HomeMy WebLinkAbout1367 SHOOTFLYING HILL RD - Health 01 1367 SHOOT FLYING HILL RD,
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Commonwealth of Massachusett
Title 5 Official Inspection Form
Subsurface.Sewage.Disposal.System.Form-Not.for Voluntary Assessments
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is required for every Centerville MA 02632 10-26-13
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms p�UptuunpU�i
on the computer, �SN OF&qs!�,,��
use only the tab
1
. Inspector:
key to move your n n o:;
cursor-do not James D.Sears v U = JA M E S m`=_
use
the return Name of Inspector
y *,
co
CapewideEnterprises,LLC
Company Name
153 Commercial St.
Company Address
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S1623
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. 1 am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CMR 16.000).The system:
0 Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10-26-13
c r�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 shalt 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.
t5ins 3H3 Title 5 Otfi' HF :Subaurtace Sewage Disposal System•Page m of m7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments
°< 1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is
required for every Centerville MA 02632 10-26-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,13,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:
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If".not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will.pass inspection if it is structurally sound,not leaking and:if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3113 Ue 5 Offidal bvvechm Form:Subsurface Sewage Disposal System•Page 2 of 17
1. Commonwealth of Massachusetts
Title 5 Official Inspection
Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is required for every Centerville MA 02632 10-26-13
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if
pumpslalarms 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
t5irts•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owners Name
information is required for every Centerville MA 02632 10-26-13
page. cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,N 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 welly*.
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
❑ 0 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 assiiiind is less than 6"below invert or available volume is less
than %day flow -
t5ms•3113 TiNe 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
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information Is required for every Centerville MA 02632 10-26-13
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 oftimes 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. [Phis
system passes N 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.l 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 Healthr 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 11 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 3H 3 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
informrequired
is Centerville MA 02632 10-26-1.3
required for every
page. City/Town State Zip Code Date of Inspection.
C. Checklist
Check if the following have been done_You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components.pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the.facility or dwelling inspected for signs of-sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,.excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with
® ❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System.(SAS)on the site has
been determined based on:
❑ Existing information. For example,a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins-3/13 Title 5 Official Ir spsdion 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
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner owner's Name
information is required for every Centerville MA 02632 10-26-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal. Tank D Box and three dry well chambers.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(include laundry system,inspection ❑ Yes Z No
information in this report.).
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2011-57,000Gals
9 ( y g (gP )) 2012-62,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
CommerciaVindustrial 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 Tile 5 official Inspection Forth: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
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's(dame
required fo is Centerville MA 02632 10-26-13
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cone.)
Last date of occupancy/use: Date
Other(describe below):
General information
Pumping Records:
Source of information: 4-21-11
Was system pumped as part of the inspection? Yes No
If yes,volume pumped:
gallons i
How was quantity pumped determined?
P
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/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):
t5ms•W13 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
�Y 1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is
required for every Centerville MA 02632 10-26-13
page. Cityfrown State Zip Code Date of Inspedion
D. System Information (cont.)
Approximate age of all components, date installed(if known.)and source of information:
1999 Permit#99-181
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 28
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4"PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 17"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 Gal.Precast
Sludge depth:
1"
t5ins•3113 TNe 5 Official btspection 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
"< 1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's(dame
information is required for every Centerville MA 02632 10-26-13
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Asbuilt-TapeSludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level.Tank and cover's at 17"below grade.In and out let Tee's. No sign of
leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete 0 metal 0 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•W13 Title 5 Official Ir"pection 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
"< 1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is Centerville MA 02632 10-26-13
required for every
page. Cityfrown State Zip Code Date of rnspedion
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•3113 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
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is required for every Centerville MA 02632 10-26-13
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-2'below grade. Box is clean and solid Wone line out. No sign of over loading
or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No*
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Us 5 OBctal Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
f
Commonwealth of Massachu
setts
mm Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is required for every Centerville MA 02632 10-26-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.).
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of pondin9 P, dam soil, condition of
vegetation, etc.):
Leaching is three 500 Gal.dry well chambees,12'x35'x2'. Chamber,s are 27"below grade, dry.
No sign of over loading or solid carry over. Wall's are clean w/no sign of stain line.'
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert.
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•W 3 Title 5 Offidal 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
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is required for every Centerville MA 02632 10-26-13
page. Cityrrown 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-3/13 Title 5 Official Inspection Fonn: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
'r 1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is required for every Centerville MA 02632 10-26-13
page. CwTown State Zip Code Date of{nspectim
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at feast 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
EAR
P -3 =3'1" �I .2
3 33' ❑
0 0 0
Y4 3
- �/ y
t5ins•3113 TNe 5 Olfida9 kispection Forth:Subwrtace Sewage Disposal System•Page 15 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner Owner's Name
information is required for every Centerville MA 02632 10-26-13
page. City/Town State Zip Code Date of Inspedion
D. System Information (coat:)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Al
15+'
Estimated depth tooiigh ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: _pate
❑ 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:
T.H. off plan 15'+ no G.W.. Bottom of leaching at 5'below grade. Bottom of leaching at 10'above
T.H..
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-3113 TrUe 5 Official laspectim 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
"t 1367 Shoot Flying Hill Rd.
Property Address
Mary Paszkiewicz
Owner owner's Name
information is required for every Centerville MA 02632 10-26-13
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5irrs•3/13 TWO 5 MOW won form:Sub�Serge Disposal System-Page 17 of 17
TOWN OF BARNSTABLE ®�
U � 6 ✓
LOCATION ' ;S/Vd 1 )"` u SEWAGE #
VILLAGE ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. ti/ a-A. S
SEPTIC TANK CAPAC= & 6- 0 Q 7 �
LEACHING FACILITY: (type),3^ ��% `�- �. (size) 1 4_
s
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 1/— S—9 ' COMPLIANCE DATE: .Sc'�7"
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Botto f Leaching Facility Feet
Private Water Supply.Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facili Feet
Edge of Wetland and Leaching Facility(If y wetlands exist
. within 300 feet of leaching facility) Feet
Furnished by
r
Q
.�
�� ! y, '
c �
►-1
A
yl
/ate/�� ' �
V
Fee $5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for Mi5po5al *pttem Construction 3permit
Application for a Permit to Construct( )Repair IX )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
L o atyon Address or Lot No. Owner's Name,Address and Tel.No.,
7 Shoot Flying Hill Rd.. , James Ellis
Assessor'sMap/Parcel Centerville ,MA 775-4.614-
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
PO Box 1089, Centerville , MA
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable)new Title-5 s tr g t P m f c)r 4 R g d r e e m s
consisting of tank, D—box and. 3 leach chamber. .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by t 's BWad of He th.
Signed -' Date 9_1r`9
Application Approved by Date
Application Disapproved or the following reaso
Permit No. i Date Issued
9 #_
♦ No.— _ � Fee
r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y _
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpprication for jBi-4pont *p5tem Con.5truction Permit
Application for a Permit to Construct( )Repair.lC )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
o at n Address or Lot No. Owner's Name,Address and Tel.No.
T110 Shoot Flying Hill Rd. , James Ellis
Assessor'sMap/Parcel Centerville,MA 775-4614
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E . Robinson Septic Service
PO Box 1089, Centerville, MA
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons. t
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
r
Nature of Repairs or Alterations(Answer when applicable)new T itle-5 system for 4 TIPdroomg
consisting of tank, D-box and 3 leach chambers.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in.-operation until a Certifi-
cate of Compliance has been issued by t 's B d o=A1
Signedn Date 9-$7-q
Application Approved by / J+ Date
Application Disapproved for the following reaso
4
t
Permit No. Date Issued I
THE COMMONWEALTH OF MASSACHUSETTS
Ellis BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( )
Ab do ed )by Wm. E. Robinson Septic Service
at 397 hoot Flying Hill Rd . , Centerville, MA been constructed in accordance
with the pr mini s of K tl b 11annd he or_Disposal System Construction Permit No. dated
Installer Designer
The issuance of this permit shall no`be co s• end as a guarantee that the system-willillffunction as esig�d. f�
Date ><� M Inspector / 1% 7111 A.
—— — ——------------------------------
No. ..� }V( Fee $5 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Ellis
Mizpoar *patent Construction Permit
Permission is hereb, rgg ed t Coyruct( )Repair( X)Up rade( )Abandon( )
System located at � b Mo Flying Hill Rc�. , emtrrville
l
and as described in the above Application four Disposal System Construction Permit. The applicant re—cognizes his/her duty to
comply with Title 5 and the following local' rovisions or special conditions.
Provided:Construction m XS
be co pleted ithin three years of the date of dsr p� it. c
Date: `'"! Approved by IK !9 7 i/ 1f� �i
TOWN OF, BARNSTABL E/
LOCATION l '� -Aa O FIV�"` 4 I�SEWAGE # — S
VILLAGE Of 4��j ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. ti
/ �72
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)3- �<,7 L (size)
NO.OF BEDROOMS 41
BUILDER OR OWNER ��s
PERMTTDATE: d�— � `l' COMPLIANCE DATE: S/9— Q/
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Botto f Leaching Facility Feet
Private Water Supply Well and Leaching Facility any wells exist
on site or within 200 feet of leaching facili Feet
Edge of Wetland and Leaching Facility(If y wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
del
— I
r
a
� 1
NOTICE.: This Form Is To Be Used For The Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated y' �r' `f concerning the
property located at 1367 Shoot Flying Hill Rd., Centerville,NMmeets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* 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.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Evaluation(according to Health Division well map) o '
SIGNED 4 Ll��l, DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
. �j
1
1
1
I
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT'OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 0210E (617) 292-5500
TRUDY CO.l'E
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Conunissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Pr Address: H d Name of Owner James Ellis
1307 Shoot Flyi]�gn'Cerviil2 ' AddressofOwner`- same
Date of Inspection:J, /7—% p e
Name of Inspector:(Please Print)Wm. E . Robinson S r .
am a DEP proved syst inspector pgrrsua tp Section 15.340 of'ride 5(310 CMR 15.000)
Company N�:, V(�m. E . Robinson epMtic Service
Mailing Address: PO Boy,. 0 9, Centerville , MA
Telephone Number: 6 F(�
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: W 4 Date: cT /T1
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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.
NOTES AND COMMENTS
9 1
� 0
d
RE r EO f
J U N 1 8 1999
TOWN OF BARNSTABLE
HEALTH DEFT. ti
s
revised 9/2/98 Page Iof11 E
�� ✓cried on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f
PART A
CERTIFICATION (continued)
"roperty Address!367 Shoot Flying Hill Rd.. , Centerville , MA
Jwner: James Ellis
Date of Inspection: 157_17_9
INSPECTION SUMMARY: Check B, C, of D:
FMM
TEJM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
TS:
B. YSTEM 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.
Indicate y , 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 complying septic tank as
approved by the Board of Health.
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 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 will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
P
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
P►op"Address: 1367 Shoot Flying Hill Rd . , Centerville , MA
Owner: James E 1 s
Date of Inspection:5-1-7
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y
PART A
CERTIFICATION (continued)
'Property Address:1367 Shoot Flying Hill Rd.. , 'Centerville , MA
Owner. James Ellis
Date of Inspection:
D. SYSTEM FAILS:
You ust indicate either "Yes" or "No to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility-or system component'due to an overloaded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
<coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARG SYSTEM FAILS:
You must i dicate either "Yes" or "No" to each of the following:
T e following criteria apply to large systems in addition to the criteria above:
T e 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
ealth and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public
water supply well)
The owner r operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of th Department for further information.
8 Pa
revised 9/2/9 ge4of11
t .
w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
i
Property Address: 136,7-Shoot Flying Hill Rd.. , Centerville , Ma
Owner. Jame s Ellis
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been-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.
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 signs 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.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at-issue,approximation of distance is unacceptable)
The facility owner (and occupants,if different from owner) were provided with information on the proper maintanance of
Subsurface Disposal Systems.
revised 9/2/98 Page 5ofII
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y
PART C
SYSTEM INFORMATION
$ropertyAddress: 1367 Shoot Flying Hill Rd.. , Centerville , MA
Owner James Ellis t
Date of Inspection:` 0 o,
FLOW CONDITIONS .
RESIDENTIAL:
Design flow:4/SO g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms(actual):*
Total DESIGN flowL
Number of current residents:_
Garbage grinder(yes or no):2--19
Laundry(separate system) (yes or no)k�Z-0; If yes, separate.inspection.required _
Laundry system inspected (yes or no)
Seasonal use(yes or no):_d. D
Water meter readings, if available (last two year's usage(gpd): 1998 80 , 000 gal.
Sump Pump(yes or no):/Zl CJ 1997 91 , 000 gal.
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Typ of establishment:
Desig flow: gpd ( Based on 15.203)
Basis f design flow
Grease trap present: (yes or no)_
Industr al Waste Holding Tank present: (yes or no)_
Non-se itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available:
Last d to of occupancy:
OTHE :(Describe)
Last to of occupancy:
GENERAL INFORMATION
PUMPING RECOR S and source of information:
System pumped as part of inspection: (yes or no)
L
If yes, volume pumped:o-2'00-6 gallons
Reason for pumping: A,4; t r
TYPYSTEM
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif known)and source of information:
Sewage odors detected when arriving at the site: (yes or no),Lo
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icorronued)
'ropertyAddress:1367 Shoot Flying Hill Rd.. , Centerville , MA
Ownw: James Ellis `
Date of Inspection: sr�7.; 9
BUI DING SEWER:
(Loc to on site plan)
Dept below grade:_
Meter I of construction:_cast iron_40 PVC_ other(explain)
Distan a from private water supply well or suction line
Diame er
Comm nts: (condition o joints, venting, evidence of leakage,etc.)
SEPTIC TANK:_
(locate on site plan)
1
Depth below grade:
Material of construction:Zconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age�_ Is.age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions: jl, 4 -� 1 v
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_ '
Distance from top of scum to top of outlet tee or baffle: G )
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outlet tees or be es, depth f liquid level in relati n to outlet invejt, structural intepty,
evidence of leakage, etc.) �/�/!i
GA EASE TRAP:
(loc 3te on site plan)
Del th below grade:_
Ma erial of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Di ensions:
Sc m thickness:
Dis ance from top of scum to top of outlet tee or baffle:
Dis ance from bottom of scum to bottom of outlet tee or baffle:
Da a of last pumping:
C mments:
(r commendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
ev Bence of leakage,etc.)
revised 9/2/98 Page 7of11
• 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
brop"Address:1367 Shoot Flying Hill Rd..', Centerville , MA
Owner: James is
Date of Inspection: 1 7_p /
Tl T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(loc a on site plan)
Dept below grade:_
Mater I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimen 'ons:
Capacit gallons
Design ow: gallons/day
Alarm p esent
Alarm I vel: Alarm in working order: Yes_ No_
Date of previous pumping:
Comm nts:
(condi on of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_V
(locate on site plan)
Depth of liquid level above outlet invert:_t�
Comments:
(note if level and distribution is equ evidence of solids carryover, evidence of leakage into or out of box, etc.) -
PUMP CHAMBER:_
(looat on site plan)
Pum s in working order: (Yes or No)
Alar s in working order(Yes or No)
Co ments:
(no a condition of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 1367 Shoot Flying Hill Rd.. , Centerville , MA
Owner: James Ellis
Date of Inspection: 6,,/•7— 6 7
SOIL ABSORPTION SYSTEM(SAS):_v
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:_
leaching trenches,number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydrauli failure, level of ponding,_d,a1"p soiyconditign of vegetation, etc.)
i
CESSPOOLS:_
(locate on site plan)
Number and configuration:-PZ)
C.
Depth-top of liquid to inlet invert-
Depth of solids layer: V
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Co ments:
(no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PR _
(locate on site plan)
Matircia lsof construction: Dimensions:
Deofsolids:
Coants:
noondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
-ropertyAddress: 1367 Shoot Flying Hill Rd.. Centerville , MA
Jwner: James Ell i
Jate of Inspection: .S/7— /
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
i
V
1A
1\
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
rop"Address: 1367 Shoot Flying Hill Rd. , Centerville , MA
Ownw: James Ellis
Date of Inspection: S—/7 r g Cl
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date web.site visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
/
1/ Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you estaaplished the High Groundwater Elevation. (Must be completed)
1216
revised 9/2/98 Page 11of11
.................
THE.COMMONWEALTH OF MASSA.&U�SETTS
BOAR® 9F HEALTH
N..... .....0F............. ,14.. .............................
ApplirFatiun for lhspoii al Works Tunitrurtiun tIrrmit
' Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system t
`..-�.- (:'' i__ .....�e.---2......
C...>�.
n-Address or Lot o
_
� Owne�j , Address
a -•---- a. 2...Cs------------- .?.............................. ................... 20 K!11�c ...:----.......------------------------------...
Installer Address
Type of Building p� ize Lot............................Sq. feet
aDwelling—No. of Bedrooms. ,�------------•---•-----_-•--_-----Ex `scion ttic ( ) Garbage Grinder ( )
a,, Other—Type of Building .......:� o. of persons......>3................. Showers ( ) — Cafeteria ( )
Q' Other fixtures ----------------------•------••••--•--•-•----•••-- ....
W Design Flow.......... .....................gallons per person per day. Total daily flow...................._ ...................gallons
y
f4 Septic Tank—Liquid capacit /..gallons Length...Z a�.-_... Width__._--ld__ Diameter______ .... Depth....10..........
W Disposal Trench—No._._ ...... Width_._�....... Total Len th_..._. ......_ Total leaching area..__....____
x P g g .. sq. ft.
Seepage Pit No---------/------ Diameter.................... Depth below inlet.................... Total leaching area..2.._4a .sq. ft.
z Other Distribution box ( ) Dosing tank )W � /,'�
Percolation Test Res Its Performed by .' .�.i_ _.__._L�;1/.Pmr' N 2..... Date.../-..�_�.3
r's5
4 Test Pit No. 1--- ....minutes per inch Depth of est it.................... Depth to ground water........................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---•-•-•---•------------- ............................ -- ---------- ----- -----------
Description of Soil.......0---••-....2-, ....... %�!✓ �' �'� - ,� 'f
_2
V
W
•-•---------------------------------------------------------------------------------------------------------------------------------------- ...........................................................
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------•------•----•-.......•--•-....•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI.E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en is d by the board 0i health
. ....... .....................�/,/
/f
Date
Application
a
Approved ---..
.... . w ............................................................
o Date
Application Disapproved forreasons:--------------------•-•---------------------------------------•------------------------•--...--••-----•--•--•--.
Date
PermitNo......................................................... Issued_.......................................................
Date
.. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... .. .•----......OF......................................
AvOiration for Disposal Works Tonstrnrtion Prruat
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................___............................................................................ ............................................... -------------------•--•--------------------
Location-Address or Lot No.
........•..---•..............................................................................•.... -••--•••-•••-•......-•-•••--_........_._._...---..........._..........._._.............._.........
W Owner Address
,.a ----••----••......-•----....---•••-•--•----•----......••---•--••••••....-----•-•••••-•---•--•----- ----•--••-••••-•---•••................••••••-•---••-••-••--...._........------....•---....•----_..
y' Installer Address
f. ype of Building Size Lot............................Sq. feet
W DwellingNo. of Bedrooms.............................. .....Ex Expansion Attic— --------- p ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ...................................................
W :Resign 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--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(Zq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' --------------------------------
•---------------••--------...
0 Description of Soil....................................................................................................----•--------------------------------------••••---••-•..._.........
x
-----------------------------------------------•-......••..........
w
x •--•••-----•-------------•-•-----•••-----•-••---•-•----••--.....--------•••-•-------•--•••--••--•••----•----••------••--------------•--•-----•-••---•--•-•••••••--•-•-•-•••--•-•---•••••....--••••-•-•••
U Nature of Repairs or Alterations—Answer when applicable.......................................__....................._.............._..................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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 board of health.
i 'd...................................................................................... ..........................
Application Approved —.... Date
Date
Application Disapproved for 'e lowing reasons:---•--....•••-••-•-••-•-••-•---••-•--••-......-----•......-•-••••..............................................
---•-•---------------------------------------------------------•-•---------------•---------•--------...•..--••-----------•-•---------------------------------------•----------------....................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Tntifiratr of Toutplittnrr
T S� TO CERTIFY, That the Individual Sewage Disposal System constructed (oo )"or Repaired ( )
by ... . - ....__.... ............................................................... --••--.. ---.----•------- ----.--
-- -- ---
at ,�-•-•- •-
has been installed in accordance with the provisions of T of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... .... ...Z;/'/2.... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTI0 SATISFACT RY.
ll yy��JjX,
DATE..............•- ... j.:...�._l_ --..... Inspector--..•-••- ......-•--- --•-•---------....----..............--•--....--•------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................
.O F....._........ ...._..............
No.....r.:.
FEE........................
Disposal Works Tlanirnrtion .rrmit
Permissionis hereby granted.......................................•-•-----•-••----•--•••••••--•-•......•••---•-•-•-----•••••-•--••-•-•--•---•-•-...................._..
to Construct ( ) ortRepair ( ) an Individual Sewage Disposal System
atNo...-•--------------------------------•-------------------------•-- ._......
Street
as shown on the application for Disposal Works Construction Permit No__................ Dated..........................................
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DATE Board of Health
.----•-•----------••----------------•-----•----•--------•----
FORM 1255 A. M. SULKIN, INC., BOSTON