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Home My WebLink About0010 SKUNKNET ROAD - Health 10 Skunk-net Road Centerville A = 192 046 Commonwealth of Massachusetts qa -o4& W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M sa' 10 Skunknet r Property Address N3 Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 c- 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 filling out forms A. General Information ��# Q33 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections r� Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 Si3938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 04/16/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 c ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding a leaching trench. At the time of the inspection there were no visible signs of past hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or El ® 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts M v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): '330 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 10 Skunknet _ Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: new leaching in 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 20"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: Standard H-10 1000 gallon septic tank 1 Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 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 ,M 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure. 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: l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: One 25' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible signs of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 4-k(L 8 e- t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 TOWN OF BARNSTABLE LOCATION 10 5i,,y'* --s,- ACk' SEWAGE 6 Na VILLAGE <<N T 6!t- z, Ile ASSESSOR'S MAP&LOT-[q Q Oq� INSTALL.EWS NAME&PAONE NO.AR c M to SEPTIC TANK CAPACITY -x,14 /a o o LEACHING FACILITY:(type)�3�3o1-;�,I,Fy/repro�s (size) Zs— X / 3 X Q- NO.OF BEDROOMS / BUILDER OR OWNER `, q� PERMTTDATE: 't 1054 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 3W feet of leaching facility) Feet Furnished by `C a 151LDNT Jr J9 /Q DP SS, (-> {3oP S9,s. r �llofit - , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: . You must describe how you established the high ground water elevation: I augered a hole to ten feet to show five plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 10 Skunknet Property Address Chris Tuft Owner Owner's Name information is required for every Centerville Ma. 02632 04/14/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file S +��J3 V AJI0 HIo t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Co Mill onweMth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Skunknet Rd Centerville MA Property Address Richard B Coughlan 10 Skunknet Rd Owner Owner's Name information is Centerville MA-- 0?632 �/4/2013 required for every page. City/rown 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 1 on the computer, use only the tab 1. Inspector key to move your cursor-do not use the return joe runs Name of Inspector Accu Sepcheck `rd Company Name + i7 Northside " ( S. Dennis, MA 02660 Company Address i Citylrown —0 3?5��e State Code Telephone Number J License Nuum�ber '/ B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �3113 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the-DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *"*This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5UIs•11/10 Tfile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 3 S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Skunknet Rd Centerville NM Property Address Richard B Coughlan 10 Skunknet Rd Owner Owner's Name information is Centerville MA 02632 3/9/2013 required for every City/Town State Zip Code Date of Inspection page. B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) Syste Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass°se soon need to be replaced or repaired.The system, upon completion of the replacement epair,as approved by the Board of Health,will pass. Check the box for"yes','no'or'not determined"(Y, N, ND)f e following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old" he septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or Itration or tank failure is imminent. System will pass inspection if the existing tank is repla h a complying septic tank as approved by the Board of Health. *A metal septic tank will p inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating the tank is less than 20 years old is available. ❑ Y ❑ ❑ ND(Explain below): t5ins•1 trio Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonw9ealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Skunknet Rd Centerville MA Property Address Richard B Coughlan 10 Skgnknet Rd Owner Owners Name information is Centerville MA 02632 3/9/2013 required for every page ER-r . State Zip Code hate of Inspection B. Certification (cunt.) 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 pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explai elow): ❑ obstruction is removed ❑ Y ❑ N ❑ ND plain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ND(Explain below): ❑ The system required pumping a than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if 'h approval of the Board of Health): ❑ broken pipe(s)a replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstructio 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 er to determine if the system is failing to protect public health,safety or the environme 1. System will pass unless Board of Health determines in cordance with 310 CMR 15.303(1)(b)that the system is not functioning in a m er which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of surface water ❑ Cesspool or privy is within 5 eet of a bordering vegetated wetland or a salt marsh t5ins•lino TM 5 Offiolal 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 10 Skunknet Rd Centerville MA Property Address Richard B Coughlan 10 Skunknet Rd Owner owner's Name information is Centerville MA 02632 3/9/2013 required for every y�te Zip Code We of Inspection page. citylrown B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,if y) determines that the system is functioning in a manner that protects the lic health, safety and environment: ❑ The system has a septic tank and soil absorption system (S )and the SAS is within 100 feet of a surface water supply or tributary to a surface water pply. ❑ The system has a septic tank and SAS and the SAS ' hin a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes I Y'f the well water nal sis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent a the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t 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 ❑ 21*1' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ URI**� 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 Y day flow j 1, Gins•11110 Tale 5 official Inspection Form:Subsurface Sevrage Disposal System•Page 4 of 17 I Commonwealth of Massachlusefts Official Iris ection Form 0 ff' Title 5 p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Skunknet Rd Centerville MA r Property Address Richard B Coughlan 10 Skunknet Rd Owner Owners Name information is Centerville MA 02632 3/9/2013 required for every State Zip Code Date of Inspection page Cityffown B. Certification (cunt.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ . ❑ L;? 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 IJ�' 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. ❑ P Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 10,000gpd. El The systeto m fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either°yes"or'no'to each of the foil , in addition to the questions in Section D. Yes No ❑ ❑ the system is wit ' 0 feet of a surface drinking water supply ❑ ❑ the s m is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you ve answered"yes"to any question in Section E the system is considered a significant threat, nswered"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•11/10 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonvvealth'of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments n et Rd Centerville MA 10 Skunkn Property Address chard B Coughlan 10 Skunknet Rd Owner Ownet s Name information is Centerville MA 02632 3/9/2013 s required for every Fa9e City/TownState 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 D any of the system components pumped out in the previous two weeks?C�[v� ❑ 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 ua 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? [J� ❑ Was the site inspected for signs of break out? [� ❑ Were all system components, a Ing 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? ElWas the facility ovmer(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: 3 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t51ns•I i/10 Tdle 5 Otfidal inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 j Commonwealth of Massachusefts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Sknnknet Rd Centerville MA Property Address Richard B Coughlan 10 Skunknet Rd i Owner Owner's Name i"�rma"°"'S Centerville MA_ 02632 3/9/2013 i required for every Page. City/Town State Zip Code Date of Inspection D. System Information Description: E/DD Qom,tA� �r4 btli?A�L bay • 3 rat- `11�a�o�s cat -C yolome, Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] Yes ❑ No Laundry system inspected? AdA Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallo erday(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 discharge o the Title 5 system? ❑ Yes ❑ No Water meter readings ' available: t5ins•1 U10 Title 5 Official Inspection Farm: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 . i 10 Skunknet Rd Centerville MA Property Address Richard B Coughlan 10 Skunknet Rd Owner Owners Name information is Centerville MA 02632 3/9/2013 ( required for every page Cityfrown State Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: e other(describe below): i General Information i Pumping Records: PUm I 2-/1 d O / 4 Source of information: =— / T Was system pumped as part of the inspection? ❑ Yes ( No If es,volume pumped: Y gallons How was quantity pumped determined? ( Reason for pumping: Type of System: xSeptic 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/Aftemative technology. Attach a copy of the current (1 operatio d , 9 maintenance contract(to be obtained from system owner)and a copy o hest inspection of the I/A system by system operator under contract : j ❑ Tight tank. Attach a copy of the DEP approval. j ❑ Other(describe): fl S i t5hs•111110 Title 5 official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 17 Commonwealfh'of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I 10 Skunknet Rd Centerville MA Property Address Richard B Coughlan 10 Skunknet Rd Owner Owners Name information is Centerville MA 02632 3/9/2013 required for every City/Tovw1 State Zip Code Date of Inspection page- D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: - - d 6 A-5 2 o? ( ems i pe-r 13 6OW Were sewage odors detected when arriving at the site? ❑ Yes X No Building Sewer locate on site plan): 1 ( �� ^i Depth below grade: feet J I Material of construction: El cast iron 40 PVC El other(explain): J Distance from priv to water supply well or suction line: feet / Comments(on condition of joints,venting, evidence of leakage, etc.): i I OK 's Septic Tank(locate on site plan): � . Z ( Depth below grade: feet Material of construction: I �(concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) { If tank is metal, list age: yeas Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ Noit Olt f i Ll Dimensions: 1 00 0) } Sludge depth: t5ins•11110 Title 5 offidai inspeman Forth:Subsurface Sewage Disposal System•Page 9 of 17 ...... of Massachusetts Title 5 Official Inspection Form subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Skunknet Rd Centerville MA Properly Address Richard B Coughlan 10 Skunknet Rd Owner owners Name infomration is Centerville MA 02632 3/9/2013 required for every page Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle ( 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 1 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, i liquid levels as related to outlet invert,evidence of leakage, etc.): ! -e- O Grease Trap(locate on site plan): Depth below grade: feet i Material of construction: ❑concrete ❑metal ❑fiberglass polyethylene ❑other(explain): Dimensions: Scum thicXto Distance outlet tee or baffle Distance ttom of outlet tee or baffle Date o st pumping: Date t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwaaith of Massachusetts Title 5 O icial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Skunknet Rd Centerville MA Property Address Richard B Coughlan 10 Skunknet Rd Owner Owner's Name information is Centerville MA 02632 3/9/2013 required for every !town State Zip Code Date of Inspection page- D. System Information (cunt.) 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 Zy1ene her(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(con i on of alarm and float switches, etc.): s *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspedon Form;subsuftee Sewage Disposal system•Page 11 of 17 I' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary-Assessments r 10 Skunknet Rd Centerville MA Property Address Richard B Coughlan 10 Skunknet Rd Owner owner's Name information is Centerville MA 02632 3/9/2013 required for every page Cityrrown 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 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note conditi of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System(SAS)(locate on site plan, a �tionequired): If SAS not located, explain why: t5ins.11110 Title 5 Otfidal Inspedion Form Subsurface Sewage Disposal System-Page 12 of 17 GommonweaW of Massachusefts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Skunkn et Rd Centerville MA Proped'Address Richard B Coughlan 10 Sku>nknet Rd Owner Owners Name information is Centerville MA 02632 3/9/2013 required for every State Zip Code Date of Inspee ion Page City/Town D. System Information (cunt.) Type: ❑ leaching pits number. ( leaching chambers number. j❑� leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): s�lnall aawt,� Cesspools(cesspool must be pumped as part of inspection)(locate ate plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cess of Materials of nstruction Indi on of groundwater inflow ❑ Yes ❑ No t5ins•1 Wo TBIe 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Skunknet Rd Centerville MA Property Address Richard B Coughlan 10 Skunknet Rd Owner Owner's Name information is Centerville MA 02632 3/9/2013 required for every City/Town frown State Yip Code Date of Inspection page. tY D. System Information (cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of constructio/signs Dimensions Depth of solids Comments(note condiaulic failure, level of ponding, condition of vegetation, etc.): -� t5ins-11/10 Me 5 Offidal Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 - i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Skunknet Rd Centerville MA Properly Address Richard B Coughlan 10 Skunknet Rd Owner Owner's Name information is Centerville MA 02632 3/9/2013 required for every page. Cityrro1nm State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate wh re public water supply enters the building. Check one of the boxes below. [hand-sketch in the area below ❑ drawing attached separately FaOA)r S D[5 At _ toy' 34 � , 3 , ��' - T � J t5ins•11f10 Title 6 Official Inspection Fromm.Subsurface Sewage Disposal System.Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora subsurface Sewage Disposal System Form-Not for Voluntary Assessments k,V-Wi 10 Skunknet Rd Centerville MA Property Address Richard B Coughlan 10 Skunknet Rd Owner Owner's Name information is Centerville MA 02632 3/9/2013 reuired for every e. CitylTovun State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: Check Slope [,Surface water [Check cellar Shallow wells I Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked wiithth local Board of Health-explain: j ❑ Checked with local excavators, installers-(attach documentation) [� Accessed USGS database-explain: / TV V°� . CCU gVUa,ad- MV You must describe how you established the high ground water elevation: S «/O -S L �- Se air Before filing this Inspection Report, please see Report Completeness Checklist on next page. tsins 11/10 Title 5 official inspection Forrm Subsurface Selvage Disposal System•Page 16 of 17 t t Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurtace Sewa a Disposal System Form-Not for Voluntary Assessments 1� Skanknet Rd Centerville MA PrQpeq Address Richard B Coughlan 10 Skunknet Rd obt,er owners Warne infommtion is Centerville MA 02632 3/9/2013 required for every page. Ciryfrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked ®' inspection Summary D(System Failure Criteria Applicable to All Systems)completed [�System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/to Title 5 Official Inspection Form Substuface Sev age Disposal System•Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 10 Skunknet Rd. 0. Property Address D, `\ Adalcio Da Cruz Clil y`\mot Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every 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. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 return City/Town State Zip Code (508)428-4028 S 14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12/21/20007 Inspe or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 10 skunknet rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 10 Skunknet Rd. . Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or,E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken-or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Rd. Property Address Adalcio Da Cruz . Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ 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 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts ti, W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 10 Skunknet Rd. M Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure,criteria are triggered. A copy of the analysis and chain of custody must be attached to.this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure El ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is Centerville Ma. 02632 12/21/2007 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)] 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 200 ,000 2006:55 :30 ,000 Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007. every page. City/Town State Zip Code Date of Inspection D. System Information.(cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 14" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------=------------.------------------------------------------------------------------------------ Dimensions: 1000 gallon Sludge depth: 6„ Distance from top of sludge to bottom of outlet tee or baffle 26 Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle . 12" How were dimensions determined? Measured 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10 skunknet rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is. required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection s , D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3-3050's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.Leaching was dry at time of inspection. 10 skunknet rd.-12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i M 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction . Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer F Custom MapIF Abutters Map Size ❑ Zoom Out J J J J J J' In , i „s°6S 0 20 Feet — � S .� Set Scale 1" _i r20 " I Aerial Photos (`nn—;nhf )M5_91V17 Tn,,,,of Rornefohlo AAA All r{nhfe room," http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=192046&ma... 12/21/2007 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Skunknet Rd. Property Address Adalcio Da Cruz Owner Owner's Name information is required for Centerville Ma. 02632 12/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:Gaherty& Miller.model 12/16/94 ground water elevations.USED:USGS observation well data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 10 skunknet rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable �ptHE 1p� ti�P� ti� Regulatory Services �saxtasTasre, Thomas F. Geiler, Director MASS. 9$prF16:yg. r Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax:'508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; warranty t this Division does not e p ty h functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. f TOWN OF AARNSTABLE LOCATION AQ SEWAGE #e D® „d -- j VILLAGE `�N T a li- !�� /�ie ASSESSOR'S MAP & LOT CJ INSTALLER'S NAME&PHONE NO•19Qe,5,("o ol sr ')-7 s <i d,2-• . i - SEPTIC TANK CAPACITY ZX,Ir /o o ar h LEACHING FACMITY: (type A d.,tyjF /rs,.0Po:�S (size) �X A NO.OF BEDROOMS ' / BUILDER OR OWNER ��l r✓ PERMITDATE: 3 ® COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ' on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by jr ,R DP SS, Q i) 0 op r @9T°� i Town of Barnstable gegu atory Services Thomas F. Geiler,Director snxivsrasEe. • � AMAK �m�°' Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-8624644 Fax: 508-790-6304 Installer &Designer Certification Form Date: •GV , Designer: GV �� y' �"" l Installer: _&4 LV- CdA IJ 7 Address: . �> Address: �s YC�LG MA M+ o2S�7 ' AO- AR 61V S 7 On was issued a permit to install a (date) (installer) septic system at-�D LUf �d based on a design drawn by (ad ess) dated (designer) .T 4certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e, greater than 10' lateral.relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow, N OF M,4 E G staller' Signatu ; 1140 OISTEa�° D I / NIFAR\PN u V ` (designer's Signature) (Affix Designer's Stamp Here) TOWN OF BARNSTABLE LOCATION /C 5;�vA-1 r 4,14C 7 SEWAGE #o2D0� e�f 6 VILLAGE Gi Ile ASSESSOR'S MAP& LOT O INSTALLER'S NAME&PHONE NO.19Ac i,,e"e a sr 7-7 5- 1C 6 SEPTIC TANK CAPACITY LEACHING FACIL=: (size) S^ -X / X NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: .3 D COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � � J 6 � � rop / D P 136 6 / 13 o? 'r No. �Q �CO / � Fee THE COMMONWEALTH OF MASSACH SETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE.,MASSACHUSETTS 0[pplication for 30igo0al bpeum Construction Permit Application for a Permit to Construct( )Repair V<Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No.` Assessor's Map/Parcel .72. f�6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i-j 5% S7 D g '7 7 S' /3 6 Type of Building: Dwelling No.of Bedrooms 7 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow *3 3 % gallons per day. Calculated daily flow 3310 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 issu hi and of H Si ed- Date Application Approved Date L3 Q Application Disapproved for the following reasons Permit No. (D Date Issued Z c 1.3 ,O Fee ` ` Entered in computer: THE COMMONWEALTH OF MASSA&bSETYS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for 3010pogal *pztem Construction Permit Application for a Permit to Construct( )Repair�pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./ /) Owner's Name,Address and Tel.No. /Vr % 7 lr/�/ia /5 �/7 �9r✓ Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. A/ v 57 ea Y Lr ec 3 6 of 7 7 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow r 3 3 / gallons per day. Calculated daily flow 3 3 gallo s. ' Plan Date Number of sheets Revision Date Title Size of Septic Tank 47 y Type of S.A.S. Description of Soil v .l •i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health'. J Si ned !� Date_ Application Approved b Date Application Disapproved for the following reasons Permit No. `,).r)o L/ Date Issued 3 O (4 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance ,,CTT0 rcr �T•r. :...� .� . . :.ERTIF'y, that the On-site S; w:se Dispvsai Syste:�Ccz�strucLed( )Repaired( )Upgraded( ) Abandoned( )by �- at / S �%P u .� Gr r� c T /? has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. :;L00 •E�l�mated Installer A OL --" /� Designer_,4.6,.Xaz The issuance of this permit shall not be construed as a guarantee that�e systeem will(funct on as designed. Date -75/o Inspector No. n L --- �O -----------Fee�J-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lfi6pooal *pgtem Cowaructiou Permit Permission is hereby granted to Construct( )Repair(-/)Upgrade( )Abandon( ) System located at /d T 2eJC2 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. Provided:Construction m st be completed within three years of the date of this p rmt. Date:- 37 Approved by 'L l I0NS�( - S E AGE PERMIT NO. VILLAGE C�..e -►�7�-e Y v / I I� INSTA LLE._R'S NAME i ADDRESS rc ti 6 U I L D E OR OWNER DATE PERMIT ISSUED q `17 � 7— OAT E COMPLIANCE ISSUED (o � � /6 t 4 Nod.!:' -c_5t. W `i Fim$.....3.....r.... THE COMMONWEALTH OF Mk.SACHUSETTS BOAR® OF HEALTH ti- ApplirFatiou for Uhipati al Works Tomitrurtion thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �ZIL /�� - ........... - �..................Pi L� .....Q-J� P...------•. .......................................... ....---•Local' n-Add�ess, or Lot No. ... La �'e t....... Oiler Address •._..__...-•-•------------------ Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...... ........_........................ Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------------------------=--------------------•--- W Design Flow............S_ ......................gallons per person per day. Total daily flow.........3_3_0_......................gallons. WSeptic Tank—Liquid capacityloA.0__gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No_____________________ Widt;h.,.................. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------/.......... Diameter___d_............. Depth below inlet__............. Total leaching area..2-g:R....sq. ft. Z Other Distribution box ( ) - Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •----------------------------------•----•----------•-------..__....-----------------......_.._...---......................................................... 0 Description of Soil........................................................................................................................................................................ x W -----•--•------------•----•-•-----------------------•-..•.---------•----•-•••---•--••---•--•--•--•••---•--------••-•-•-----------...-----•------------•-----•-•--------------•••••••--•--•-----...------ UNature of Repairs or Alterations—Answer when applicable._______________________________________________________________________________________________ ..•----•----•-•-------•-•-••----••-----•--•------•----•--••••----••-••••••-••-••-••-•---•-------------------•--------•--••------------•-••----•-----•--••----•---•-•••-----••••-•--•-•-•.._....._....__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by the b rd of health. Signed—� _._... -------------- 1_-'•-7- 'L- Date Application Approved By____.____ ....... Date Application Disapproved for the following reasons-----------------------------•---•.-..------------------------------------=--•---------------•---•-•••-••-------- E.. ----------------- --- Date PermitNo......................................................... Issued-....................................................... Date r 9 Nod., . :• Fus.....y` ..� ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH' ...........................................OF..........................................-----......................................... Apptiration for Diipo,titt1 Works Tunitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................--......_...................................................................... ..----•----------...---.......•-----------.....---•---•--•----------•---•--•-----•-•------••------ Location-Address or Lot No. ......................_.......................................................................... _........••--------...............•-•--•---...•------•-----•-••--------•--•--•----.............--- Owner Address W Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..............................................Expansion Attic ( ) Garbage Grinder ( ) �P Other—Type T e of Building ............... No. of ersons...._..._._..____.__....._.. Showers Yp g ------------- p ( ) — Cafeteria ( ) Otherfixtures ------------------------•----------------......-----------•-•------•-••--•••••.............. ---••-------------------------------•......-------- .gal W Design Flow............................................gallons per person per day. Total daily flow............................................ 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.__r- /..__--___- Depth below inlet.._.yr.o......... Total leaching area... ....sq. ft. Z Other Distribution b�x ( ) #osing tank ( ) i� aPercolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water....................... 14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1 -----------------------------------------------•-----.....-•----•----------..........------•-•.............................................................. DDescription of Soil........................................................=.................................... ............................................ ----- U ---------------------•----------------•--•-----•---------...---=-•---------........------.....--•-----------------------------------••-•------------------------------------------• --- �,..,. UNature 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 TITLE 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. Signed---------------------- Date Application Approved-B Date Application Disapproved for the following reasons: 5��.................................................................................... -------------------- ...•-•••........•••••--•-----••••----•-•••-••••....-•••••--••-----•--••-•-...-••••----•..............••----•--•-•-••-•--•-•••••••-••-----••••--••••••-----•••••••••••----••••••••---••-...••••......... Date PermitNo------------------------N---•-----------------------•--. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifirate of Toutpliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by................................................................................................................................................................................i Installer at. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------. dated------------------------------------- ---------- THE ISSUANCE O THIS CERTIFICATE SHALL NOT BE CONST 'UE AS A UARANTEE THAT THE SYSTEM WILL F ION S ATISFACTORY. DATE--------.-f�.. : �'----•---- . ...------•------•----•---•.... Inspector. " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF...................................................................................... No.... FEE....: ---- Disposal orko �C�ontrnrtion amit Permissionis hereby granted...................................................-••-•-•-•••-••••-••••••--•••--•--•-•••••-•••-••••••.......••••••-••..........--....---...... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo................................................................................................................................................................................................ Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... Health DATE............................................................................... FORM 1255 HOSES & WARREN, INC., PUBLISHERS 5%w6LL FAMtL-y - BEORooM � uo GAIiaAGE GcLNCEcz. _ � - 33oG.Rv. D Al L.Y I=L OW w 110 X SEPTIC, TANK = 33Ox15t>% =-495G.P. Q. . U5E- l000 GAL. ol•5Po5AL_ PIT v6E 1000 GAS• / S� 5%DGWfALL AREA. = 1�o S.F �v • � t 6 50TTOM s� AR EA s .. yO `F•_ s. . P -TOTAL. O S5►6N * 42 5 G.P D- -TOTAL. r>A1L�( F%-C>W ; 33oG.1?o. 168 c _ _ _ _ - - pTIA ti� PE2Cot-ATION RATE 1''IN VAIN oPLI-�55 - -- INA N,�, -7 ro�'�Oa qBINCHARD 6 �j•,- I Cn o BA TER 4:�` H K� 21046 00 35 ato•s 18Te�' TO' SUd ZONAL TOP FND 1_ 9 a ooO. F6 = 98' .�� •�' LOMW loov tNV. SJ i011•, 0 6T. INV. Z 4L G a6PToL I� Joao TV• - j INV. INV. 9& z. 9� YL WASKGD I{ Cra N 6 ceP—TIFIGD PLoT PLA► + PRoFII� - i - LoC4'clorJ . II g`- I2 NO SCALE 5CA>_E i� VATS q-13-91L I! -- tjl Q0 r REF 626 C,E 11 + EQ-sow GOMPL`(5 1nJ T NE tQV 1N ESN - 'TOWN OF ZA A!3*�c ANU IS dr G • �54 � COi,F. I.00p.TED WITN11.1 Nr t~ c LAIN DATE -\3•$Z -28 82 _ BAxTE2e WIM INC. °I EQ6 REG I S'T D'UAW D S v F-V�YoeS •TIII�j PLQti Ili NCT 4t�5�D Gld AN 03TCMVILLE • MiLs$• IIINSTR-uMEN-1' SVQVCy i�'TNE SuOuO No-r DC v,c.n-To oc�c^c•_MINc ��T �Ir�c�� APP�.II_A►-�T• ��' CoNST. t.... ASSESSORS MAP : I4 - TEST HOLE LOGS NOTES: (} PARCEL : U-i'L 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH FLOOD ZONE : �� ( SO I L EVALUATOR : �. ML THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF F 0 WITNESS m- ulk T BOARD OF HEALTH REGULATIONS. REFERENCE : bK- DATE : Noyem e-p- Z-Op 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLATION RATE : / SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO C LA5S - 501L,,a L-T kk-' 0='7q / INSTALLATION. c if 0 TH- I , F-L, J �� 0�1 TH-2 ( q � 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE (� ( {� �at?�� DETERMINATION. YI, !� /f 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS LOpr Q I-OAM/1 I b / SPECIFIED OTHERWISE) T� (N (� f LOCATION MA P(�,t� � 5) THE DESIGN.OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE DISPOSAL. nq,- A291 v0 - � 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) If C MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON /'� A.BASE OF 6"OF CRUSHED STONE. v j?F- 11 ILE Nod fl YkLLS WJl 0 I _001W_. SEPTIC SYSTEM DESIGN , -wla . w_r ( f TOP �1= FLOW ESTIMATE 1�9 -_off . W _ �vI 0- ry~ Y L/D BEDROOMS AT 110 GAL/DAY/BEDROOM - 0 GAL/DAY l(. .. ..,jvvjj(f _.role -.. . i' Tt IT1 ' SEPTIC TANK j 330 GAL/DAY x 2 DAYS GAL USE 1 00C)GALLON SEPTIC TANK SOIL ABSORPTION SYSTEM jkA-10oe- 3 0 UN ITg w11,33 S7-01v S I D_ AREA: . L( � 0 0 -1 la5 •�� 1 P 171 63 1�? BOTTOM AREA: 2S X (2_ y 0' q2 2 125' C ( Z �a 1 \ SEPTIC SYSTEM SECT ION � 0 � r�� 1 eNo ,I �- 1 �Q I" l (o2. �`7 / 6D - t a /, �, 1 �- "- __ -� ' �►z+ � C�V T wilt) 11 , (a�Sp�n nrt yo I GAL57 70 SEPTIC TANK leVe sn14 ° — , SF= F parr Z V)O SITE AND SEWAGE PLAN \�AOFA1,4 LOCAT I ON : /U 5.)L0,) ./,1C--T a I I �.-� ��` l, '' �ov�l1° Cn�T1e��L wt� Md � s�l No. 1140 -T '50 +7`' � PREPARED FOR }��-C-l-f (0/,/5 7", 'INIT,aR�P`' ,� 1t � :al DARREN M. MEYER, R.S. SCALE : / - � 43 'VINE STREET DATE : /1 22• D`'I DUXBURY, MA 02332 DATE HEALTH AGENT (781) 585-0293