HomeMy WebLinkAbout0844 SHOOTFLYING HILL RD - Health (2) 844 SHOOTFLYING HILL, CENTERVILL
A= 192 040
�J�RECYc�Ea�n
UPC 12543
No.53LOR
HASTINGS,LIN
1
ems. 1 /^ 1
No. Fee 670✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppficatiou for Migaar *pgtem Construction Vermtt
K
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 0complete System ❑Individual Components
Location Address or Lot No. ^wr Owner's 1Naame,Address and Tel.No.
\Q
Assessor's Map/Parcel )--OHO cf l v". .� !��-T r �e"v
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
—,-2z ( t - d q—f
tiv�-ti5
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow '1 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S 14W
a,.
Nature of Repairs or Alteraf ns(Answer whe applicable)- 15T VA_ c� 5'0
4
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 Cod and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this
Si
ned Date — 8—fit
Application Approved by Date
Application Disapproved for the ollo mg reasons
Permit No. Date Issued
No. / � '6' .n Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLICHEALTH DIVISIONi-TOWN OF BARNSTABLE., MASSACHUSETTS V
�.
Rppfication for Migogal *pztem C1Cong4ruction Permit �
Application for a Permit to Construct( )Repair( -)Upgrade( )Abandon( ) fkomplete System ❑Individual Components
Location Address or Lot No. � rV Owner's Name,Address and Tel.No.
Assessor's Map/Parcel `� -(��(7 C.�CK
Installer's Name,Address,and Tel.No.�^ Designer's Name,Address and Tel.No.
Lk t- D "�.(���� 7
"ems- & LjA r�t cv— �`� Ctw--i 5
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �{�C� gallons per day. Calculated daily flow `1 gallons.
Plan Date Number of sheets Revision Date
t
Title
Size of Septic Tank SC77P, 00 Type of S.A.S. u
# Description of Soil
ri
Nature of Repairs or Alterati ns(Answer when applicable) - Vti,SC —66 nJa .� 7 ��•
Date last inspected: `
Agreement: -
I' 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 Cod and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B e4
gS d Date —
Application Approved by Date -
Application Disapproved for the olio mg reasons
t
Permit No. �q� ———— ———��l/ � ——— Date Issued
——
—————————---
THE COMMONWEALTH OF MASSACHUSETTS 1
BARNSTABLE, MASSACHUSETTS
Ce` iftrate of Compliance
THIS IS TO CERT ,that the On-site Sewage Disposal System Constructed( )Repaired'( )Upgraded(L
Abandoned( )by �—� �✓``E' t C._ _
at S c t tit ( has been constructed in accordance I
with the provisions of Title 5 and the for Disposal System onstruction Permit No. �1`�- �//� dated
Installer Designer
The issuance of this permit shall n tube c strued as a guarantee that the syste w function s designed.
Date �' ti' Inspector
---------------- --------------------- {
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
r
p
X'Noo-ear *pgtem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgra e( Abandon ) y
System located at r t
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
r
Provided:Construction must be completed within three years of the date of this permit.
Date: y Approved by
" 1/6199 .
NOTICE: This Form Is To Be,Used For the Repair Of Failed
Septic Systems Only. "
r�
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
�'
construction permit signed by me dated Cr-Tnk , concerning the
property located at S meets all of the
following criteria:
VThe failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
t
There are no variances requested or needed
z The bottom of the proposed leaching facility will not be located less than five feet above the r'
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable] ?
L/. v wetlands, the bottom of the ro se a
If the S.A.S. will be located with Z50 feet of any vegetated etian p po
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
� 4
Please complete the following:
A), Top of Ground Surface Elevation(using GIS information)
s
B) G.W.Elevation +the MAX.High G.W. Adjustment
DIFFERENCE BETWEEN A and B
SIGNED : DATE:
(Sketch proposed plan of system on back].
q:health folds:cert
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TOWN OF BARNSTABLE �g
LOCATION e q aaT //l L( SEWAGE # T 9'' ��
VILLAGE s�,�-���,��'li ASSESSOR'S MAP & LOTS -a O
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY % C'�O
LEACHING FACEL=: (type) /,r/ l RXT6/1_.S' (size)
NO.OF BEDROOMS
BUILDER OR OWNER iF-E-1 7'
PERMTTDATE: 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 o�fk4ching facility) Feet
Furnished by / '
s
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- y
TOWN OF BARNSTABLE
LOCATION � SEWAGE # ?7- 24'�-'l�
�!ILLAGE ASSESSOR'S MAP & LOT ' w a O
INSTALLER'S NAME&PHONE NO. 1"r i7GA, �i r
SEPTIC TANK CAPACITY / Cc,?V —
LEACHING FACILITY: (type) a/L.S size
NO.OF BEDROOMS 4/
BUILDER OR OWNER .1
PERMTTDATE: COMPLIANCE DATE:?-- -Z:�-f--op_
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 lgching facility) Feet
Furnished by / ``
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SEACOAST ENGINEERING COMPANY
21 VILLAGE WAY
DUXBURY, MA 02332
(617)934-7322
•CIVIL ENGINEERING SITE PLANS
•MARINE ENGINEERING ¢ •STRUCTURES.
•PERC TESTS March 19, 1997
R
Board of Health
Town of Barnstable `
367 Main Street
Barnstable, MA 02601 AR 2 199
� T o��FBARPJS�:
RE: Mr. &Mrs. John T. HannonacrN°fPr
844 Shoot Flying Hill Road, Centerville,MA
Title V Septic Inspection g `
Dear Sir:
Enclosed please find a copy of the successful Title V septic system inspection at the
above property. Please review at your earliest convenience.
Should there be any questions concerning this matter, please feel free to contact this
office at(617) 934-8188 or(617) 934-7322. '
F•
Very truly yours,
Paul�A. Brogna,P.
cc: Mr. &Mrs. John T. Hannon'
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld Trudy Coxe
Goren,«
Argeo Paul Celluccl Davld B.Struhs
LL Governor Corrxnbaloner'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address $ a y (-z( N-v �•��` Z�»7 Address of Owner.
Date of Inspection: � (If diferent)
Name of Inspector.
Company Name,Address and Telephone�umbe?r:
CERTIFICATION STATE1�fENT
I certify that I have l:rsonally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the :!me of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
�1 Passes
Conditionally Passes
Needs Further Evaluation 3y the Local Approving Authority
Fails
Inspector's Signature: j� Date-
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria'as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more,system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes
inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked structurally unsound, shows substantial infiltration or emfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street 0 Boston, Massachusetts 02108 0 FAX(617) 556-1049 9 Telephone (617)292.5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ?;yy
Owner. tv�CZ z
Date of Inspection:
B)SYSTEM CONDITIONALLY PASSES (continued)
— Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
or due to a broken, settled or uneven distribution box. The system will pipe(s)
ib Pis inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
— The system required Pumping more than four times a year due to broken or obstructed pipe(s). The system wt11 peas
inspection.if(with approval of the Board of Health): ;
broken pipe(s) are replaced
obstruction is removed
�? FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS LNI—ESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIOKING IN A
SAVNER WHICH WILL,PROTECT THE PUBLIC HEALTH AND 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—Arab.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic
p tank and soil absorption m and is less
rp system than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for ooliform bacteria and volatile organic compounds medicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate n trogen is equal to or leas than 5 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4,yy rj��o o'` �-�(���(� \�1L ZU ►a�i
Owner.
Date of Inspection: Mom' �� "SCE\tV -T. \4
DJ SYSTEM FAILS:
I have determined that the system violates one.or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of sewage into facility or system component due to as overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to as 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 dc;th in cesspool is less than 6"below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: .
s
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a rigaifieant threat to public
health and safety and the environment because one or more of the following conditions exist:
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 Il of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional ofTice of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddreaa:
Owner. CT-\,), SO L
Data of Inspection: i r��5• \-�N T• ��/�H h�G nl
--t1 I-Avl
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
* V None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
N As built plans have v
/ been obtained and examined. Note if the are not available with NIA_
L P - y /
✓ The facility or dwelling was inspected for signs of sewage back-up.
�[ The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
N The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum.
f The sue and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrdfive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
VA G �^ —\O N\oN7\;)S. 7 \
5 L
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: g y y
Date of Inspection:
RESIDENTIALFLOW CONDITIONS
Design flow 2 Zc-gallons
Number of bedrooms:-7-
Number of current residents:-
Garbage grinder(Yes or no): w, _
Laundry connected to system(pea or no):�U
Seasonal use (yes or no):_�o
Water meter readings, if available: \c\q-A Z k, Q C c C>AL
Last date of occupancy: 1 c\`\
C O.M M ER C IAL/I ND U S TRLaL-
Type of-eatablishment: N�
Resign flow:�jcallons/day
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)
Noa-sanitary waste discharged to the Title 5 system: (yea or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_:j�`-,
If yes, volume pumped: ¢allons
Reason for pumping: 1AC- �� 7vN���hl Z, h!4�,` G—\ 1 V,)Y CUT'sG�,\
TYPE OF SYSTEM
Septic tank/distri ion box/aoil absorption system
Single oesspool
Overflow oesspool
Privy
Shared system(yas or no) (if yes, attach previous inspection records, if any)
_V' Other(explain)_ �:.4 fX-Z'A 11:
APPROXIMATE AGE of all components, date installed(if known) and source of information
Sewage odors detected when arriving at the site: (yes or no)�1G
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addr s: G \'N j11�
Owner. �n1L t t 111Z'j
Date of Inspection:
SEPTIC TANK_)
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_ather(erplain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thiclmess:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or bane:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
GREASE TRAP:_N i A
(locate or,site plan) /
Depth below grade:
Material of construction:_concrete_metal FRP 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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or bafIles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of lee.kege, etc.)
(revised 11/03/95) 6
E
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address:-
Owner- I G
Date of Inspection:
-,A
TIGHT OR HOLDING TANK
(locate on site plan) —NI
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX_ N)
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER_ N�
(locate on site plan)
Pumps in working orden(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):LA
(locate on site Plan, if possible; excavation not required,but may approximated y be PP by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number._
leeching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatiea,etc.)
CESSPOOLS:_Z
(locate on site plan)
Number and configuration: S�:;>I�rZ/��L (G�\� VZ A'� `�
Depth-top of liquid to inlet invert: 'A y" --i," A�
Depth of solids layer.
Depth of scum layer.
Dimensions of cesspool-' S n 5:
Materials of construction: V,)LoCy-
Indication of groundwater. NQ"-p
inflow(cesspool must be pumped as pert of inspection) -Nt)4'1o;N c �s�?�c 5 �.,�0.� '�.•��`� C ;
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
C" Lyc VA OS 13'(73LA\JL-'C �'A\Lvac,
O C
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, oonditioa of vegetation, etc.)
(revised 11/03/95) g
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) .
Property Add ts&-
Owner. 1alt� Zv1��
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM: ,
include tied to at least two permanent references landmarks or benchmarks
locate all wells within 100'
G X S-T H G 7—
C,
G'aS57 0
DEPTH TO GROUNDWATER
Depth to groundwater. \ L t feet
method of determination or approximation: (- C t y5-,Zl'G-'t 01-1�1
(revised 11/03/95) 9
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Commonwealth of Massachusetts .4 PR �� o
Executive Office of Environmental Affairsvofe 199wow �
Department of la, lDAelf ~
Environmental Protectio
Wllilam F.Weld rudy Coxe
Gown,« S—tary
Argeo Paul Celluccl David B.Struhs
LL Gosma Conrnbsbna
�j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
a' PART A _
CERTIFICATION
Property Address: �5yy Address of Owner.
Date of Inspection: ,�1 1 LG—i-%x(L,1i,_LC- (If different)
Name of Inspector. -� <_N/� k
Company Name,Address and Telephone umbdr-
z1 NI I A6CE ��`!� �v�i�v2�1� r��1 v L��3"-
CERTIFICATION STATEMENT
I certify that I have}vrsonally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the :line of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inapactot's Signature: �� J � �\ Date;
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more.system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes
inspection.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Wlntef Street a Boston, Massachusetts 02108 a FAX(617) 556-1049 a Telephone (617)292.5500
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9iTBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
A PART A
CERTIFICATION (oontinued)
Pt oPer�tyAddreaayy
Owner.
Date of I pectiow
B}SYSTEM Co NAII;Y PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with
Health): approval of the Board of
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection.if(with approval of the Board of Health):
broken pipes) are replaced
obstruction is removed
t:l FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIOKING IN A
?riANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES.THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
-PPIY well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is hie
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11103/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address;-
Owner.
Date of Inspection:
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
— Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SASS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
Liquid dc;th in cesspool is less than 6"below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
J
w
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: .
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional ofliice of the Department for further information..
(revised 11/03/95) 3
.a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
PropertyAddrem 5,yy S\AGG—,
Owner-
Date of Inspection:
Check if the following have been done:
4 Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as past of this inspection.
NL As built plans have been obtained and examined. Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
✓ The site was inspected for s'_ egns of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
// tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
V The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrdilve methods.
LThe facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
Mo\v�V� Y\1G t-� AV�
,-
\
(revised 11/03/95) 4
r. a
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: $y y
Owner.
Date of Inspection: SG\A�N -T,
RESIDENTIAL FLOW CONDITIONS
;
Design flow 2 Zp gallons
Number of bedrooms:`2-
Number of current residents:-L
Garbage grinder(yes or no):-1E0
Laundry connected to system (pea or no):�U
Seasonal use (yea or no):_t:�o
Water meter readings, if available:
'.�Gop VAS
Last date of occupancy: 1 c%5 b
_COMMERCL4L/INDUSTRLA-
Type of establishment: N�
Design flow:_allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
�I�:Z�-•l3T{�L t �f.i A 1�-Z �L-l��2'�T�11-'(�i
System pumped as part of inspection: (yes or no)�lLe`-,
If yes,volume pumped: gallons .
Reason for pumping: raL=1=>C7
TYPE OF SYSTEM
Sept tank/di tribution bvx/soil absorption system
V/ _ Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
' Other(explain) a-4 \4,c e \T s,�, 5
APPROXIMATE AGE of all components, date installed(if!mown) and source of information:
Sewage odors detected when arriving at the site: (yes or no)�\G
(revised 11/03/95) 5
G
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addreaae ,'\-\ A�
Owner.
Date of Inspection: > r�2S' So\�N 'T• �N\�1 p N
SEPTIC TANK_1-4)
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions:
Shud depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scL=to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage; etc.)
GREASE TRAP:_N J A
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain)
Dimensions:
Scum thiclmess:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, stntcturnl integrity,
evidence of leakage, etc.)
(revised 11/03/95) 6
o% c
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addrraa:
Owner.
Date of Inspection ��� �1Z5•. �G��N -T. \�/�N\yGN
TIGHT OR HOLDING TANK:
(locate on site plan) —Nl
Depth below grads:
Material of construction:_concrete_metal_FRP_other explain)
Dimensions:
Capacity: Gallons
Design flow: aaLons/day
Alarsn level:
Comments:
(condition of inlet tee, condition of alarm and boat switches, etc.)
DISTRIBUTION BOX:` N
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER_ H I
(locate on site plan)
Pumps in worlang order-(yes or no)
Comments:
(note condition of Pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddread
Date of Inspection:
901L ABSORPTION SYSTEM (SAS):__LA J A
(locate on'its Plan, if Posslle;excavation not but may be a ra d=ated i'eRu� y PP by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number._
leaching chambers,number:_
leaching galleries, number-
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetaticn,etc.)
CESSPOOLS:_Z•
(locate on site plan)
Number and configuration_ Z S%?���2/�s 1� (G c�\� �t GZ/��{ W A'S c7,<
Depth-top of liquid to inlet invert: y
Depth of solids layer. 1
NG7tVL i
Depth of scum layer-
Dimensions .
of cesspool: S•E"i.S.—) b•5'n�,,�'
Materials of construction:
Indication of groundwater. \c
inflow(cesspool must be pumped as part of inspection) Ov^
Co ,
mments: note( condition of so' sig
ns igns of hydraulic failure, level of ponding, condition of vegetation,
gets n, etc.)
_Cs \aVA hlc S�Vt� OT 13"C7ZAQ-L-)C C-A\Lv(L>✓
V�\uSvptV_ STA\hl\l�l( OC
G\'\1��� CC`�'�?cam->✓.
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.)
(revised 11/03/95) 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropertyAddresa: IE�ly`N Shoe.
Owner. \alp Z�A�
VV,
Date of Inspection: 9 Sc'�irl T �'�ANNoN
SHI'MH OF SEWAGE DISPOSAL SYSTEM:
include tier to at least two permanent references landmarks or benchmarks
locate all wells within 100'
�o
OATO
L
6j
GGSg�oo� L�SS�oL
DEPTH TO GROUNDWATER
Depth to groundwater. VL feet
method of determination or approximation:
(revised 11/03/95) 9
March 19, 1997
Board of Health
Town of Barnstable
367 Main Street
Barnstable, MA 02601
RE: Mr. & Mrs. John T. Hannon
844 Shoot Flying Hill Road, Centerville, MA
Title V Septic Inspection
Dear Sir:
Enclosed please find a copy of the successful Title V septic system inspection at the
above property. Please review at your earliest convenience.
Should there be any questions concerning this matter, please feel free to contact this
office at (617) 934-8188 or(617) 934-7322.
Very truly yours,
Paul A. Brogna,' .
cc: Mr. & Mrs. John T. Hannon