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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form. Inspection forms may not be altered in any way.
A. General Information �9G
1. Property Information: MAP 228—PARC 124
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21 SOUTH MAIN STREET — CENTERVILLE, MA 02632 [a i
Property Address r
MILNE, FRANCES
Owner's Name ; ;L-
21 SOUTH MAIN STREET
Owner's Address p
CP
CENTERVILLE MA 02632
t
City/Town State Zip Code
SEPTEMBER 18, 2006
Date
2. Inspector:
JAMES D. SEARS
Name of Inspector
A & B CANCO
Company Name
350 MAIN STREET
Company Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
508-775-2800
Telephone Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training
and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved
system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The System:
® Passes ® Conditionally Passes ® Fails
® Needs Further Evaluation by the ocal Approving Authority
a!2:v� LD,�
Ins 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 2
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p COMMONWEALTH OF MASSACHUSETTS
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Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. Certification (cont.)
21 SOUTH MAIN STREET
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Inspection Summary: Check A, B, C, D or E/always complete all of Section D
A) System Passes: N/A
® 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: N/A
® 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:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Not for Voluntary Assessments
�,y SJOy
Subsurface Sewage Disposal System Form
B. Certification (cont.)
21 SOUTH MAIN STREET
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
B) System Conditionally Passes (cont.): N/A
❑ 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
® 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: N/A
® 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
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
S Title 5 Official Inspection Form
9 d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
21 SOUTH MAIN STREET
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
C) Further evaluation is required by the Board of Health (cont.): N/A
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
Y 9 P
health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
® The system has a septic tank and SAS and the SAS is within a Zone 1 of a public
water supply.
® The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well'
Method used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria
indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3.Other:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
r Title 5 Official Inspection Form
9 C
Not for Voluntary Assessments
" s.e Subsurface Sewage Disposal System Form
B. Certification (cont.)
21 SOUTH MAIN STREET
Owner's Address
CENTERVILLE MA 02673
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
D) System Failure Criteria Applicable to All Systems: ./
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® 0 Backup of sewage into facility or system component due to overloaded or clogged SAS
or cesspool
® ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
® ® Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
® ® Liquid depth in cesspool is less than 6" below invert or available volume is less than
'/2 day flow
® ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped:
® ® Any portion of the SAS, cesspool or privy is below high ground surface 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.]
YES No
® The system is a cesspool serving a facility with a design flow of 2000 gpd— 10,000 gpd.
Yes No
® ® The system fails. I have determined that one or more of the above failure criteria exist
as described in 310 CMR 15.803,therefore the system fails. The system owner should
contact the Board of Health to determine what will be necessary to correct the failure.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
4 Title 5 ®fficial Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
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: N/A
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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Not for Voluntary Assessments
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Subsurface Sewage Disposal System Form
C. Checklist
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
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
® 0 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?
N/A ® 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, including 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)].
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
` Not for Voluntary Assessments
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Subsurface Sewage Disposal System Form
D. System Information
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02673
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
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: 2
Does residence have a garbage grinder? ❑ Yes ❑ NA
Is laundry on a separate sewage system?(if yes separate inspection is required] ® Yes No
Laundry system inspected? ® Yes No
Seasonal use? ® Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 2004-74,000 GAL/2005-74,000 GAL
Sum pump?
p p p � Yes IZI No �
Last date of occupancy:
Commercial/Industrial Flow Conditions: N/A
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):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 8
COMMONWEALTH OF MASSACHUSETTS
F Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02673
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
General Information
Pumping Records:
Source of Information: N/A
Was system pumped as part of the inspection? ® Yes F 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:
UNKNOWN
Were sewage odors detected when arriving at the site? ❑ Yes No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
r Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Building Sewer(locate on site plan):
Depth below grade: 1'
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:
feet
Material of construction:
concrete ® metal ® fiberglass E:] polyethylene other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) . ❑ Yes F No
Dimensions: 1000-GAL PRE CAST
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle 26"
Scum Thickness 2"
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 16"
How were dimensions determined? TAPE&SLUDGE JUDGE.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
f11M Title 5 Official Inspection Form
Not for Voluntary Assessments
4t y0�
Subsurface Sewage Disposal System Form
D. System Information (cont.)
. 21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02673
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid
levels as related to outlet invert, evidence of leakage, etc.):
TANK AT WORKING LEVEL, TANK AND COVER AT 16".
INLET AND OUTLET TEES.
MOTE: INLET COVER UNDER CEMENT SLAB.
Grease Trap (locate on site plan): N/A
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): N/A
Depth below grade:
Material of construction:
❑ concrete ® metal. ® fiberglass ® polyethylene ® other(explain)
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
A Title 5 Official Inspection Form
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Not for Voluntary Assessments
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Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES ,
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Tight or Holding Tank (cont.) N/A
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 a 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 OVER
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-BOX IS 16" X 36" —Z BELOW GRADE, ONE LINE IN —TWO LINES OUT.
BOX NO GOOD — NEEDS TO BE REPLACED.
Pump Chamber(locate on site plan): N/A
Pumps in working order: ® Yes ❑ No
Alarms in working order: ® Yes No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
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N Title 5 Official Inspection Form
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Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
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: 2
® leaching chambers number:
leaching galleries number:
® leaching trenches number, length:
® leaching fields number, dimensions:
® overflow cesspool number:
® innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)-.
LEACHING IS TWO 1000-GALLON BLOCK POOLS WITH COVERS AT 18".
LEACHING IS FULL — NEED TO REPLACE.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
a
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A
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, damp soil, condition of vegetation,
etc.):
Privy (locate on site plan): N/A
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
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!a Not for Voluntary Assessments
G� Jar
Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Sketch of Sewage Disposal System: Provide a sketch 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.
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COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to NO ground water: 12'
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:
TEST HOLE AT 12' NO WATER, TEST HOLE AT 4' BELOW BOTTOM OF LEACHING.
BOTTOM OF LEACHING AT 8' BELOW GRADE.
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection F rr%e c e i v e d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form CEP 2 7 Z006
Inspection results must be submitted on this form. Inspection forms may not be altered irl any wa g
A. General Information J Engineering&Se
urveying
1. Property Information: MAP 228—PARC 124
21 SOUTH MAIN STREET- CENTERVILLE, MA 02632
Property Address
MILNE, FRANCES C 511 LL101 1v
Owner's Name
21 SOUTH MAIN STREET
Owner's Address
.CENTERVILLE MA 02632
City/Town State Zip Code
SEPTEMBER 18, 2006
Date
2. Inspector:
JAMES D. SEARS N
Name of Inspector t_::
C7
A & B CANCO n
Company Name �: N
350 MAIN STREET
Company Address
WEST YARMOUTH MA 02673
City/Town State Zip Code m
508-775-2800
Telephone 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
s Further Evaluation by the Local Approving Authority
I ctor'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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 2
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COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
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Subsurface Sewage Disposal System Form
D. Certification (cont.)
21 SOUTH MAIN STREET
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Inspection Summary: Check A, B, C, D or E/always complete all of Section D
A) System Passes: N/A
® 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: N/A
® 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:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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COMMONWEALTH OF MASSACHUSETTS
d
Title 5 official Inspection Form
Not for Voluntary Assessments
i'1M SJev
Subsurface Sewage Disposal System Form
B. Certification (cont.)
21 SOUTH MAIN STREET
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18,.2006
Date of inspection
B) System Conditionally Passes (cont.): N/A
® Observation of sewage backup or breakout 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
® 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: N/A
® 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
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 3
COMMONWEALTH OF MASSACHUSETTS
Title 5 Official Inspection Form
'a
i'1M Syev
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
21 SOUTH MAIN STREET
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
C) Further evaluation is required by the Board of Health (cont.): N/A
2.System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public
health,safety and environment:
® The system has a septic tank and soil absorption system(SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
® The system has a septic tank and SAS and the SAS is within a Zone 1 of a public
water supply.
® The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
® The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well—
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria
indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3.Other:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 4
COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
a
Not for Voluntary Assessments
See, Subsurface Sewage Disposal System Form
B. Certification (cont.)
21 SOUTH MAIN STREET
Owner's Address
CENTERVILLE MA 02673
Cityrrown State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
D) System Failure Criteria Applicable to All Systems: ✓
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
® 0 Backup of sewage into facility or system component due to overloaded or clogged SAS
or cesspool
® ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
® ® Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
7 ® Liquid depth in cesspool is less than 6' below invert or available volume is less than
'/z 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 surface 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.]
YES No
® The system is a cesspool serving a facility with a design flow of 2000 gpd—10,000 gpd.
Yes No
® ® 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 5
COMMONWEALTH OF MASSACHUSETTS
o- Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
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: N/A
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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 6
COMMONWEALTH OF MASSACHUSETTS
F Title 5 Official Inspection Form
d
Not for Voluntary Assessments
pw Vev
Subsurface Sewage Disposal System Form
C. Checklist
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
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?
N/A ® 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, including 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)].
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 7
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02673
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
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: 2
Does residence have a garbage grinder? ❑ Yes NA
Is laundry on a separate sewage system?[if yes separate inspection is required] ® Yes No
Laundry system inspected? ® Yes No
Seasonal use? ® Yes No
Water meter readings, if available(last 2 years usage(gpd)): 2004-74,000 GAU2005-74,000 GAL
Sump pump? ® Yes ® No
Last date of occupancy:
Commercial/Industrial Flow Conditions: N/A
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):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 8
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.) .
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02673
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
General Information
Pumping Records:
Source of Information: N/A
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:
UNKNOWN
Were sewage odors detected when arriving at the site? Yes E No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 9
COMMONWEALTH OF MASSACHUSETTS
a Title 5 Official Inspection Form
d
Not for Voluntary Assessments
4j Gov
Subsurface Sewage Disposal System Form
De System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Building Sewer(locate on site plan):
Depth below grade: 1'
feet
Material of construction:
® cast iron [3 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 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-GAL PRE CAST
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle 26"
Scum Thickness 2"
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 16"
How were dimensions determined? TAPE &SLUDGE JUDGE.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 10
COMMONWEALTH OF MASSACHUSETTS
p
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02673
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid
levels as related to outlet invert, evidence of leakage, etc.):
TANK AT WORKING LEVEL, TANK AND COVER AT 16".
INLET AND OUTLET TEES.
NOTE: INLET COVER UNDER CEMENT SLAB.
Grease Trap (locate on site plan): N/A
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): N/A
Depth below grade:
Material of construction:
® concrete ® metal ® fiberglass ® polyethylene ® other(explain)
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 11
COMMONWEALTH OF MASSACHUSETTS
4 = Title 5 Official Inspection Form
a
!� Not for Voluntary Assessments
Jav
Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code.
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006
Date of inspection
Sketch of Sewage Disposal System: Provide a sketch 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.
l
I
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5
fide; )(final!rspecunr.P.+nn :>ubsurrtx St.c.i_c�'isp�s:d$.s;,:n
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
21 SOUTH MAIN STREET
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
MILNE, FRANCES
Owner's Name
SEPTEMBER 18, 2006'
Date of inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to NO ground water: 12'
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:
Cate
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:
TEST HOLE AT 12' NO WATER, TEST HOLE AT 4' BELOW BOTTOM OF LEACHING.
BOTTOM OF LEACHING AT 8' BELOW GRADE.
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Fee`✓ r�'Q�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
e Vs ,
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE MASSACHUSETTS.,
2"rication for Miopozar terry Construction Permit
Application for a Permit t rotruct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components
Location Address or Lot , {jc)4a%'Aj Owner's Name,Address and Tel.No.
GCf�`a
Assessor's Map/Parcel � 0
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow J gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank IS AtType 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 En ' ental Code and not to place the system in operation until a Certifi-
cate of Compliance h ealth.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons /
Permit No. Date Issued e GS
. F? ' " ?� i Fee
No w
r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
�'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
r
0[pplication for 33topooaf *potent Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Womplete System ❑Individual Components
Location Address or Lot I , ` IJ%Ck>42%UJ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel { "� ��, G
,,...,.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�G - °C--
Type of Building:
- Dwelling No.of Bedrooms J _--Lot Size '�,'sq.ft. id' Garbage Grinder( )
Other T e of Buildin No. of Persons s Showers( ) Cafeteria(
)
YP g
Other Fixtures
Design Flow 3 gallons per day.'Calculated daily flow �J'`4 gallons.
Plan Date Number of sheets Revision Date
Title 4
Size of Septic Tank js �`�11 5 %� Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer w en applicable) `�11�•�\
`T t fi ✓ �� t�. r _ L 17
Date last inspected: f
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 iz onmenta Code and not to place the system in operation until a Certifi-
cate of Compliance has be€n-issfii`de 'by fhis B ealth.
Signed Date
Application Approved by r Date x�'A
Application Disapproved for the following reasons
Permit No. '00W ' f Date Issued
———————————----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance � �
THIS IS TO CERTIFY, that the On Sewage Disposal System Constructed( )Repaired ( )Upgraded(✓)
Abandoned( b/y \�—G1� P
at �f7_1 yIIu y et�,W I,<W k has been'constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Pert '" *' dated '
Installer Designer "
The issuanc of this p� hall not a construed as a guarantee that the s ill functioas de tgned
Date 6 �" s 'r` Inspectof...,.
No. ,�*� -----------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS
Misspozar *pgtem Construction Verntit
Permission is hereby granted to Construct( )Repair( )Upgrad (\�andon( ) _
System located at \19 :'O'- A-Ac5 c)(9-cu /
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 must be completed within three years of the date of thi -dinit.
^�
` `~ A roved b,.
Date: pp
c �,r 1/6i99
NOTICE: This Form Is To' Be Used For the Repair Of Failed
Septic Systems Only.
CER=CATION OF SKETCH AND APPLIC 17ON FOR A DISPOSAL
WORKS CONSTRUCTION PER EIT (WITHOUT DESIGNED PLAYS)
hereby c-- ' that the application for dig w Y �Y , p postal orris
construction per signed by me dated C concerning the
property located at ` Sao V Q Cc meets all of the
following criteria: I
The failed system is conne.::ed to a residential dwelling only. There are no commercial or business
}uses associated with the dwelling.
l e soil is cl U assiued as CLASS I and the percolation rate is less than or equal to i minutes per inch.
- ere are no wetlands within 100 fer pos
:of the oroed septic system
6, /Th There are no private wets within 1J0 fee;of the oroposed septic
Th srre n
� 1- ere is no increase in flow and/or change in use proposed
There are no variances requested or needed.
• bottom of the proposed leaching faclity
i ne -will not be located less than five feet above the
ma.=um adjusted groundwater table elevation. (Adjust the zoundwater table using the Frimmor
�me hod when applicable]
If the S.A.S. will be located with? 0 fe`t of any vege aced wetlands, the boaom of the proposed
P .
leac ing facility will not be lccated!ess than touneea (1 Y) feet above [he ma dmum adjusted
zmundwater table elevation,
Please complete the following: //7
A) Too of Ground Surracz =iTvation(us�S,infannation) I
B) G.W. Elevation 'Iola .. the A-a (. �agh G.W. Adjussrtent ll (If `0
D TTERE`+CE B E i7VEEN' A and B 6/0
(Sketch proposed plan of syste-n on bac'<1.
q:health,alder. -c
�w��, � �
^. ..
v
�,
�.•.
.� _ I
J.
j TOWN OF BARNSTABLE
LOCATION SEWAGE
VILLAGE J/ c ,24. ASSESSOR'S MAP & LOTV
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) iti-t// 11/A A (size)
NO.OF BEDROOMS
Sbq6D£it OR OWNER L:,'Y t��a�,�>✓
PERMITDATE: W ;?-6�'`;ZC7 kCOMPLIANCE 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 2 ching facili Feet
Furnished by 7
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N Fns.......�11~. ........
THE COMMONWEALTH F Ts
BOARD OF HEALTH
a`�11 75 .�"-------------------
Appliration for Mipwgal Vurkg C�nnitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: Ma.L e
Sa�✓�'A !. _.....11�t........b/_�n l 5------• ..................................................................................................
Location-A dr ss or Lot No.
---------------------------& 1. l;�..... ._.... 1 � �q� c, s z .:,Axs
Owner Address
l ® .......c�!sL. -•• IN k ....
Installer Address
UType of Building Size Lot___________________________S q. feet
Dwelling—No. of Bedrooms_______ ________________________________Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures _______________________________ __
Q _ z-�i/--.....
�---------•lions.
W Design Flow........................15... _.._....gallons per person per day. Total daily flow------------(....7._............_........_ga
WSeptic Tank— iquid capacity/.a,,`;Jallons Length................ Width----------------- Diameter_............. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...........:......... Diameter----_............... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................
-----------------------------------•----•---------------------------------.................................................................................
0 Description of Soil.........................................................................................._- .--••--------------•-•-------------------------••-•--••-----------•-•----.
x
V ....------•---•-....---•--•--------------•-••--•-----•--•------•-------•-•---•••-•-----------•--•••---•---------------•••-•----------•----------••---•--•-----------------------•....-••-•-------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable._/T4�/0,..-!9..� _' .eAiv Na:...�.y�!w�
W__Cr.*..../112. v...45_Azn.... 1e-X-s�-- ` -k POD 4 .........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T y g g p y
5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasgbssu�eed by t and of health.
Si e . ---...-••----------------•-.•-•--- ����� ••.
--
Date
Pa
Application Approved By----•-.. . -- :. --------------------------- ..... .....h^..
Date
Application Disapproved for the'f ollowing reasons:_
-----•....................••......•..•----•-•----......--•-••.................------•----_ •---...-••--
------------------------------------------------------------------------------------------------------•---------------------•--•-------•----•-----•----------------------•-----....-----•---••----------
Date
Permit No......................................................= .....,._.. Issued.................... ............................
Date
N .l.. G! Fes$.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�+
Appliration for BiopooFal Workfi Tomdrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
0-SAP&D-DAD.....4R_P .......AMA Y ....... .......... ----- --- . -------. ........ --------- -----
Location A d s or Lot No.
y Orwwn�er ��l (� �/�'�"�fjAddrfs��
W r; � i��...... I'�'r!-•----_____---•---------------•------•- �"�� i��F-*. 'T�IId�?"^__
Installer Address
Type of Building Size Lot......_.....................Sq. feet
U Dwelling—No. of Bedrooms.__________________ ___Expansion Attic ( ) Garbage Grinder ( )
PLI4 Other—T e of Building No. of persons____________________________ Showers Cafeteria
dOther fixtures[_....._..---••--•-•-------__-•-- �+
W Design Flow........................V__.f�_.___� gallons per person per day. Total daily flow.............
._ ....................gallons.
WSeptic Tank��iquid capacity/,'f* Mons Length................ Width................ Diameter---_------------ Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length.............._..... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter............._...... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------------------__---
(s, Test Pit No. 2................minutes per inch Depth-of.,Test Pit .-. Depth to ground water_:......................
__________________________________________________________________r........................................................................................
ODescription of Soil........................................................................................................................................................................
-- ----- --- ------•------------
- ---------- ---- ---- ---
U Nature of Repairs or Alterations Answer when a licable rAUM __' _VX
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i I T I_.:" 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b ssued by t al d of health
--- ... -•-
Date�+t
Application Approved By...... -•--- ! 'I* /�••---•--------------------- ---- --- ----D.- .
Date
Application Disapproved for the following reasons.-------•------------------•---•-------------------•-----------------------••-•-----------------------------••--
----------------------------•-•••-•----•--•----•------••------------------•-----•._......._..•--•--------I---•-•---••----••---•••--•-.__--------•--•-••-••••••-•-•-------------•-----••---•-••-------•---
Date
PermitNo.......................................................... Issued-...................................:...................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........oF.. ./ �'" � ...........................
WOW-
Trrfifira tr of T oiaitph aurr
TV IS ADS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ".. ... " --------------------------------•..---- ................--------------...............................................................................
fn a ................................................. �.
has been installed in accordance with the provisions of 5 of The State Sanitary Code as descr be in the
application for Disposal Works Construction Permit No .__ ______._./_�.11........... dated .'. ". -----------------'..........
THE ISSUANCE OF THIS CERTIFICATE`SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL UNCTION SATISFACTORY.
DATE............. ` j` �� .................................. Inspector...--- C/ ----------------...---------........._
THE COMMONWEALTH OF MASSACHUSETTS
-BOARD OF HEALTH
......... .....0F.. ": i ' ....................... FEE......
Diopooa1 10orkii Tonotrudion .rrotit
Permission is hereby granted..z) !- .----- 4 r -------------------------- ...............................................................
to Construct (. or Re air ( an Individual Sewn e is osal Sy tem
Street ��f/
as shown on the application for Disposal Works ConstructionAP * No. _. .�__ Dated____ .:_) .......................w
-•-------------------------------
--------
DATE........-------- .........................................
Board of Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS -