HomeMy WebLinkAbout0057 STAGE COACH ROAD - Health 57 STAGE COACH RD., CENTRVILLE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. Cityrrown State Zip Code Date of Inspection t
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information �l /�/Il�lP
filling out forms
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-donot S.M.Jones Title V Septic Inspection
use the return Company Name
key.
Lane
w Company
Address
Centerville Ma 02632
Cityrrown State Zip Code
774-248-4850 smjonestitle5@gmail.com, S14522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 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
9/24/2019
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
_ p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,A;0
u 57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. Cityrrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The property located at 57 Stage Coach Rd Centerville is served by a Title V septic system consisting
of a 1000 gallon septic tank and 2 1000 gallon precast leach pits in series. The system was found to
be in proper working condition at the time of inspection.
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/20,19
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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 18
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4"
t,
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. Citylrown 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.7/26/2018 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
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is Centerville Ma' 02632 9/24/2019
required for every
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 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El ® 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
l5insp.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
4�
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma , 02632 9/24/2019
page. Cityfrown 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
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
fill Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. City/Town 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 gpd
Description:
Number of current residents: 0
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: vacant/unknown
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
e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
57 Stage Coach Road
v --
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
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 below): -
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. City(Town 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):
Precast septic tank and 2 precast leach pits in series
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
5. Building Sewer(locate on site plan):
Depth below grade: 3
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.):
Joints in good condition, no leakage, vented through roof.
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
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2.5feet
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 gallons
Sludge depth:
5"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness 211
Distance from top of scum to top of outlet tee or baffle 7"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Opened covers and took
measurements
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 does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. Water level was even with outlet, tank was not leaking and was structurally sound.
Inlet and outlet covers are on risers.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: -Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Stage Coach Road
u
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. City/Town 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.):
* 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:
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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is Centerville Ma 02632 9/24/2019
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
s.a.s. consists of 2 precast leach pits in series. The first pit was found with standing water 1.5' below
outlet invert and a stain line even with outlet. Second pit was found dry with stain lines approx 4' from
bottom. Second pit has riser.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 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
.� 57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is Centerville Ma 02632 9/24/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�o Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
v 57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
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
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
page. Cityrrown 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: 12'+feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 57 Stage Coach Road
Property Address
Avelino Carolino
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2019
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 4 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 depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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P11
COMMONWEALTH OF MASACHUSETTS 1
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Address of Owner: 40 HARLON ST.MANCHESTER CONN 06040
Date of Inspection: 2/25/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Company Name: TITLE V SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET MA.02636
Telephone Number: 508-664-6813
CERTIFICATION STATEMENT
I certify that I have personalty inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:70D
The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.if the system Is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection Is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
inspection does not Imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.THE SEPTIC TANK AND ONE LEACH PIT NEEDS TO BE PUMPED NOW AND THE SYSTEM SHOULD
BE MAINTAINED EVERY TWO YEAR.
revised 9/2I98 Page 1 of 11 +
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Date of Inspection: 2/25/00
INSPECTION SUMMARY: Check A, 6, C, or D:
A. SYSTEM PASSES:
X I have not found any information which Indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
n1a The septic tank Is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance
attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the inspection;or the septic tank,
whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The
system will pass inspection if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health.
Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due
to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction is removed
_distribution box Is levelled or replaced
Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if
(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Date of Inspection: 2/26/00
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health In order to determine if the system Is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less
than 5 ppm,Method used to determine distance n1a(approximation not valid).
3) OTHER
n/a
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Date of Inspection: 2125/00
D. SYSTEM FAILS:
You must indicate either`Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
Identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
- X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
- X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
- X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
- X Liquid depth in cesspool Is less than 6"below invert or available volume is less than 1/2 day flow,
- X ,Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Il.
_ X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
- X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
- X Any portion of a cesspool or privy is within a Zone I of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy Is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,
ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either'Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
- X the system is within 400 feet of a surface drinking water.supply
- X the system is within 200 feet of a tributary to a surface drinking water supply
- X the system is located Ina nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 67 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 46 02632
Name of Owner: ERNEST SQUATRITO
Date of Inspection: 2/26/00
Check If the following have been done:You must Indicate either"Yes"or"No"as to each of the following:
Yes No
X - Pumping Information was provided by the owner,occupant,or Board of Health.
X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.
Large volumes of water have not been Introduced Into the system recently or as part of this inspection.
X - As built plans have been obtained and examined.Note if they are not available with N/A.
X _ The facility or dwelling was Inspected for signs of sewage back-up.
X - The system does not receive non-sanitary or industrial waste flow.
X - The site was inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X - The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of
construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been
determined based on:
X _ Existing Information,For example,Plan at B4O,H,
X _ Determined in the field(if any the failure criteria related to Part C Is at Issue,approximation of distance is unacceptable)1 5.302(3)(b))
X _ The facility owner(and occupants,If different from owner)were provided with Information on the proper maintenance of SubSurface Disposal
Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Date of Inspection: 2126100
FLOW CONDITIONS
RF_S113F_NTIAL:
Design now: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):
Total DESIGN now: 330 gpd
Number of current residents:2
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or.no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
THE SYSTEM HAS NOT BEEN PUMPED IN THE LAST YEAR. ,
System pumped as part of inspection:(yes or no);W
If yes,volume pumped n/a gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Ply
_ Shared system(yes or no)(if yes.attach previous Inspection records,if any)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1976 WITH A NEW PIT IN 1996 PERMIT 96--692
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
. 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Date of Inspection: 2126/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 30"
Material of construction: cast iron _ 40 Pvc X other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
THE SEWER IS 20 PVC;THERE IS TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 24"
Material of construction: X concrete_ metal_,Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: L 8'6"H 6'7"W 4'10
Sludge depth: 16"
Distance from top of sludge to bottom of outlet tee or baffle: 18"
Scum thickness: 12"
a_ Distance from top of scum to top of outlet tee or baffle: 0"
Distance from bottom of scum to bottom of outlet tee or baffle: 0"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.THE SEPTIC TANK NEEDS TO BE PUMPED NOW,AND MAINTAINED
EVERY TWO YEARS.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
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
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
nla
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Date of Inspection: 2/25/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: Na gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm In working order:NO
Date of previous pumping: n/a
Comments:
(condition of Inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution Is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Date of Inspection: 2125100
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,If possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(2)1000 GAL G X 6
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Aftemative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PITS APPEARS TO BE FUNCTIONING PROPERLY..SYSTEM SHOWS NO SIGNS OF FAILURE.ONE PIT WAS 1/2 FULL AND HAS NOT
HAD MORE THAN THAT IN IT.THE OTHER PIT HAD SOLID IN IT AND NEEDS TO BE PUMPED.
CESSPOOLS: _
(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: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla
PRIVY:
(locate on site plan)
Materials of construction: n1a 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
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Date of Inspection: 2/26/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
RT
PeC�
A M
�6 38
r AC49
as
36
e ac
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 57 STAGE COACH RD. CENTERVILLE, MA MAP 173 P 45 02632
Name of Owner ERNEST SQUATRITO
Date of Inspection: 2/26100
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
_ Checked with local Board of health
Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
UGSS MAPS AND CHARTS-10+FEET
revised 9/2/98 Page 11 of 11
3768
PROMPT HICKEY SEPTIC SERVICE ,-BPHONE DATE OF ORDER
PROFESSIONAL P.O. Box 2078 4976 0 2/2 9/0 0
SERVICE TEATICKET, MA 02536 JOB NAME LOCATION
57 Stage Coach Road
(508) 790-4888 (508) 540.7650 Centerville, MA 0 2 6 32
FAX (508) 540.3097
TO Realty Executives
........................................................................................................................................................................................................................................................ ......................................... .. ..... ...
PHONE
P.O. BOX 173'
...... __..
ORDER TAKEN BY
Centerville , MA 02632
TERMS: PAYMENT DUE WITHIN 7 DAYS OF SERVICE
DESCRIPTION AMOUNT
Title 5 pumping 6P_3S
.... . ..I._. . . ....... ......... .. ...........
.................................. _ _. . ................................... .. .a.1.1.o.n.s _
..................................................................................................................
pp t� ` g
...... _.
A rox &V
_.. ..
r_
........... 7�i�
pump...._tank....._&.......pit..._..........._........................_....................................... ..........'`........' \...._.._ ... .... . .. _- .
e.nd.. of, _road.....last lzou_se..on_ 1ef_t .. ..._
...not...exposed
left markers-where.. t.anlc...A S .,
...........__I......_............... ..__.... ........_......._...._..............................................__.................................................._ .._...... ............_
LABOR HOURS RATE AMOUNT TOTAL MATERIAL
TOTALLABOR
WORK ORDERED BY DATE COMPLETED TOTAL
LABOR TAX
PAY THIS AMOUNT-I-
Thank`YOU
SIGNATURE(I hereby acknowledge the satisfactory
completion of the above described work.)
,41,� TOWN OF BARNSTABLE
LOQ rrmON S,9 e, �� °# ��• SEWAGE # ! `�
VILLAGE a" ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)/®po / � (sue)
NO. OF BEDROOMS S .PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER-
DATE DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
4
4
I
7y,
i /
t
f
3z / So 3�Fr
ASSESSORS MAP
NO-
.............No.
F: ....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Ui!,pw tl Work.6 Cnnnitrnrtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
• ( ?'4 f L_� a7 -----------••- -----ee."l �/�/- .......................................................
Location-Address or Lot No.
'U"rr,01 eih-------------------------------------------------
,Q/�/� Owner Address
...................
�/..f_'_!!. ......................................................... -•----............................. -_...-----•------..........................
Installer Address
UType of Building Size Lot............................Sq. feet
t•� Dwelling— No. of Bedrooms.........3..________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons...........----------------- Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------------------- -------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
R' Septic Tank—Liquid capacity........___gallons Length---------------- Width_______._.-____. Diameter................ Depth................
Disposal Trench--No. .................... Width.................... .Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter._. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
�-' Percolation Test Results Performed by. ---•---------------•----- Date.
a
Test Pit No. 1................minutes per Inch Depth of Test Pit.................... Depth to ground water........................
Lz, Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water.............._.........
O. ----------------------------------------•--•--------------------•-•-----•---.....-•------------.........----.................-----------••-----......--...--.
Descriptionof Soil--- --------••----••-------------------•---------------•----.........--------...--------.----------------...--------------------------------.......-------••.......•----
x
w _
x --------------------------------------------------------------------------- -- ...
U Nature.of Repairs Alterations—Answer when a licable.__ /7.�1��9_ _ _-._-._r`...,�__�._../aaa_...���...�
r ,[� -e�-n -----------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by t e oard of health.
Signed ...... ....... .......t
..... _........ ......�-.-�.)..°-.....-
.c.s
Da
Application Approved By ----..- .. ... ---- --- ---------------
Application Disapproved for the following reasons: ....................
........... ............................................. ............................ ........................................
Permit No. ..... Issued --_--" '-..' . !'` �7� ...-..
Daze
No.. �l ' 1 �� .� FRs..... ...
THE COMMONWEALTH OF MASSACHUSETTS
It
'\ .. BOARD OF HEALTH
J TOWN OF BARNSTABLE
Appliration for Di►ipniu1 Works Tonstrnrttun rrrntit
Application is.hereby made for a Permit,to.Construct ( ) or Repair ( 6,)n Individual Sewage Disposal
System at: ,r 3 r' r_
fie S �? C.f� ��GF � '/✓% (Q_.............•--...-----------•---
...... ----•-• ....---. ---_---• ---- •----•--....-- ••. ..._--•.....----
. Location-Address or Lot No.
....... tot.A1 `.!... -------------------- ----•--------•--..................
Address
� Installer Address
K Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms.........��•--------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ---------------------"-----•---------.......------..................................................................................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.__._--__..-gallons Length________________ Width-:----------_:- Diameter—........:.... Depth................
x Disposal Trench-- No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................ Date........................................
j Test Pit No. 1--------------"minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs, Test Pit No. 2.........:......minutes per inch Depth of Test Pit.................... Depth to ground water........................
ODescription of Soil..........................................................................................................................................................................
U Nature,of Repairs or Alterations—Answer when a licable.-.-�L-_/�,fZw—/ .......e- •,1___C�.15� Z�..._
P PP
r
- .rx�------- � .. .-'�s?� -9-----_-:z�<<'� ------
.,. Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by t e board of health.
1� �
Signed ........................_`l .�. ........ .:......... ..........�.....�.7
Date
.Application Approved By ...:. --� �rtz,< /'.. .... /1..... �'.. • � �"""
--- -------- --
..............................
i -^ Dare
Applica ion Disapproved for the following reasons: ....................................................
...... ............................ ............. ...+C/. ..................... ....._.... ....... . ............. ........ ....................
Y �Gr Dare_,....._.
Permit No. l.. .`r«.�....~........... Issued -- .' `" .
" - -------._.-- •—.._.--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifirate of Complianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
' by ........................................................ ---------------------------------------------- ----
at ........S57... ...:; .._ ...... -�-t
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No.'.f� ��``� .. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 6E CONSTRU X►S A GUARANTEE THAT THE
,SYSTEM WILLF,NCTION SATISFACTORY
DATE_.................._._..- .-G� ..... ...... Inspect r - ... -
F
__ -------_._-----_.__----____—---—---..._ _—__—_—__--__—___—__,—______
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No• �„ TOWN OF BARNSTABLE FEE....... ............
Disposal Disposal Works Tonstrudion Wrufit
Permission is hereby granted--.-4e...................... �rt�
f to Construct ( ) or_Repair (,/�an Individual Sewage Disposal System
atNo.•-...'F -...... U' �� ------ --- ---- ?'-4.......................... -- -----------------------------------------------------
Strcct'�
as shown on the application for Disposal Works Construction PermiVfl. ated_5_7_9 - Z
Boa
Board of Health
„y! �•--r—y `-�
DATE------. ---•- ..........•' ` -•••..............•__
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
�/6 O ld d
1
No...... �/. . Fick .. ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ...........OF..................................... ........................
Appliration -for 11-4poiittl Workii Towi#rurtion Prrulit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
RL
. --:- - -29-- ..... pw -•----------------- -----------------
at- n- dress _ a
Owner Ad re
a � .�-.---_�.' . - .---------------------------------- �..�t ,� ham_—��..�� `'��`�—
Installer
ess
UType of Building Size Lot_:�,6a.1 �1- _.____Sq. feet
Dwelling—No. of Bedrooms.................
.3 .....Expansion Attic ( ) Garbage Grinder ( )
.a Other—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------•---•---------------------•-----------------------:. .
d -------=------
W Design Flow_____________-5.0---------------------gallons per person per day. Total daily flow-__-__-____________--.-_---_...-......_._:._gallons.
WSeptic Tank—Liquid capacity-1-007s_gallons Length----_---------- Width-.--___-._.--_ Diameter_ _ . eptll---____-__---.-
x Disposal Trench—No. .-................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..--_............... Diameter-----4--- .....
Deptli below inlet---W....----- Total leaching-area sq. ft.
z Other Distribution box ( ) Dosing tank ( ) d b R C d- - 12 a �Z ,- 1�(, I I -
Percolation Test Results Performed by-------------------------------------------------------------------------- Date.............
,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit____________________ Depth to ground water...,--_--__-..--.--.__
fT Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water.___.'::_,_--_--__------
----------
Descri Description of Soil. L� �.� � ? ri
��'�
x p _ _ ` ti - --------------------
-----------; : ,// ,�, b 'jJI /
.......(�.--------- _......
`..1: _------•-"'�N----`1'l__Gw�sfb!�_._--- _-----.._..
M ---------•------- - -------._-_----------------�--•-----------,---------..--.--------.------------------------.- .
V Nature of Repairs or Alterations—Answer when applicable....................._--..-.____.-._--____-.---_---.__-_-_.____---__------._...._-___.__-.:----.
-••-------------------------------•--------------------•--•--•--------------------•-•----------------------------------------------------------•------------------------..-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by
the board of health.
Sign ---- • -- --• --•--•--
Date_
Application Approved BY - � f*! � .-.. 1.�. '� ------
Date
Application Disapproved for the following reasons------------------------=------------------•------------•------------•---•---------------•----•----------_.....
--------------------------------------------------------------------------------------------------------•..----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........-...............................................
Date
No......,,dj w F�s..... f?..
THE COMMONWEALTH OF.MASSACHUSETTS
BOARD OF HEALTH
OF.
t
A•,ppfiration -for Disposal Works Tonstratrtioat Vantit
Application is hereby made for a Permit to Construct ( ) or..Repair ( ) an Individual Sewage Disposal
f, System at: f`
dress itr �J N.
Owner Ad ess
W 17-
Installer Address
U Type of Building Size Lot---110.- _Q(7_% __ Sq. feet
Dwelling—No. of Bedrooms--------;:..._.... __---__-Expansion Attic ( ) Garage Grinder ( )
p, Other—Type of Building ---------------------------- No. of persons____-_-__._--_-___-__-_- Showers ( ) — Cafeteria ( )
a' Other fixtures
_---------------
W Design Flow................S-Q----_-_--___-••--gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.-1004gallons Length................ Width................ Diameter................ Depth--------........
x Disposal"Trench—No--------------------- Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter-------(r---------- Depth below inlet...:...........Total leaching area-..-------------- ft.
z Other Distribution box ( ) Dosing tank ( ) l���bt �/
o b 1st- z �-7
a Percolation Test Results Performed by--------- ------_-------------------- ................................ Date---------------------------------------
a Test Pit No. 1................minutes per inch Depth of Test Pit_---_-___;__--__-._- Depth to ground water_..--------_---.__.--...
G Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
--------------------------------... ---------------------------------...._..--•-=-•---------
--------------
DDescription of Soil__.,. df ---------------- --------------------------------
x -
'Vf'
W .........� � .�.� �.. = r � �/ - -•----,tiri�Q-'.�....-•--•------
- ___________________________ _ __ ______ ______ __ _ _ _ ___ _Y_._�r-_
W
Nature of Repairs or Altera ion ""Ai�wer w en;a licable.------------ -------- ------------------------------------------------
Y _ --- =--------------------------------------------------------- - ----------------- ----------------------- - ----------------------------------------------...._..-_._.
Agreement
The"undersigned•agrees to install the afbredescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate.of Compliance has been issued by the board of health.
Signed.............................---------•--------------------------------- --.-.
Application Approved` By._ I ....................... Date
---- -- ----- ---•----•- •--
r , ' Dat�-/ -
Application Disapproved for the following reasons: ...............................:
Date
PermitNo..:::......-........................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHU SETTS
BOARD OF HEALTH
a- : : O F.
�. ..... ......
ertifiratr of V%M/,ittatrr F
�
T IS_ TO CER"lIF. Y;;`That the Individual Sewage Disposal System constructed (L„�OOr Repaired ( )
by ..........................--••---- ----------•--•--••--•---------•-•---•-•••-•--••-..........--------• -•--•-•-••••-•-••-•---
In
at _.... .- .-;C Gr��� ��.. .. '
has been installed in acc�dance wjth the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No-------- +—............. dated..,. .........
THE ISSUANCE OF THIS (CERTIFICATE SHALT. PI T BE CONSTRUED AS A GUARAPITEE TFI T THE
"i SYSTEM W 'FUNC=N SATISF�ORY,:a�
DATE------ ----_.•'- ---•�•-• ...... •:•... ......:... Inspector..
THE COMMONWEALTH OF MASSAC TS
4.
BOARD OF EALTH
,.: ..... OF........... --.w...............:... ...
•
No. --/--j -• FEE_ ..
5 t oo or omitrurtivit Urrmit
Permission is hereby granted-_ t . -•-• . y « ............... ......
to Construct (k<or Repair ) an Individual Sewag isposa yste
at N� .....
•------------------------------------------•----
� treet
as show on'.the application for isposal Works Construction Permit No..:.................. Dated.
*.
r' 'K ` = ............-
i �.. r
x
DATE----- ------------------------------------------------------ (!(/
FORM 1255 HOBBS 11, WARREN. INC. PUBLISHERS
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L. C LET I O t�l �'40�'54&V/J, E P F- 1.1 O.
VILLAGE — — — — —
IW57aLL R•S 1 WE ADDRESS
5ULI DER 5 /f\1hM ADDRESS
DL.TE PERMIT 155UED
_D ATE_COMP_LI W ACE ISSUEQ -
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