HomeMy WebLinkAbout0094 THOREAU DRIVE - Health 94 THOREAU DR
Centerville
A = 191 - 188
S M E AD®
KEEPING YOU ORGANIZED
No. 12534
2-153LOR
OSU&AIN
MIN.RECYCLED
INMATNE CONTENTtOYo
CertmeeRbersourcing POST-CONSUMER
wwwsfiprogrmurg
sF ino
MADE W USA
GET ORGANIZED AT SMEAD.COM
I
No. � ' ® Fee l
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplitation for DispoBal .pstem Construction Permit
Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. �'�cs..�, 1',Y�- Owner's Name,Address,and Tel.No._j�`;
Assessor's p�al ^E'�C t- «!\
Instaaller's Name,Address,and 1.No. � G���2�n) Designer's Name,Address,and Tel.No. I.X%
� i�✓� y ra�►e R. �.
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(min.re uired) 2010 gpd Design flow provided 3 gpd
Plan Date 7 1 0 Number of sheets 2— Revision Date
Title
Size of Septic Tank se-in" n Type of S.A.S.(2_N_J�c R
Description of Soil "Z-L-
Nature of Repairs or Alterations(Answer when applicable) dl�;�ryg¢� �r� g, k�
S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintena the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Co nd not to place the system in operation until a Certificate of
Compliance has been issued by this Board He lth
Signed Date nl 10,7 14 1
Application Approved by f - Date
Application Disapproved by Date
for the following reasons
Permit No. ® P Date Issued � 0
L-- -------_��_�_ - - - _- ----------- --
f
TOWN OF BARNSTABLE
LOCATION ,� � D� SEWAGE# ZQ`0 -LASS
VILLAGE Ce i_e ASSESSOR'S MAP&PARCEL ��11
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY c
LEACHING FACILITY.(type Svq 4646ft (size)
NO.OF BEDROOMS c�qA*P-cT
OWNER rr� I rtG
PERMIT DATE: .00AVI Z01A COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
t
" '3mc `" -.
D3 _ � e�
No. )-C) 1 O Fee
THE COMMONWEALTH OFjMASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplication for aispoBal 6pBtrut Construction permit
Application for a Permit to Construct(<Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.4�kf 'W p C F-M-A, Owner's Name,Address,and Tel.No_f::-r:,- �� e,A ►� s
t.Cns�r.iw.C, ct ll Z
Assessor's Map/Parcel 0k leg 4 ��� �J�J"L C e A,L.
Installer's Name,Address,and Al.No. } L- f-6,v� Designer's Name,Address,and Tel.No. Mk (:et��,. ��-
aeye:tr �.n st ;�• (gV, itse- S.rref yr` and Sw�✓c loth ke 21? t,,J. y rf+;
rs'.r ens A 4�o�P 1 -A ..
Type of Building:
Dwelling No.of Bedrooms Lot Size Z sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 220 gpd Design flow provided �}� gpd
Plan Date 071 O Z n) R Number of sheets �- Revision Date
Title
1 -
j Size of Septic Tank �.��y e;r" O Type of S.A.S.
Description of Soil s{..C. ` y
i
Nature of Repairs or Alterations(Answer when applicable) C OA ,- w E t%V
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintennaan' d tf�fore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Co • anew"d not to place the system in operation until a Certificate of
Compliance has been issued by this Board o �He iadth/�
Signed /t/v Date � ! 0� 10 )_0
Application Approved by t�• . S Date 7--
Application Disapproved by Date
for the following reasons
Permit No. 0 0 y 7 Date Issued '" y
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( NJA�Repaired( ) Upgraded( )
Abandoned( )by n Lt `y,q
at O has been constructed in accor ace
with the pro isio`ns of Title
,5 ..d-the-for Disposal System Construction Permit No. �Q V 5dated
Installer V/ k__�fT__- Designer �'tc (_Ct (_ {� Q t�LCt✓C,1
#bedrooms , Approved design flow " L C� gpd
The issuance of this permit sh �1 not ercon�sttrued as a guarantee that the system ill function a esigntd.
Date � C7�� Inspector
i
--------------------------------------------------------------------F� ------------------------------------Fee---------
� 0_V
.-- No. 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS--
�. Nsposal *p$tem Construction 3permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) / Abandon( )
System located at C_ V 1
i and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 this permit. �^
Dates a Approved by `
Town of Barnstable
Inspectional Services
•
Public Health Division
11ARMAat.e,
" Thomas McKean,Director
a ° 200 Main Street,Hyannis,Na 02601
6 Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
70
Date: Se age PermiW241 °`205- Assessor's MapTarcel
Designer: Jri 9 Ji`. Installer:. c� � ey,�
n
Address: A Address: w rvir-
f
S
1
On��—� C& was issued a permit to install a
k ( a {nstal er)
6 rep-Q VN V'-( based on a design drawn b
septic system at g y
n (address)
dated 0
(designer)
I certifythat the septic s stem.referenced above was installed substantially according to
P y
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory"
system:referenced above was installed with major changes i.e.
I certify that the septic sys � ges
greater than 10' lateral relocation of the SAS or any vertical:relocation of any component
of the septic system) but in.accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed ce with the terms of
the RA approva npplical le)
Afistailis Signature)
Lt"411) 74
a
(Designers Si atur,') (Affix Designers Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC.HEALTH DIVISION. CERTIFICATE
OF •COMPLIANCE `WILL NOT BE ISSUED UNTIL 'BOTH THIS FORM AND AS
BUILT CARD ARE RECEIVED:BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
VtoWeptslHEAU MSEWERoonnec6SEPTICOesiperCertification Form Rev 8.14-I3.DOC
Town of Barnstable
+ IARNSfABLE,
6 A Inspectional Services Department
Public Health Division
i 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
O 1 YEAR DEADLINE CRITERIA
tatic liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool
❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation
❑ A portion of the cesspool is located within a Zone 1 to a public well
❑ A portion of the cesspool is located within 50 feet of a private water supply well
with no acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
i
Commonwealth of Massachusetts l9f 496 /GrL�t
r� ,2
Title 5 Official Inspection Form
rr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r a
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is
required for every Centerville MA 02632 6-22-20
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l 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 theproperty 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
6-22-20
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
,jij Title 5 Official Inspection Form
w:.
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6=22-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System,Passes:
❑ 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:
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
,w; Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11.7
94 Thoreau Dr
v"JJ
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
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 ON ❑ ND (Explain below):
❑ obstruction is removed ❑ Y El ❑ ND (Explain below):
❑ distribution box is leveled or replaced El ❑ 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):
r
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
r� 'Ni Title 5 official Inspection Form
Ni Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
> "a•
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
page. Cityfrown 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
i
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
'1 ii Subsurface sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
page. City/Town 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 '/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 water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
a ,3 Title 5 Official Inspection Form
'► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
-'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
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 flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 6-2020
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
w_
'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
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:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If es volume pumped:y p p 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
f
4 ` Commonwealth of Massachusetts
,; Title 5 Official Inspection Form
M► Subsurface sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
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):
Approximate age of all components, date installed (if known) and source of information:
Tank and d-box 2017 with leach pit from 1980's.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
"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
C�'i. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign leakage.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 10 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, i
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
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
r� Title 5 Official Inspection Form
,�r�
w:
ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
page. City/Town 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
1"
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 had water level 1" above outlet invert.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
r� ,w Title 5 Official Inspection Form
Ill Subsurface sewage Disposal System Form -Not for Voluntary Assessments
._. ,> 94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
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: 1-1000 gal
❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�Ni Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r U <,
� ? 94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
page. City/Town 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.):
Leach pit was filled to capacity with water level above the inlet pipe.
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
i
Commonwealth of Massachusetts
;,. Title 5 Official Inspection Form
ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:- tll • 94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
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
I�i•
Title 5 Official Inspection Form
w.
�1�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�is_ ;> 94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
page. City/Town 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
CIS ¢
•
a v
ty
45 •t �- �r
LI)
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
crl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r a
jc
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
page. City/Town 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: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
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
i
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Thoreau Dr
Property Address
Erica Kuenzel
Owner Owner's Name
information is required for every Centerville MA 02632 6-22-20
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
No. �J/ Q r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ye
PUBLIC HEALTH DIVISION - TOWN'OF BARNSTABLE, MASSACHUSETTS
Appfitation for Misposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System L91,diidual Components
Location Address or Lot No. c(C'� V�OJ� �C�'p Owner's Name,Address,and Tel.No.S�`Yz'$�9 707
(`�M
Assessor's Map/Parcel �
Installer's Name,Address,and Tel.No. S-?)V-'eS'F-Q5._<SJ Designer's Name,Address,and Tel.No...,
O
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(min.required) gpd Design flow provided AJJJgpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signe Date
Application Approved by Date /g l�
Application Disapproved by Date
for the following reasons
Permit No. / Date Issued
i�g...
No. �J I�� Fee Q
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye
ftpllcatlon for Disposal *pstem Construction Vermit
y Application for a Permit to Construct( ) Repair(vr Upgrade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No. �-( �` \t<p,T- f 1, Owner's Name,Address,and Tel.No.5b7 Ye-rr-9 7p,r
Assessor's Map/Parcel ` 7
r Q"
Installer's Name,Address,and Tel. o. Designer's Name,Address,and Tel.No.
Type of Building: J
Dwelling No.of Bedrooms 'VI 1A Lot Size sq.8. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures "
Design Flow(min.required) gpd Design flow provided A gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil f
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signe Date
r
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 29 / 7 — 0 j Date Issued
---------------------- ---------------------------------------------------------------------------------------------------------------
�, Ir
THE COMMONWEALTH OF MASSACHUSETTS
S � ` �� BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by at
i. cS:f' �.� U has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NQZ�P/? <<j dated 3�� l
Installer Designer
#bedrooms Approved design flow �J , A gpd
The issuance of his permit shall not be construed as a guarantee that the system will-fun Dr as designed.
Date I Inspector 1.�,✓ p� P Q
--------------------------------------
No. / d/ / —r_ 5 1 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
3Disposal bpstem ConstrUrtion Permit
Permission is hereby granted to Construct( ) Repair(.� Upgrade( ) Abandon( )
System located at �'� —7 ACn(--C7-A (J
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be/co npleted within three years of the date of this p it.
Date / L1 / L7 Approved by
L
j1KE Town of Barnstable Barnstable
Regulatory Services Department i e'caC j
BARN STABM
639. Public Health Division
DµAtA 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4991 0019
February 22, 2017
Edgar R& Dorothy L Tucker
94 Thoreau Drive
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 94 Thoreau Drive, Centerville,MA was inspected on
02/14/2017 by Matthew Gilfoy, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Septic tank is leaking.
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
��fa:sMcKean, R.S., CH
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\94 Thoreau Drive Centerville.doc
`. Town of Barnstable
6 9. ,��� Regulatory Services Department
Ufa�
Public Health Division
200 Main Street, Hyannis MA'02601
Office: 508-8624644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
h
DEADLINES TO'REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15,000)
An"x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground w ..
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code
§360-9.1)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER l
Repair deadline: ljQc.J f
Q:ISEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
L Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.-,i
;M 94 Thoreau Drive M
co
Property Address
Dorothy Tucker
Owner Owner's Name
information is
required for every Centerville ✓ Ma 02632 2-14-17
page. City/Town State Zip Code Date of Inspection li"
CA
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information C/
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Matthew Gilfoy
use the return Name of Inspector
key.
B&B Excavation
r� Company Name
374 Route 130
Company Address
Sandwich Ma 02563
CityFrown State Zip Code
(508)477-0653 S113640
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2-14-17
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 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.
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
�o �S 1D�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
® Y ❑ N ❑ ND (Explain below):
Upon inspection the septic tank was only half full showing that the tank is leaking. The tank will need
to be replaced.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (Actual) _2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 300
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See below
9 ( Y 9 (gp ))�
Detail:
2014-30,000gallons 2015-30,000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: 4 monthsDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
IL
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Date of last pump unknown
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, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is Centerville Ma 02632 2-14-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Permit 10-16-75
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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. Town
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2
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:
1000gallons
Sludge depth:
7"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 2
Distance from top of scum to top of outlet tee or baffle Tank is leaking
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Measured
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 was only half full at time of inspection showing that the tank is leaking. Tank will need to be
replaced.
Grease Trap (locate on site plan):
Depth below grade: NAfeet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
.
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert NA
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.).-
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: (1) 6'x6'
❑ 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.):
Leach pit was dry when inspected as property is not in use. Stain lines were unable to be determined
do to concrete being old and discolored. Leaching is approximately 42 years old.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M °V 94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
R EAR
Al- 51' 51= 19'
A2-65' 52-25'
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: No GW 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: Permit dated 10-16-17Date
❑ 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:
Permit on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Thoreau Drive
Property Address
Dorothy Tucker
Owner Owner's Name
information is required for every Centerville Ma 02632 2-14-17
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System Information— Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
No.• g Fps...............�..-......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® O HEALT
_. OF.............. !...:h --.._..........................-- .......----
Applilcation -for M_qpuial Works Tonji#rurtion Vrrmit
Application is hereby made for a Permit to ( ) or Repair ( ) an Individual Sewage Disposal
System at
on-Addres Lot No.
Owne ....................•................_......Address
Installer Address
Type of Building Size. Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms___________ _________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ----.-___________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
fl, Other fixtures ------------------------------te
W Design Flow..................... a____---_-_-.-gallons per person per day. Total daily flow................��__.._........._..gallons,
WSeptic Tank—Liquid capacity�V3jQ_gallons Length---------------- Width---------------- Diameter................ Depth...---.--__----
x Disposal Trench—No- ____________________ Width--.-__-_:_____--_.__ Total Length------___--_-_-._-.. Total leaching area..------------------sq. ft.
-----------_ - -- - ------------t
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---------.-..---_.-__--
�z Test Pit .No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
________ _________________'� __.________ ..........
O ------------------------- - Q �� -
Descriptio f Soil___S;- :.. ... -.. ] ----+._. ----•-------------
U •---------- -- - ----------
'�P 7 7., '
w -------------------------------------- -------------------------------------- ---- �* _ '�:.
UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------.-.--.-...._---____-__-.... ll
---------.-•-----------------------------------------------------------------•----------------•---------- -------------------------.--.------------.------_-----------_------••----•------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigi d further agrees not to e the system in
operation until a Certificate of Compliance has been i sued by turd of health.
igned.-- ... -- - ------------ - -----•-------------------------- -•---
Dat
Application Approved By-------- .. ... .... ---- ..�A liL 7
Application Disapproved for the following reasons:---•-----------•-------•------- --•--•--•---•-•-•---••-------•---------------------------Dace..._....------
...........................•-----------•---------•----- ----------•----•••------------------------------------••---•--------•-----••-•-------------------------•----------------------•------•----------
Date
Permit No......................................................... Issued..-a�0--------8
------------•------................
Date
C TOWN OF BARNSTABLE
LOCATION \�'k SEWAGE#90(]- O Ste(
=ILLAGE Ci=,,7CNe,1-y�\\--P ,_ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.Q-tt,-.n cQ �P(3 6fz;-J-' ���•at V��
SEPTIC TANK CAPACITY 5_0
LEACHING FACILITY:(type) `-- �� (size) V.
NO. OF BEDROOMS ` ) s� �
OWNER i�E, c —CUC.`G J`—
PERMIT DATE: 3 �`� `� COMPLIANCE DATE: 17
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility)) d Feet
FURNISHED BY :KEJ \t
j�h�✓L�W'°`� —f"6C�u�
c
orve
4: k Q3 " a® � opt
LOCA N SEWI�,C,E PERMIT IJO.
_ _
_IwST ER 5_ W tAE A RES-S_
BUILDER 5 tJ1 MF- �. ADDRESS
DATE PERMIT ISSUED ' ILI - - -
-ON. E. COMPLI &&ICE ISSUED :
r
/�/��
��J .�1
I�1 '
v%
'raeoar :-
�'' c�u
77
W.
3AT lit &77
�'�It?1�I�i0
crfy
i• r
LBAcIUNG_, t
tsiae)
�u BR o OAR
FEI TDA Mb C'mII'd I =
b�axaniufl��djusroim� te#a'the Boni of tehf�►g Facility
P11a�rsm
P1Y' elidlreacing �cil�ty # Set :.
Ede of�et�atd�ndleg.��£a�y�trst�vd�east ,`
i
pare' ,A. 1
is ,i-d - /fir
No. ....76 FEE..............................
A
kTHE COMMONWEALTH OF MASSACHUSETTS
II BOARD OF HEALTH
.... ......... .....................................
OF )rr �.,.-� �%-
Appliration -for i_qvugttl `Works Cnonstrurtion I,jleruti#
j Application is hereby made for a Permit to Construct ( ) or Repair'( _ ) an Individual Sewage Disposal i
ISystem at................ -----•-----------------------• • --- - ------------ - s ue ✓,
l Location-Address,-' or.Lot No
--
( ! ...`/, i Owneri"' Address -
J ... .---------------------------------i----- t? --••••-••...................................••-••---•-••--•--._.........................•....
Installer Address
UType of Building _,. Size Lot-----------------------------Sq. feet
�-+ Dwelling—No. of Bedrooms.--._.--_ -----------------------------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ------------------- No. of.persons.......................... Showers ( ) — Cafeteria ( )
134 Other fixtures ------------------------------------------------------
W ' Design.Flow............................................gallons per person per day. Total daily flow---------------------------..................gallons.
P4 II Septic 1•ctnk—Liquid capacity-.----.----gallons Length................ Width---------------- Diameter........-------- Depth----------------
.{ Disposal.Trench—No- -------------------- Width-------------------- Total Length_--.-_---.-___-_-_ Total leachingg 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.---------------------------------------
aTest Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water........................
G� { Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-.-..----_.-- -_-
--------------------------------------------------------------------------------
O 1 --- - •------
Description of Soil_: .5:T-- mac' L- �/ .........................y L -- ...... ........... •.._... •.
.---------------� (----- ..--„---'...�u-%' -%v�f` -.-- ----y-/--•'D--`'`-'1,•�_, G.,._., ___-• �'/ --, ,-` =" ------------/�-= - ----- ` I
W /./;.
--------=------------------= ------------------------------=--- �J?�r- �.. J'-��4�-- ------
U Nature of Repairs or Alterations—Answer'when applicable---------------- O---------------------------------------------------------------
---------_.: .
------------- ---------------------•- ------------•-------•=------=-------- - ---. --•-- -.------- ----•---------•---
Agreement:
The undersigned' agrees to, install the aforedescribed 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
I operation until a Certificate of Compliance has been issued by the boardh health.
I ---------------------• ' - -----
f, e; ( / //
-�r .1�I_ < �__1_� r2.Fef ; /��G�.t%/ . (cam
Signed-:� ••---•-•--�.................•-- - ------ -•-•,-- -
/ at
! PL
APPlication Approved By.---
-------------_ mac- --------------- -�d�- S
Application Date
pP cation Disapproved for the.following reasons:---•--------•............... ...........••-•-----•-•.....••-•-......••----------.....:. ......_---:..._.:._
--------•------------------------------------•----._...•-----•...............................................................................................
Per No................. - -- . Issued-=., ��—f-= __'7 Date -
Date —
1 '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFF HEALTH
aC /..
frnfifira#r of TomV attrr
THIS-IS TOEPTIFYU T�t the'Individual Sewage-Disposal System constructed or Repaired ( )
' / --by __-1 .._ _�. `-''�..- s l ----------------- -•-•--••.
� � / Installr
�•
�at-
. Ji
�.
J has been installed in accordance with the provisions of :\;'IZ_}XI of The State Sanitary Co le as Oescribed in the
4 , application for Disposal Works Construction Permit No---,`� ____ _ 1�-___--.---_- dated :. ..�_. 7.5...
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS AAUARANTEE THAT TIME
SYSTEM MALL FUNCTION SATISFACTORY.
DATE ...... . -•. Inspector
THE COMMONWEALTH OF MASSACHUSETTS
�1 BOARD OF HEALTH
G
f •
No......................... FEE
��i5$r>Lt�M .fir tr,� �u"Yt5#rtar#it�It rrntt#
Permission i reby granted. ---� ._. 1 .��_`----------- ----------------------=----•---•-- ..•..
to Construct or Repajy4�) an Individual •ewage isposal stem i
�l
at No;;' /A-�"------L'--,'''=•�`Z- l� �`--.....7-----'~'l'�! re' t '--------�------------�y----------------------------------------
Sit
as shown on the application for Disposal Works Construction Per'lit No.-.�•____ ._ --.- 7, `
-
atec__.-
...............•-------•...... --•v•--,--
e✓- Board of Health l
DATE S z •••--- ......... v
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
PLOT PLAN SHOWING LOCATION OF BUILDING
IN
CENTERVILLE BARN STABLE MASS.
FOR
r
ALAN E. SMALL INC.
SCALE' I °= GO' DATE' AUG. 4) 1975
CHARLES N SAVERY INC REG. C.E.a L.S. 712 MAIN TT HiY"NIS , MASS
P, DRIVE
32 � 5 I.`l9 "
Nk
,k
Owe\\\ng
2h � Q-
2,3 6 22'
15, t23 s.F
17
34.00
I herehy cAdify th t the huilding exists
on the munc as sh>>wn on this plan and
is in accgrdance with the zoning 1 A
r jr,,-,n-,fc ci t7r Tjwn of Barnstable,
\S .
Reeistere.1 Lind Surveyor
THIS LOT IS NOT LOCATED IN A FEDERALLY DESIGNATED FLOOD PLAIN ZONE. 72238A
PLOT PLAN SHOWING LOCATION OF BUILDING
IN
CENTERVILLE BARN STABLE MASS.
FOR
ALAN E. SMALL INC.
SCALE: I "= 601 DATE AUG. 4), t 3.75
CHARLES N SAVERY INC REG. C E.a L S. 712 MAIN 4T "MY"NIS , MASS
i
v DRIVE.
ick 3`\4
►?+ N zI
4 '
r
6 2.2
23 >
�- 15,12 3 s•F
Z
Z 17
34.00
24 I�
I
herehy certify th .t the building exists a►��"°F�
on the ground as shown on this plan and
is in accordance with the zoning
, U MINTS � -1
r I Irpm-»rc cf 1hN Town nE Barnstable. `
s o •
9 T Y t 0t
ReRlstereJ Lind Surveyor
THIS LOT IS NOT LOCATED IN A FEDERALLY DESIGNATED FLOOD PLAIN ZONE. 72238A
1•) Assessor's Map 191 Parcel 188 4f
2.) Bk. 30374 Pg. 261 0
/ 3.) Plan Book 272 Page 58 o
/ 4.) This property is in the Saltwater
Estuary Protection Area o �'
/ 5.) This property is in Flood Zone X go
/ Map 191 Firm Map 25001CO561J 7/16/14
Parcel 187 Q o $a
o
48 ter'
/ e F \ See Note #19 Locus
Joffe
/ �° � boo ooe
------------
-:3 il) N
00
/
C,4 ST^ "� CENTERVILLE, MA
^� �
912), SITE LOCUS
Patio 1 \ NOT TO SCALE
�'--� House #94
+ oFBedroo�o — — S. t + DB `_ — Map 191
1 / /� t + ' + 5\ Parcel 182
Enclosed
++++ + * + + + F + 1 See Excavation Notes
I + + + N
VAI �=u 25 _0
I Paved _ ` �l Lot 22 S 10`48'33"
I o/w Garage TP #1 SAS 15,123± Sq. Ft. 17.00
Ar
5
TP #2
�o,°y--- Top Concrete
I - �2� o
--�_ TBM EL 49.8
N 83 24'33" / S 31*12'05" W o���sH V DS oy.
W 34.00 ��
1 76.75' F H Ty,
N . 21
Map 191 S aisrER
NOTE: Parcel 190 /TAR\PN ,
LOCATION OF UTILITIES IS APPROXIMATE AND ALL Map 191
UNDERGROUND AND OVERHEAD UTILITIES MUST BE Parcel 89
DETERMINED IN THE FIELD PRIOR TO COMMENCEMENT
OF ANY WORK, THIS INCLUDES, BUT NOT LIMITED TO,
REQUESTS TO DIGSAFE, ANY PRIVATE UTILITY COMPANIES
AND THE LOCAL WATER DEPARTMENT. Proposed Site and Septic Plan
94 Thoreau Drive Centerville, MA
Prepared by:
Prepared for: All Cape Septic and Survey
GRAPHIC SCALE Eric and Erica Kuenzel 618 Route 28
94 Thoreau Drive West Yarmouth MA 02673
20 0 10 20 40 80
Centerville MA 508 771-4200
allcopesepticOgmoil.com jl
IN FEET B . MA heck: SM Dw 249
I 2020 Sheet 1 of 2 C
( ) July 2, Set Y' 9 #
Y
1 inch = 20 ft.
CONSTRUCTION NOTES RAISE MIN, 20" DIAMETER COVER RAISE MIN. 20" DIAMETER COVER
EL=50.O± TO WITHIN 6" OF FINISH GRADE TO WITHIN 6" OF FINISH GRADE
1.) ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE, TITLE 5(310 CMR 15.000):
STANDARD REOUIREMENTS FOR THE SITING, CONSTRUCTION, INSPECTION, UPGRADE, AND a 49.2t
EXPANSION OF ON-SITE SEWAGE TREATMENT A DISPOSAL i EL=4 f
AND D SP SAL SYSTEMS AND F(Xt THE TRANSPORT H.5
AN DISPOSAL ORT
D D SPOSAL OF SEPTACE, AND THE LOCAL BOARD OF HEALTH REGULATIONS.
2.. ANY SEPTIC S \ \ \YSTEM
�/ r \ \
COMPONENT INSTALLED IN A LOCATION WHERE THERE IS POTENTIAL FOR / / // \
VEHICLES OR HEAVY EWIPMENT TO PASS OVER IT SHALL BE DESIGNED 70 WITHSTAND AN H-20
LOADING. IF UNDER AN IM
PERVIOUS
OUS SURFACE. SHALL SYSTEM ALL 8E VENTED T VE 0
0 3.) TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS AND 0-BOX SHALL 8E INSTALLED ON A STABLE
MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. 47 3 M m 4.) COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK, THE DISTRIBUTION BOX, AND GEOTEXTILE
THE SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN 6' OF FINAL GRADE. LEACHING THE
FIELDS, TRENCHES, AND OTHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL 46.4 45.6 FABRIC
HAVE AT LEAST ONE(1)INSPECTION PORT CONSISTING OF PERFORATED 4"PVC PIPE PLACED Existing
VERTICALLY TO THE BOTTOM OF THE SAIL ABSORPTION SYSTEM WITH A CAP, TIED WITH MAGNETIC
MARKING TAPE, ACCESSIBLE To WITHIN 3' OF FINAL GRADE. a }
5.)PIPING.SHALL CONSIST OF 4" SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A 45.9
OTHERWISE.
CONTINUOUS GRADE OF NOT LESS THAN 2%FROM THE BUILDING TO THE SEP71C TANK 46.1 o r 45.47 45.3
AND NOT LESS THAN 1%OERSE. 00 it 45.1 _ 3/4" to
6.) DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4' DIAMETER SCHEDULE 40 GAS BAFFLE 1-1/2" STONE
PVC (OR EQUIVALENT) LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED_ LINES SHALL BE CAPPED DB-3 H-2O (Double Worn)
AT END OR AS NOTED.
7.) LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO(2) FEET BEFORE D-BOX TWO (2) 500 GALLON PRECAST
PITCHING TO THE SOIL ABSORP1iCIN SYSTEM, DISTRIBUTION BOX SHALL BE WATER TESTED TO 43.1 CONCRETE LEACH CHAMBERS WITH 4' OF
ASSURE EVEN DISTRIBUTION.
1,500 GALLON STONE ON ENDS AND 4" ON SIDES
8_) GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES
IN.ORDER TO PROVIDE A WATERTIGHT SEAL. 12't SEPTIC TANK r 18't 12't --�
9.)HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE LEACH CHAMBERS 5.1'
DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. (EXISTING) (END VIEW)
IN WITH 3t0 CMR 15.22t, ALL SYSTEM COMPONENTS SHALL BE MARKED WITH
MA FLOW PROFILE
MAGNETIC
IC MARKING TAPE.
11.) THERE ARE NO KNOWN WELLS OR WETLANDS WITHIN 150' OF THE PROPOSED SOIL ABSORPTION SYSTEM. NOT TO SCALE EL=38.0 Bottom Test Hole
1THE CERTIFICATE OF COMPLI FROM THE DATE OF THE ANCE, THE�PERIMETER ON OF ESHALL B SOIL E STAKED SYSTEM
FLAGGED L TOLPREVEPT NT 1st Floor Plan
USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM.
13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR.THE SYSTEM AS DESIGNED UNLESS N.T.S.
CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE ENGINEER.
14.) THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE SYSTEM DESIGN CALCULATIONS
BOARD OF HEALTH AND THE DESIGNER, THE DESIGNER SHALL CERTIFY IN WRITING THAT THE Bedroom
AND THE APPROVED PLANS. 48 HOURS ADVANCE SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN
NOTICE IS REQUESTED.ACCORDANCE WITH'THE TERMS OF THE PERMIT Garage Living #2 SEWAGE DESIGN FLOW: EXISTING TWO BEDROOM DWELLING 0 110 GPD/8EDROOM = 220 GPD
15.) LOCATION OF UTILITIES 1S APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR -� 'n`jt{0 (MINIMUM DESIGN REQUIRED 220 GPD)
DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO SEWAGE DESIGN FLOW PROVIDED: TWO (2) 500 GALLON CHAMBERS
COMMENCEMENT OF ANY WORK. THIS INCLUDES, BUT IS NOT LIMITED TO, REOUESTS TO=SAFE, Both �p� DA D cy, WITH 4' STONE ON THE ENDS AND 4' STONE ON THE SIDES
ANY PRIVATE UTILITY COMPANIES, AND THE LOCAL WATER DEPARTMENT.
16.) CONTRACTOR SHALL VERIFY THAT ALL WASTELINES ARE CONNECTED BY WATER TESTING Kitchen Dining Bedroom Vt = [(25.0 x 12.83) + 2(25.0 + 12.83) (2) x .74 = 349 GPD PROVIDED
WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. Bath #1 F H 349 GPD PROVIDED > 220 GPD REQUIRED
t CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIG TO INSTALLATION OF ANY
SEPTIC SYSTEM COMPONENTS. - D 21, SEPTIC TANK CAPACITY REQUIRED: 220 GPD X 200 = 440 (MINIMUM)
18J TEST HOLES COMPLETED PER STATE ENVIRONMENTAL CODE, TITLE 5. SOILS CAN 13E
� O SEPTIC TANK CAPACITY PROVIDED: 1.500 GALLON SEPTIC TANK (EXISTING)
VARIABLE AND TEST HOLE DATA IS NO GUARANTEE OF SOIL CONDITIONS IN OTHER AREAS IF C�STER A GARBAGE DISPOSAL IS NOT PERMITTED WITH THIS DESIGN FLOW
SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS, DESIGN ENGINEER IS TO INSPECT THE
SOILS PRIOR TO PROCEEDING WITH INSTALLATION OF ANY SEPTIC COMPONENTS. Enclosed S'gNITARt N
19.) EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND Porch
ABANDONED IN PLACE OR REMOVED AS REQUIRED. AREA TO BE COMPACTED TO MINIMIZE SETTLING. ZZA
(INCLUDING EXISTING SEPTIC TANK) Proposed Sewage Disposal S ys t e m
TEST HOLE LOGS 94 Thoreau Drive Centerville, MA
Test.Hole i (EL=48.5t) Test Hole 2 (EL=48.5t EXCAVATION NOTES
Depth Elev. Layer Soil Class Soil Color Depth Elev. Layer Soil Gloss Soil Color 1) EXCAVATE ALL MATERIAL ABOVE SOIL HORIZON Ct (SEE DEEP OBSERVATION Prepared for:
HOLE LOG) WHERE POSSIBLE FOR A LATERAL DISTANCE OF 5'
0"-8" 47.8 A Loamy Sand tOYR3/2 0"-8" 47.8 A Loamy Sand t0YR3/2 IN ALL DIRECTIONS BEYOND THE OUTER PERIMETER OF THE LEACHING AREA,
8"-20" 46.7 B Loamy Sand 10YR5/6 8"-20' 46.7 B Loamy Sartd 1bYR5/6 2) FILL MATERIAL SHALL CONSIST OF CLEAN GRANULAR SAND, FREE FROM ORGANIC Eric and Erica Kuenzel
MATTER AND OTHER DELETERIOUS SUBSTANCES, WHICH MEETS THE TEXTURAL g 4 Thoreau Drive
20"-60" 43.5 C Sandy Loom 10YR6/6 20"-60" 43.5 C Sandy Loam 1OYR6/6 CRITERIA PUT FORTH IN SECTION 15.255(3) OF TITLE 5.
60"-126" 38.0 C1 Med Sand 2.5Y6/4 60"-126" 38.0 C1 Med Sand 2.5Y6/4 3)OF FIILLFY THE BOTTOM SURFACE NTO THE RETAINING STRUCTURE.
EXCAVATION PRIOR TO PLACEMENT Centerville, MA
4) PLACE FILL ONLY WHEN BOTTOM SURFACE IS DRY,
DATE OF TESTING: 07/01/20 Prepared by:
SOIL EVALUATOR: DAVID FLAHERTY JR I CERTIFY THAT 1 AM CURRENTLY APPROVED BY THE DEPARTMENT OF and Survey
All Cape Septic WITNESS: DAVE STANTON BARNSTABLE HEALTH AGENT ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR 15.017 TO CONDUCT P P y
SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED 618 Route 28
PERCOLATION RATE: LESS THAN < 2 MIN/INCH (Cl LAYER) BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE NO GROUNDWATER ENCOUNTERED DESCRIBED IN 310 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY West Yarmouth, MA 02673
NO MOTTLING ENCOUNTERED SOIL EVALUATION AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, (508) 771.-4200
SOIL EVAL TION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM
ARE AC TE AND 1 RDANCE 73t0 CMR 15.100 THROUGH 15.1O1 olIcopesep.ticOgm0ii.com
Date: 07/02/20
DAVID FLAHERTY JR, CER FIED SCL E ALUATOR Sheet 2 of 2
Project No. AC-249