATION RATE: <2 MIN/IN 2.sY s 4
20% GRAVEL 42 /60" 20% GRAVEL
DAILY FLOW: 330 G.P.D. & COBBLES & COBBLES
94.3 96" 94.5 94"
DESIGN FLOW: 330 G.P.D. C2 C2
MED. SAND MED. SAND
GARBAGE GRINDER: NO-not allowed with design 2.5Y 6/6 2.5Y 6/6
LEACHING AREA REQUIRED: (330) = 445.9 S.F. <5% GRAVEL <5% GRAVEL
.74 90.8 138" 90.8 138"
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY PERC RATE <2 MIN/IN. "C" HORIZON
PROPOSED D-BOX: 1 INLET, 3 OUTLETS, H-10 RATED NO GROUNDWATER ENCOUNTERED
USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 99 SHEAFFER ROAD, CENTERVILLE, MA
SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO.
TOTAL AREA:.............................................................. 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 236-18
DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 9/1/18 P.T.M. 1 Of 2
4
* ——64—— EXISTING CONTOUR
x 60.98 EXISTING SPOT GRADE �, p�, N
m
—W EXISTING WATER SVC.
—G EXISTING GAS SERVICE eai° 600 `r>y
H.i -- OVERHEAD WIRES G �a 9S4iP ��o CF
a
TEST PIT 'Qp
BENCHMARK
9�
LEGEND 5reo��e o��c°r°�
0*
LOCUS
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LOCUS Pcye p
a
LOCUS MAP
NOT TO SCALE
9�
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r
S 39*19'00" W
100.00' =
i
X 101.87 /
X 10 A M
SHED
LOT 153
15,255±S.F. TP-1 0102.31
,z.a X 0
EXIS77NG LEACH PITS FIREPIT� 0 TP-2
(FROM RECORD AS-BUILT) 102.18 'CI,N
TO BE PUMPED, FILLED
WITH SAND & ABANDONED
0
102.22 +/ 15' BENCHMARK
\ / k 0 .21 X ORANGE DOT/STEP
—� 102.49 EL.=103.71
P Ln 0 z BM - - .
13 103.71 Ln
Ln o U x 102,60 0 N cn _
cn
�
M �� DECK AC\'4--, - o rin g
103 .�lOL,S-7
EXIS77NG SEP77C TANK 102.93
(TO REMAIN)
TOP OF TANK, EL.=101.60t
INV.(OUT)=100.27f 102.90 EXISTING
HOUSE(#99) GAR4GE
T.O.F.=103.7f
•
102.64 103,80'
• X
x 102,34 103,24 103,25 102.80
4.
I 0 10E,,t�7
/". • 102,05 x 102.38
DR/VEWAY•
• 100.00' IV
• �;
N 39-19'00_" E
100.22 100.32 edge 100.57 of pavement 100.74 100.80
S HEA FFER ROAD
OF ,yq
``� ss9�yG PARCEL ID: 172-069
o PETER T.
Mc PROPOSED SEPTIC SYSTEM UPGRADE PLAN
� CIVIL
CIVIL "'
No. 35109 99 SHEAFFER ROAD, CENTERVILLE, MA
' S( `� � Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
OWNER OF RECOED Engineering by: SCALE DRAWN JOB. NO.
McLAUGHLIN, SUSAN J Engineering Works, Inc. 1"=20' P.T.M. 236-18
L 99 SHEAFFER ROAD 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED� SHEET No.' CENTERVILLE, MA 02632
(508) 477_5313 9/1/18 P.T.M. 1 of 2
s ,
NOTE: TO PREVENT BREAKOUT, FINAL GRADE
SHALL NOT BE AT, OR BELOW, EL.=99.5
SEPTIC TANK PROPOSED D-BOX FOR A DISTANCE OF 15' FROM THE EDGE
OF THE PROPOSED S.A.S.
INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT PROPOSED S.A.S.
OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE
INSTALL RISER & COVER OVER ONE CHAMBER AND
T.O.F.=103.7t SET TO 3" OF F.G. TO SERV AS INSPECTION PORT
F.G. EL.=102.9t F.G. EL.=102.9t F.G. EL.=102.3t F.G. EL.=102.3t
vEN
MAINTAIN 2% SLOPE ER S.A.S.
L20' L = 5'
®"SCH 0(PVC) ®"SCH 0(PVC) 2" LAYER OF 1/8" TO 1/2"
DOUBLE WASHED STONE
u-ilo-I 6 ®®a�aea (OR APPROVED FILTER FABRIC)
14' as®ease
EXISTING 48' UQUID aaaaaaa ---3/4" To 1-1/2- DOUBLE
LEVEL 4' 4.8' 4' WASHED STONE
GAS INV.=99.22 _PROPOSED INV.=99.05
INV.=100.27t EFFECTIVE WIDTH = 12.8'
EXISTING INV.=99.00
EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS
SURROUNDED WITH STONE AS SHOWN
NOTES:
H-10 RATED ,
`
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP CONC. ELEV.=99.8t
INVERTS, PRIOR TO INSTALLATION. BREAKOUT ELEV.=99.00 50
INV. ELEV.=99. e
2) D-BOX SHALL BE SET LEVEL AND TRUE TO aaaIaase
GRADE ON A MECHANICALLY COMPACTED SIX
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.=97.00 ,
310 CMR 15.221(2). 4' 2 x 8.5 = 17.0' 4' y.
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0'
PERVIOUS MATERIAL
4) GAS BAFFLE TO BE I 1 LE I 1 5' (MIN.) ABOVE G.W.
AS MANUFACTURE Y TUF-TITE, ZABEL OR EQUAL. LEACHING SYSTEM SECTION
NO G.W., EL=90.8 -
SEPTIC SYSTEM PROFILE
N.T.S.
GENERAL NOTES: BACK OF HOUSE
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER. rins
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DECK
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
LOCAL RULES AND REGULATIONS. ra
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE M
DESIGN ENGINEER. �0
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN Cn
ENGINEER BEFORE CONSTRUCTION CONTINUES. (n
5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM..__.._ N __
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF t► �13O '�tk
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. \ -0 \
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. Nam\ N
8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE \ o 8
DIRECTED BY THE APPROVING AUTHORITIES. ft.12
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
CONSTRUCTION.
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS SEPTIC LAYOUT
IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL SOIL LOG
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. DATE: AUGUST 30, 2017 (REF#15,767
14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC SOIL EVALUATOR: PETER McENTEE PE(SE#1542)
SYSTEM COMPONENTS NOT SHOWN ON THE PLAN WITNESS: DONALD DESMARAIS R.S.HEALTH AGENT
EL.Ev. TP-1 DEPTH ELEv. TP-2 DEPTH
102.3 A 0 102.3 A 0"
SANDY LOAM SANDY LOAM
10YR 4/2 10YR 4/2
6"
101.7 B 7" 101.8 B
DESIGN CRITERIA
SANDY LOAM SANDY LOAM
10YR 5/4 10YR 5/4
NUMBER OF BEDROOMS: 3 BEDROOMS 99.3 c1 c1 36" 99.2 37"
SOIL TEXTURAL CLASS: CLASS I COARSE SAND PERC COARSE SAND
DESIGN PERCOLATION RATE: <2 MIN IN 2.5Y 6/4 42"/60" 2.5Y 6/4
20% GRAVEL 20% GRAVEL
DAILY FLOW: 330 G.P.D. & COBBLES & COBBLES
94.3 C2 gg" 94.5 C2 94..
DESIGN FLOW: 330 G.P.D.
MED. SAND MED. SAND
GARBAGE GRINDER: NO-not allowed with design 2.5Y 6/6 2.5Y 6/6
LEACHING AREA REQUIRED: (330) = 445.9 S.F. <5% GRAVEL <5% GRAVEL
.74 90.8 138" 90.8 138"
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY PERC RATE <2 MIN/IN. "C" HORIZON
PROPOSED D-BOX: 1 INLET, 3 OUTLETS, H-10 RATED NO GROUNDWATER ENCOUNTERED
USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 99 SHEAFFER ROAD, CENTERVILLE, MA
SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: 1,. SCALE DRAWN JOB. NO.
TOTAL AREA:.............................................................. 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 236-18
12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO'DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD (508) 477-5313 9/1/18 P.T.M. 1 Of 2