The URL can be used to link to this page

Home My WebLink About0172 SKUNKNET ROAD - Health 172 SKUNKNET RD. CENTERVILLE A = 171 007 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address , Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 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. Inspector Information '51-:t 139-9 2 on the computer, use only the tab Mathieu Rebello key to move your Name of Inspector cursor-do not Rebello Septic Inspections use the return Company Name key. 30 Norse Rd Co � Company Address South Dennis MA 02660 City/Town State Zip Code 774-722-0271 SI-14140 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CHAR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/9/19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts a p Title 5 Official Inspection Form 1- ha Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is Centerville MA 02632 5/8/19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced . ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road vie Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � } Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c `v� Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: 1-1500 gallon tank 1-distribution box 8-infiltrators with stone 36'x15'x10' Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 131 gpd 9 ( Y 9 (gpd)) Detail: 18-50,000 1746,000 Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: N/A Y Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe below): N/A 3. Pumping Records: Source of information: previously pumped 2 years ago. Tank will be pumped following inspection Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 518/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/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): Approximate age of all components, date installed (if known)and source of information: 1997 per board of health Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"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 tight,proper venting, no evidence of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Jr< 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. precast Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3-4" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" 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.): Inlet and outlet Tee's in good working condition. Liquid level is equal with outlet invert with no evidence of leakage. Septic tank is in need of pumping and will be pumped following inspection. t5insp.doc-rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A p gallons Design Flow: N/Agallons per day t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts (p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,J 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: NSA Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box is level with no solids carryover or evidence of leaking. 1 inlet with 2 outlets no speed levelers present t5insp.doc•rev.7I2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 8-30'x15'x10" ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form up Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): stone and soil found dry, no signs of hyrdaulic failure or unusual vegetation. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction NIA Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road v Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/201 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Assessing'As-Built Cards http:Hwww.town.barristable.ttla.us/Assessirg/HMdisplay asp?mppar... 'DOWN OF BA MABIE L--OC_A-TvI � ON �_-A V ""S-r- -!A SBWACM• VUJAM� -k-A =/i4{, - ASSMSM MAP&LOT lL-AQ•) WTAUAR'SNAMBAPMMNO.._FSn= 9 ? SBPM TANK CAPMM t f-dA gb-r a. LBAC MO FACMHY:(" �r _A ..�.� .% oia)�(a sic is NO.OF9PDROOM3 INtziLmewltES� REM DATM 11-21. & COMP.V=t')AM -22-9 7 up+tmoo Dtamce Baaeep me 1►ltdm®►AgjmtedQrotteTiDkmdBammotlaeAietFsadry -� Pie AivWWW[S%fflyWGUmdtAW%IntFwft Nmf w todn on die of%thin 20 tatdkmd t cuing%) Fm Edv of WWmd and Latalot F-ft(pm7 wako6 eaht w"300tatofbwhWthc+b) Fe+ AuddKA er :D.L ST'(; � 1 ol- I of 1 8/20/2015 3:34 PM Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 7+ feet Please indicate all methods used to determine the 9 high round 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: plans and test hole ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: system is installed per plan SAS is above high groundwater Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 ' Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 172 Skunknet Road Property Address Jaimie Donovan Owner Owner's Name information is required for every Centerville MA 02632 5/8/19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated 9 depth to high roundwater included P 9 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form S��( - Not for Voluntary Assessments H Property Address C w ner ON ner's Name Information is required for every Ce '`'V�! "e _ y� (O �O a A, page. City[Town State Zip Code bate of In action 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 fl on the computer, U use onlythe tab 1. Inspector: key to move your cursor-do not Q ✓ y kee the return y. Name of Inspector Q Company Name �� Company Address City/Town (So? c; ^� 62 State 4/ U Zip Code j ,`Jv l` �o�- Telephone Nu r 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"10R 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority fag Inspector's ignature 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 god 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•3113 Title 5 Official InspectionForm.SubsurfacaSewage0lsposel System•Page 1of17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4-Oe, Property Address / Owner ON ner's Nm ae m inforation is required for every page. City/Town State Zip Code Date of In pection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) ;Syste�m Passes: have not found any Information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t6re-3/13 Title 5 Official Im pec tics F orm:Su bsul ace Sew age Syslem•Page 2o117 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ON ner Cw ner's Name / information is Ce hrv� required for every dd dd page. Cityffown 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 obstructedpipe(s). The Y q P P 9 Y 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 mannerwhich 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 t51ns-W 3 Title 5 Official Inspection F orm Subsurface Sewage Dlsposel System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Ory ner Ow ner's Name Information is ro—/ required for every Q� tlyl IleUa�?�page. City/Tow nState Zip Code Date o Inspect B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered, A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ p�-' 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 YZ day flow t5 m•3/13 Tito 5 Of flcial Iris pec tlon F orm:Subsuf ate Sewage oisposst System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / ON ner CW ner's Name information is Qj required for every ��✓yt Ile- C�*4 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No 171 ;1_< 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- 10,000g pd. ❑ The system fgjj_$. 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. 1 ris-3/13 Title501AcidInspee bon FamSubsulaceSewageDlsposel System-Page 5of17 ' Commonwealth of Massachusetts 7. Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °? 4- S U H 4, Property Address Ow n Ow ner's Name required information is Ge k4 !/// a)6 c -1� required for every T page. Cityl Tow n State Zip Code Date of Irfspectioh C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? Els 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, I Y p , 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): Number of bedrooms (actual): 3- 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): t9ns•33113 Tiue 5 olflci ei ins Poo Lion F orm Su bsrrf ace S"e Disposa System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ner 0�ner's Name inf Z- 1 information isrequiredforevery t/!�/ 0)t6 ?� 9 a page. Crty/Town State Zip Code Date of I spection D. System Information Description: Number of current residents: ,.,.,�..�-�— Does residence have a garbage grinder? ❑ Yes L•1 No--'No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes t� information in this report.) Laundry system inspected? ❑ Yes No.—�--- Seasonal use? ❑ Yes �No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: C ✓��n Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: i5ire-3113 Title50fticial InspectionFam Subsurface Sewage Disposal System-Page 7of17 Commonwealth of Massachusetts Title 5 Official Inspection Form -- o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2�Z S4 !mot N �-4-C, 7L Property Address R Ow ner Owner's Name information is required for every Ile page, CityfTown Slate Zip Code Date of Inspec ion�� ..__ D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: ---- Gl c9'� crT Q l.✓vtn� Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons Howwas quantity pumped determined? Reason for pumping: Type of S m: 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): 11 L•yt3 Title 5 official Ins poc lion F orm Subsuiace Sewage Disposal System•Pape 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System F(\o)�r^m - Not for Voluntary Assessments rY l �/ Property Address Owner Ow ner's Name information is 6eplAl-k l4 / l/ cp b 9 p q required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed/(if �known) and source of information: q 99 Were sewage odors detected when amving at the site? ❑ Yes YNo Building Sewer (locate on site plan): Dept h bel ow g ra de: feet Matedal 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: feet Material onstruction: 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) \El Yes El No Dimensions: `=� �` /0 Sludge depth: 1,9ns'Y13 Title50fM1cial IrapecUonForm Subsurface Sewage Disposal System-Pape 9017 ' Commonwealth of Massachusetts Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow ner Ow ner's Name nformation Ce��yv,/l nforr required for every i page. Ci flown State Zip Code Date of Insp ction 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): coo r � Z-10 a�S Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dim ensions: 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 pum ping: Date l5rs•3113 1WoSotficiallnspecuonForm Subsurface Sewage Disposal system Page 10of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow ner Ory ner's Name information is et �y / V required for every e page. Crty/Town State Zip Cade bate of Ins ection D. System Information (cons) 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 workin g 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 t5ns•W 3 Title 5 of Acisi Ins pec6m F orm Subsu lace Sew age System.Page 11 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address A ON ner ON ner's Name Information is CQ� /� / � 9 required for every l- O� Lllv page. Cityfrown State Zip Code Date of Inspecti n D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: Ism-3113 Title 5Offlclal lnspec6an Form Subsuiace$"a Disposal Syslem Page 12 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address eG Ow ner Owner's Name information is �� Ile / required for every page. City/Town State Zip Code Date of Inspectio D. System I rmation (cont.) TYpe 20/� l0 ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): G'y► v O/ / C I a�l G N C- 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 3113 Tits inspectionForm.Subsurface Sewaoeofspaael System Page 13 of 17 t5ire• 7 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System For - Not for Voluntary Assessments Property Address o+ O+v ner Av ner's Name information is ll required forevery C�0 y! G��Jd 9 d9' page. LAyilown State Zip Code Date of Ins e i p ton 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 construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): UNra•3/13 Title5Officlag IrupecknForm SUbsk"Ce SewageDlsposel System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,/ Property Address ON ner Owner's Name inform `/„information is C��1 ✓(/� /" / /¢ � 3oz required for every `"C page. Crty/Town State Zip Code Qate 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 Z-rh e pub' ater supply enters the building. Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately Q O 4- 0�1 - t51ns 3113 TWe5Official Ins poc bon Form Subsurface Sewagepisposal System.page 15d 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �? / 2C2 S/j--U 0 /120✓ Property Address (-2e a C ON ner Owner's Name information is required forevery page. CityRown 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: 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) I� Checked with local Ma 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: GI42 Before filing this inspection Report, please see Report Completeness Checklist on next page. t5ins•W3 Tide 5 official Ins W bon Form Subsurface Sewage Disposal system-Page 16of 17 Commonwealth of Massachusetts Title 5 Official ,Inspection Form Subsurface Sewage Disposal System Form -/Not for Voluntary Assessments p( 9l� S!'!"(it N Property Address u Ow ner Owner's Name information is l- requiredforevery e"J ✓!�< 2 �pZG�� 9 �((! page. Vy/rown State Zip Code Date of irisFe—etiulT E. Report Completeness Checklist D Inspection Summary: A, B, C, D, or E checked 9-Inspection Summary D(System Failure Criteria Applicable to All Systems) completed 2---Sv em Information — Estimated depth to high groundwater L"J Sketch of Sewag e Disposal System either drawn on page 15 or attached in separate file Ons•3113 Title 5 official im pec tlon F arm subsurtace Sewage Disposal System•Pepe 17 of 17 TOWN OF BARNSTABLE LOCATION 9?-b-- SEWAGE.# l , _ A VILLAGE ASSESSOR'S MAP &LOT l 7/• oo -7 INSTALLER'S NAME&PHONE N0. ? SEPTIC TANK CAPACITY t enyLr LEACHING FACELITY: (type) FUQ-6 e�-rA L-A-- (size) NO.OF BEDROOMS si--7 19 BUILDER OR OWNER Ca,*701,2to4 JIZ Q L_ht-a -- PERMITDATE: COMPLIANCE DATE: -X c17 Separation Distance Between the: _ Maximum Adjusted Groundwater Table and Bottom of Leaching Facility -S 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 IL 3i .L L7 �6� ASSI SSORS MAP-Pad No. ` PARCEL NO;r . _ 0-12 2- <• �� '�' c Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYicatfou for Wootar *raem Comoructfou 3permit Application is hereby made for a Permit to Construct(/Or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. /72 7 Owner's Varne,Address and Tel No. Assessor's Map/Parcel InstaWr's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. A Type of Building: Dwelling No.of Bedrooms Garbage Grinder(. D Other Type of Building rellee No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Zz gallons per day. Calculated daily flow gallons. Plan Date �" y �� Number of sheets Revision Date Title Description of Soil o �15 0W 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 issued49��o7ard He Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued 17 .. . A No. Fee THE COMMONWEALTH OF MASSACHUSETTS 1 PUBLICCHEALTH"'DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS Zipplicat bn for �Btgpogal 6p5tem Congtruction Permit Applicationds hereby made for a Permit to Construct(vor Repair( )an On-site'Sewage Disposal System at: Location Address or Lot No / 72 G�c�717 Owner'sName,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder G/* Other Type of Building', No:"of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per.day. Calculated daily,flow gallons. Plan Date Number of sheets Revision Date Title t Description of Soil t Nature of Repairs or Alterations(Answer when applicable) r � Date last inspected: Agreement: rF 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. Signed Date 0 Application Approved by Date t/fl Application Disapproved for the fol owing reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( Zorepaired/replaced( )on by InstallerAll' -ow,,s7�d�/G7`i;_i at l I ZZ !2�_o,cf 1`4242- -�_ /° � �^,/l%/rlias been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9,1--C—.? Sl dated ,10 - _ - 9 e Date Inspector THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. yJ No.—T /�' s— q Fee Z6 l) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Dioogar Opgtem Congtruction Permit Permission is her by granted to 42r �C31.-p 11/ K�wS zn to construct( vol repair( )an On-site Sewage System located at No.# 2 / Sveet and as described in the above Application for Disposal System Construction Permit. 1 ` _ ,6 o. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. Date: Approved by Board of Health SEPTIC PROFILE TEST HOLE LOGS T.O.F. AT - (NOT TO SC&f) ACCESS COVER TO WITHIN R' OF FIN. GRADE I �~ ACCESS COVER (WATERTIGHT) TO FFF ENGINEER:_ _ ._�4:er .. MINIMUM .75' OF COVER OVER PRECAST f WITHINOF FIN. GRADE -+� - 2% SLOPE REQUIRED OVER SYSTEM ]71 - --- ----_. --_----- ---- _��-QSo 5 WITNESS: c7,117, RUN PIPE LEVEL Y DOUBLE �S v qv tJ. ;• o,0 --- I - --.- j ---FOR FIRST 2' r WASHED PEASTONE O• DATE' PROPOSED �ss2_d k GALLON SEPTIC - ORIFICES TO BE 3/8" TO 5/8" PE RC. PATE TANK _�.o___) _____` 1 ►�`-�`'.1--/1!'� _-----.___ �� 'e t !l Q II °OP.� a L1 P#ea AT `TABS SOILS wLONG S ' .9r ;5'.WIDE_ CRUSHED STONE OR MECHANICAL - COMPACTION. (15.221 [21) —- DEPTH OF FLOW = 3 j's' TO ? -t j T DOUBLE WASHED STONE I LP ] [P SLOPE) TEE SIZES: (— __X SLOPE) SLOPE) °' ;,_:��r► t-I F i✓f C 4`' 41' 5O. �' INLET DEPTH —L A'f E G> I -- 1 o LOCATION MAP OUTLET DEPTH FOUNDATION— 0� --- SEPTIC TANK -- --- I"I -.-. _- D' BOX - - - - ' LEACHING ASSESSORS MAP )� ._ PARCEL FACILITY 5.0 L � `'� `'' - Ff_UOO ZONE _._....�_- I G , �► I BUILDING ZONE: SETBACKS: FRONT - ---Z`' - r•---- ------ — 1 -- _. � .`�.�, L� � SIDE ►rc; ✓'h.K_k r��' I r t N 2 s t c.�,4 REAR - i o C' �ri l�-'T k I , �,r1 -'-- Q PLAN REFERENCE: 4_ -� II � �, -'t-o •,, 1 "" � S i I 7 Y-E-r�^'/r • f2 f.� G � Z•O F�� Lam' I C_ 4 - T 7__ __ I o NO TES__ �. �- -o-(? !� - �_ � a SEPTIC DESIGN: (cARBAcE DISPOSER 15 ----t� �`r V✓��G ) - 330 GPD i . DATi�N" I`�' 1-1.�`��.�_.!�hS 'V4 0-_ -,�'�v.►_; ',� C.>��cb- :7 [)ESIGN FLOW: BEDROOM`) (DLO GPD) USE A � ,O GPD DESIGN FLOW 2. MUNICIPAL WATER IS w SEPTIC TANK: 3--V GPD (_?) = t,.c.o GALLONS 3, MINIMUM PIPE: PITCH TO BE 1/8" PER FOOT. ( \ / I �� I 5►x \' - - - --j /�' USE A 1�..� v_Q (�Ai_LON SEPTIC TANK 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO--H__%_ ii 5. PIPE JOINTS TO BE MADE WATERTIGHT, 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. IF - -- -- ENVIRONMENTAL CODE TITLE V. f30TTOM:___ Q ! ( 14_) _ � � GPD 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE f / TOTAL: S.F. GPO USED FOR LOT LINE STAKING. 45o '�?�� 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. 7 �- _.� Fl �-� .LZf 1.' �� 1►l FRS-f. � I�R r 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT 4 '! s T Fa�-+� , +�'" .N. `'SQ �r-�� : .PT �� '`. ; INSPECTION AY BOARD OF HEALTH AND PERMISSION OBTAINED j f; �( FROM BOARD OF HEAL TH. � w` // i I p,/ y .� .G,-ro�.4;� �+.-� Ec_t-12`�_,_�� Ic i�' .r.�_•A-� _ 40 -- - 1__EGE. JU 100.0 PROPOSED SPOT FI_FVAIION 10Ox0 EXISTING SPOT El_E-`JATION f hbbi PROPOSED CONTOUR SITE AND SEWAGE PLAN OF -- - U)o E X I S T1 N G ('O Pa T O L.I R - -- i BOARD OF HII.ALTH IN THE TOWN OF: MA APPROVED DATE ------_ PREPARED FOR- , f}� t` 0 2.� '4O ;,r FOet ' SCAM: _2.o DATE: down dope, engineering, inn. CIVIL ENGINEERS LAND SURVEYORS �y a PHONE. 508--362--4541 FAY 508--362-9880 i'-�q�;±,a� ' � �... H. t f 939 I71n1n fit . _yelrmouth, ma 02075 ,1D8�f ; 7r,; T. UJ.�LA, P. .lLa3^2 DATE - , tv I�K1hA1 �.Si��' SEPTIC - PROFILE_ _ TEST HOLE LOGS �. I T.O.F. AT EL. a 4..5' =----- -._--_. =_ =•- --_- __ - ^._-__- _ -F. -- (NOT TO SCALE) f-- ACCESS COVER TO WITHIN (r OF FIN. GRADE ACCESS COVER (WATERTIGHT) TO _ FNGINFFR:_ �V , :I•.? MINIMUM .75' OF COVER OVER PRECAST WITHIN Ir OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM WITNESS0 1 RUN PIPE LEVEL __ T DOUBT E J FOR FIRST 2' WASHED PE/STONE. D?' DATE: PROPOSED 1 s y -_ .. % /�� -- - ORIFICES TO PF �;13'' TO 5/8' � -'� GALLON SEPTIC ,t L2 -- �1 .'.-- { _ ! ''4q.'I PERC. RATE `` -- - • ( —_.J J -- -' �_ � ----via- _O tr$ .r }( — TANK H- 10 !I�1- �� van-.�--0-n--r-----r_—r_�_n - .�� . .� 00 00 00 00 ao 0o a o„ ° G _.._. . CLASS _ -- SOILS P �s.� S tit 9 --- s�� , � O G1 n.. 4 c1 n� Ql�n� O n n_ 'V n., _ :ff t L-------- --- ----� �, s f�_47� ► �O'LONG BY 15 'WIDE �„ SiN*;pie - — G CRUSHED STONE OR MECHANICAL COMPACTION. (15.221 [21) DEPTH OF FLOW = - - 3/4- TO 1 -1,2" DOUBLE WASHED Sit NE LP (,Z_% SLOPE) TEE SIZES: (- I_ 7: SLOPE) (- .Z SLOPE) %C i;1 �rl I F-I F'i✓f w �`' _ 50 ti SO INLET DEPTH = __. 0 LOCATION MAP 1" Z OUTLET DEPTH _-'-- Io" --�-__— - ASSESSORS MAP ��_ PARCEL FOUNDATION-- 01 - SEPTIC TANK - — l I t -- - — D' BOX LEACHING o FACILITY p �_ S ` s FLOOD ZONE I �.( I BUILDING ZONE: ._ -.-- _ SETBACKS: FRONT - j - -- SIDE - 10 C,14 �„ L�✓tG (�k '. r�f l i l►� 1 a�� b t;`C_ i REAR - F PLAN REFERENCE: __. .. :_ .Lq — �11 47, 1 \ - �` '.—._� ,��.' a b a H•ti1J I 9.l 7 L � 0 1+' --'L' "°1 0 /] f/ti/ �� I -S � i�-ttt-r.1fa.✓i -( (24.r , � ' LUI+:G. C✓ ----*-^' - .Li , G i � .4 ^ I _ SEPTIC DESIGN- D+SPOSER Is 10 — ra ( GAGE h GAR ►`J --------------- I sI _ • - BF DRQOM ti ^RC) nA GPD DESIGN FLOW 2. MUNICIPAL WA<VR IS v% L_PTfC TANK: 'bV GPD (?) _ �e , O GALLONS 3. MINIMUM PIPE_ PITCH TO BE 1/8" PER F O(-,,. ; fir_� ;_; - 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO- JSE A 6--p-P GALLON SEPTIC TANKbl \ - - il' 5. PIPE JOINTS TO BE MADE WATERTIGHT. - i_FAGH!_NC - --� 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. ENVIRONMENTAL CODE. TITI-E V. ! Zq = �33 - Gpp 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE 4 HOTTOM:__� ? �5 --_ - (-.....-) USED FOR LOT LINE STAKING. TOTAL: S.F. ��- GPD 9, PIPF FOR SEPTIC SYSTEM TO SCH. 40- 4" PVC. " • V.;�; {? - '- - - -- ' - -` "" -� 9. COMPC>NF NTH; NOT TO BE BACKFILLED OR CONCEALED WITHOUT i I-T , �� -; N * ,� �. - >"✓,_f� v•,�;r.1 :.1 . ,PZ. IrJSPECTIOrJ fTY HOARD OF HEALTH AND PERMISSION OBTAINED ROM BOARD OF HEALTH. 1-71 100.0 j PROPOSED SPOT ELEVATION 10Ux0 EXISTING SPOT ELEVATION ♦ 1+0� ♦ PROPOSED CONTOUR SITE SEWAGE PLAN OF 100 FXISTING CONTOUR i \ BOARD OF HEALTH IN THE TOWN OF: MA APPROVED DATE -------- __. ---- PRFPARFD FOR: t?r►� j FNt _ t SCALE: R_._, --`' '_ DATE: _ .c..k�c down cape engln een.ng, .III C. ,� (.0-. z_..i I- CIVIL ENGINEERS Of LAND SURVEYORS Any � PHONE 508-362--4541 H ' ? FAX 508-362-9880 �. q rT- .JOB# = -� c,l�• 0.41A, P. .IIk sm DATE ✓f� e:�ta 1 iri st . yarrn.outh, ma 02a7F, t4 es�