HomeMy WebLinkAbout0071 WASHINGTON BURSLEY WAY - Health 71 Washington Bursley
Centerville
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/ TOWN OF B�RNNi STA.ELE
,OCAI I0N �� ��Sh� n �s l- LJc SEWAGE #
r1x LACE dQ'e y;l ASSESSOR'S MM&LOT
NSTALI.ER'S NAME&PHONE NO. I
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;O.OF'BF,DROOMS.
WILDER OR OWNER
'EI ITOATE:.� COMPLIANCE DATE:_
41,
icparation Distance Between the.
Aaximum Adjusted Groundwater Table to the Bot om of Leaching.Facility .�,...._ met
Yivatc Water:supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
dge of Wedand and Leaching Facility(If any wetlands exist C
within 300 fee of leaching faci'ty) i / � .,.T_,v„�Feet
furnished by WK --�rJti C— ////
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.'� 71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.
A. General Information
1. Inspector: 53-�
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
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
3-23-09
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.
L—D 3( bj
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/ day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ E Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
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`fives"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.
t5insp official document-03/08 Title 5 Official Inspecbon Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered opened, and the interior of
P p 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?
I ® ❑ 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 official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 15
X, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 550
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 156gpd/2 yrs
Sump pump? ❑ Yes ® No
Last date of occupancy: 12-08
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) 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:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5lnsp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 30"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 24
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: 20
Distance from top of sludge to bottom of outlet tee or baffle
12"
Scum thickness 5'
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
13"
How were dimensions determined? Tape
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
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 scum of to to of outlet tee or baffle
P
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1M 71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No,
Alarm level: Alarm in worldng order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document•03/08 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System SAS locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 6-Infiltrators
❑ 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.):
Infiltrators in good condition with no sign of backup into d-box or surrounding stone.
9 9 p 9
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is Centerville MA 02632 3-23-09
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
D
o � r
f-
A-F- g6' a- - 3�
t5insp official document-03106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 71 Washington Bursley Way
Property Address
Fannie Mae
Owner Owner's Name
information is required for Centerville MA 02632 3-23-09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 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:
Original design plans show no groumdwater at 12'.
t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
cM 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information fo is CENTERVILLE
required for MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:
g A. General Information
When fillip out /s2A
forms on the
computer, use 1. Inspector:
only the tab key
to move your MICHAEL DEDECKO
cursor-do not
use the return Name of Inspector
key. COMPASS REALTY DEV CORP
Company Name
k P.O. BOX 2384
IL 0 Company Address
MASHPEE MA 02649
City/Town State Zip Code
508 221 5003
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 ,
r..�
12/19/06 `ri C-)
=��, Fla
Inspector's Signature Date 8 r1:3
The system inspector shall submit a copy of this inspection report to the Appr v IN Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a(shared Pstem-or
has a design flow of 10,000 gpd or greater, the inspector and the system owner hall sutlrnit they
report to the appropriate regional office of the DEP. The original should be sent t the sy`s,tam owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of insp
ection 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•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M s 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health).-
broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a D€P certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
VNI 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
❑ Pq Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
Required pumping more than 4 times in the last year NOT due to clogged or
❑ obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ (' Any portion of cesspool or privy is within 100 feet of a surface water supply or
1� tributary to a surface water supply.
l5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
informationis
required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ X 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.
t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GM , 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ Has the system received normal flows in the previous two week period?
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
5 ❑ 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?
IvI ❑ 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•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): —�— Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No
Laundry system inspected? ❑ Yes No
Seasonal use?
❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)): NI
Sump pump?
❑ Yes No
Last date of occupancy: � A
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Wl Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
�
Depth below grade: 3
feet
Material of construction:
❑cast iron K40 PVC Elother(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Ja r w� T� Nk'S w lip 1-zcl ft'3co
iJ
Septic Tank(locate on site plan):
1
Depth below grade: feet
Material of construction:
[concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
------------------------------------------------------------------------------- ------------------------------------------
Dimensions: 1 So®G K L
it
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle 4
it
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? asu,"
t5insp•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title S Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. Cityfrown 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.):
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade.-
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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
t5insp-Oa/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
R 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.):
W
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
_
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
1 0 �
3 Z �
�� - 3ol 13 �
l Z-3y � 62- 1 lI
j 3, qZ ' 63- 32`
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 WASHINGTON BURSLEY
Property Address
C/O DAVID HOLT
Owner Owner's Name
information is required for CENTERVILLE MA 02632 12/19/06
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site
Exam:
IS]/Check Slope
Surface water
[Check cellar
El"Shallow wells
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
[S� Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
OF BARNSTABLE
LOCATItN?�
EWAGE # a 4
VII.LAGE ASSESSOR'S MAP & LOT_/
INSTALLER'S NAME&PHONE NO. .�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ��
(size) ly
_
NO. OF BEDROOMS
BUILDER OR OWNER p
PERMiTDATE: to
0000MPLLANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and LeachingFacility ty (If any wells exist on site or within 200 feet of leaching facility)
Edge of Wetland and LeachingFacility If Feet
ty( y wetlands exist '
within 300 feet eac ng f ty)
Furnished by" Feet
C"
j
4
i
Site visit to 71 Washington Bursley Wen. March 14, 2007.
Saw 6 bedrooms. Septic is only for 5
Contacted Broker who is handling foreclosure sale for bank David Holt of Toady Real
Estate Centerville. 508-790-2300. He said he would open up one bedroom wall in garage
apartment to make only one bedroom. Please follow through .
Linda Edson
4
a
v�
q6 Z4 S'T.y�.J. 13OFN OF BARNSTA.BLE
LOCATION �EWAGE # Aocr��
VILLAGE Z l ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. .� 7 `7
SEPTIC TANK CAPACITY 1 SC14
LEACHING FACILr1Y: (type) '1to flT e5- (size) _ �l
NO.OF BEDROOMS
BUILDER OR OWNER o
PERMTTDATE: D COMPLIANCE DATE: p
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Welland Leaching Facility (If any wells exist
on site or within 20.0 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If y wetlands exist
w'i'tlun-3Q0 feet Feet
Furnished by
i
j
i.
i
*7t E ti
OF BARNSTABLE LOCATIVi 1301 j G� 5A h,6 j�I EWAGE # 4
VILLAGE ASSESSOR'S d ASSESSOlIR'S MAP& LOT 7crZ �'
INSTALLER'S NAME&PHONE NO.& SXc`,4i/ T qr 7 -a! 7 `7
SEPTIC TANK CAPACITY _J,15 06
LEACHING FACELITY: (type) f4 FJ"I td"4fa1'5 (size) 4.Z X !;!� .
NO.OF BEDROOMS
BUILDER OR OWNER zelalzo
PERMTTDATE: ® CQCOMPLIANCE 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 y wetlands exist
within 300 feet eac ng f ty) Feet
Furnished by
f
No.zzoy 3 Fee //i o, -`
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye✓✓S✓
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pphration for Me;pogar *pgtem Cow5truction 3permit
Application for a Permit to Construct Repair( )Upgrade( )Abandon( ) Bl Complete System O Individual Components
Location Address or�Lot o. rsle (,Jp-4 Owner's Name,Address and Tel.No.
CX v1�-r`�0 lrrui I l,c AKamw 1 rjcca
Assessor's Map/Par el /
\ 0 c Pc 1 $-Z I/07 Cccyr ora tsv. $k J-( a hn i s 2 fc01
Installer's Name,Addres , " Designer's Name,Address and Tel.No.
° d�, f �, Cii'4 Z8 h-cj 51zphs., /�•W o I s c+� Pe
O 116� h ® &%111r.M-Ael S 1.�Ver' � G2655
N Type of Building:
Dwelling No.of Bedrooms live Lot Size 54j t?o5 sq. ft. Garbage Grinder( __
Other Type of Building No. of Persons Showers( Cafeteria( )
Other Fixtures
Design Flow 116 A.j l I d, gallons per day. Calculated daily flow ss"o gallons.
Plan Date /c,1111d ioo Number of sheets to m Revision Date
Title S,fz 9 Scz h c. P lc.n
Size of Septic Tank ( 43 4 IGMA Type of S.A.S. Lee,cw Cr,*ulrvs IZ. V.44`x I'
Description of Soil Ke.fc, 4,, se%;1 to ge an YA 4 of P-9 97(
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions o Title 5 of the Env' onmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issMe ,this d of lOt 6a^
Signed 1 E S Date t 8 s°d
Application Approved by Date
Application Disapproved for the following rea ons
Permit No. 2-,CW —d'72/ Date Issued re�
v 3
-Z,IfL'?J—to Fee
No. -
O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
�J PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Rpprtcattou for Migogar *pgtem Congtruction Permit
Application for a Permit to Construct(X)Repair( )Upgrade( )Abandon( ) X Complete System El Individual Components
LRcaation Ad re$ r Lot o rs to (�JO y Owner's Name,+A�d+dress and Tel.No.
'�i'l'`(J ✓JS /"�e �72.4 �rv�l�l Andrtw 1 ricca
Assessor's Map/Par el
v' D1Q �G1 S Z (!o? Lorpornkr. QoJt � Nyavlhls G?GO1
I staller's ame,Addre�jss, Designer's Name,Address and Tel.No. q 1 t 3
RCjh►� *,Ow, At W Ism Pe
o �clrr N'10 1-tdv..�re•-1
j Po 116 7 �,�As �"`�� bIz I')14�K 5h C�k rat,11e MA GZ65'S
N Type of Building:,
Dwelling No.of Bedrooms rivt Lot Size S6,CtoS sq.ft. Garbage Grinder(44
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 110�od 161r" gallons per day. Calculated daily flow SSG) gallons.
Plan Date /00&6 joc, Number of sheets 'Ab Revision Date
Title Stk. E S!pPflr. Pt4A
Size of Septic Tank 15CrO 4ftllc►w Type of S.A.S. ke4ct7 C6w be*S' 14 rc 41 %Z
Description of Soil Re}cr ♦a So-I Io V c*, Pi 4 rt P-Ss 97 Fl
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 o Title 5 of the Env' onmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss e ' y this o f Ca*
`yJ Signed U QIG�E s i�K. Date o c..r ► ;�3
e Application Approved by Date
>' Application Disapproved for the following reasons
Permit No. Date Issued O �9
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance ✓-
Abando TH �d IS IS TO
O CE Y,tnt tPe`e On-site e ag DisposaJrSyste tlp fCp structed( )Repaired( )Upgraded( )
S y (�,l
atv / S �°a has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. T WV 6 3 dated �O
Installer Designer
The issuance of this ermit h 1 not b4 cco s ed as a guarantee that th wi fu c ' n as desi ned�
Date p i ( Inspector U� X1 r V A 1,
———————————————————————————————————————
No. ?iQ�GTJ Fee �Q d r
THE COMMONWEALTH OF MASSACHUSETTS
/7Z-00Sc0Z-PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mtgool "tem (Congtruction Permit
Permission is hereby aac}tted to Con ct�✓Repat grade( )Abandon k
System located at �6-s 6 ( � ��� GIr 10-
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. �
Date: , I U Approved by
DESIGN [DATA 1-1.5" WASHED STONE
S��Ic Farn�l•� c Bcdr+oorr� � :
,&0Gs.rba3c Grinc( r r 12'
Daily Flow = S x 110 jp4AA6. S50 J.. ' .�. .
Sepite.-Tame - 55 o x zooTo = 1100 �I
USE 1560 G A LLaN TA► W- - 44'
LW14CHIIJG SYSTEM DESIGN
App li ca+con Arca Rcj v%re S1 PLAN OF LEACH CHAMBERS
s50 GPO : O,74 GPDISF = _ -7 9 3 SF
NO SCALE
A"Iscafia. Arca Design �2' w,cQe 'c 44' ion% v Z. y;r4n
S1dcwa.11 Nrrn (44 ,z)`Z 2-24 SP
Be torn AMA 4ary iz'' s2S SF
To Ffial Arca 752 S '2 '1
FINISHED GRADE
peresls-hon R•tC L $ n=w/IAd1 36-MAX.- 12-MIN. /\��\//\/��/\\ \/\/\//\/\\/j\/jj\\//��\/\\/ COMPACTED_FlLL
Class T S.i I s 2_I PEASTONE
I5, O 3/4'TO 1 1/2
_ 3300II DOUBLE
WASHED STONE
jom
EPHEN \
sECTTON
29. .
�`` NO SCALE
No.30216
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