HomeMy WebLinkAbout0134 WEQUAQUET LANE - Health 134 Wequaquet Lane
Centerville
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1521/3 ORA 1001- P2
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No. Fee
r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ye
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
T[ppYica�tion for Oiopozat *potem ctCott�truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel � �'y(y�'Uc
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
d C6 fS"al 6jnp,�,ee"0 14e,� 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 gallons per day. Calculated daily flow gallons.
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 maintenapthe afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the onmenta odenot to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo alth.
Signed Date J'
Application Approved by Datelhffm r
Application Disapproved for the following reasons l
Permit No. 0 u 3 I Date Issued I I a d
• No. .�/y Fee
4 -` � � Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS
Ye
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pprication for Mood bpgtem Conotruction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1140
3 t,J �� ✓-cG Owner's Name,Address and Tel.No.
�c LR- Sudrt=�► G
Assessor's Ma /Parcel
p ,�- - CE4�(��'tC
y In Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
!'` �'�""`�"►'��' C�°�� �IG-���
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ' Type of S.A.S.
Description of Soil
l,Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and mainten ce-of the afore described on-site sewage disposal system
in accordance with.the provisions of Title 5 of the En* onmental,Code and)not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Boa, alth.
Signed " / ? Date 11A I /
Application Approved by l�/r / �fp K Date
Application Disapproved fo the'following reasons r/ Jy i
Permit No. ado K-G 3 / Date Issued I I 2`//U t
--- —————— ------ — — -- --------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
VJ
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired( )Upgraded( )
Abandoned( )by K.,Ir4 U rl rg�
at I Zy (n/P l/i t A al ,)r� _A"o . ro J1)rv, lle has been constructed in accordance
With the provisions of Title 5 and the for Disposal System Construction Permit No. 7 r l o t^I-6 3/ dated I I (/�
Installer Designer
The issuance of thi p 11�t shall not be construed as a guarantee that the sy to wi�l/,unction as designed.
Date I a 1 3 O `t Inspector ,t
No. --/'—_-^^-- ------Fee--.— /r
' /g .�
v THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Digpozar *pztem Con6truction Permit
Permission is hereby granted to Con'st�ru-cat( ) ep/a�i-r,( ) )UU made( Abandon(
System located at T �t l l ( �V I /C 1 1 �� n n!
( 1 ��
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.
x
Provided:Con t uction mu be co,"pleted within three years of the date of this permit.
Date: ' I Approved b J
-- , i t I PP Y
0
TOWN OF BARNS,TABLE
'Dill t'
LOCATION � T4rAY� 1 _e�� SEWAGE # 'SOU ` 63
.r
y1LLAGE ea4ty Lila/1P ASSESSOR'S MAP& LOT 50 J
INSTALLER'S NAME&PHONE N0. u
. 3
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER C3
PERMIT DATE: ?1 = WO L/ 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
i
t
L41 �
33 �a
q7
3a
V eJ rpf
TOWN OF BARNSTABLE
i.. _" TICiN V-71LA SEWAGE # 20O - 63,E
VALLAGE ('04, ed a%llll� ASSESSOR'S
/MAP & LOT SOLSY
,,INSTALLER'S NAME&PHONE NO. ��. Y/1 f►PY /t �� �� ',Z,P
SEPTIC TANK CAPACITY �
LEACHING FACILITY: (type) (sizemD
NO,OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: I 1�2`��y� COMPLI.ANCE 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
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V Cot - IC , .�r�Pct
December 6, 2004
Outback Engineering
165 East Grove Street
Middleborough MA 02346
(508) 946-9231
Town of Barnstable
200Main Street
Hyannis, MA 02664
Subj : 134 Wequaquet Lane
Septic System Inspection
To whom it may concern:
Outback Engineering has conducted the necessary inspections for the newly
installed Title V septic system for the subject property.
I hereby certify that the new septic system has been installed in conformance
with the approved plan prepared by Outback Engineering.
ry truly yo s,
J mes A. Pavlik, P.E.
rincipal
i
Commonwealth of Massachusetts
x Title 5 Official inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�Vw /3
Lt/L (2 W oi Q tie 4 /f�
Property Address
Ow ner Ow ner's Name
information is ��. �✓� //W 0J6 3� ?
required for every y o
page. 5 crown 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.
Inn'"rtaW outforrm A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector: (�
key to nave G✓ / �/ / J
cursor-do not
use the return key. Name of Inspector
�--�
r/f1� tl Company Name
Company Address
City/Tow n rS�\ O / 0 State�0 Zip Code
J
Telephone Nu Rier 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
4J Title 5(310 C-M 15.000). The system:
�— Basses ❑ Conditionally Passes ❑ Fails
❑ ; eeds Further Evaluation by the Local Approving Authority
I
C)
t_L;r �0 /
Cy N Insp L's Sgnature 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.
Mns-3/13 TWe5drAcial InspecOonFcrm Subsurface Sewage0lsposel System•Page 10117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
4
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/3`f I'tA 4�o Z_
Property Address
Cw ner Ow ner's Name
information is /
required for every �2�+ ✓lam/6 /�� �o�63oZ �o /.�
page. Crty/Town State Tip Code Date f Ins action
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 CM 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):
Gns•3N 3 Title 5 Official Ins pec Uon F orm SubsLexe$e wagsDlspossl System-Pie 20117
�L\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
d
Property Address /
ON ner Cw ner's Name /
information is e� )„ l!/� Ile— / / T �o�� ?� ell oA.?
required for every _ � TG .�J'
page, Cityrrown State Zip Code Date df Ins ection
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
16.303(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
t5ns•3/13 Tide 5 0f flciel ins pec tlon Form Subsurface Sewage Disposal System•Page 3 of W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a14 c,2ue � L- /
Property Address
le-
ON ner ON ner.s Name I
information is �eoi-�2✓vi /e �/¢ D�6 3� �� /3
required for every
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 tole 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
❑ 2,,-' 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
t9re-M 3 Title 5 01facial Ire pec ban F am:Subsurface Sewage Disposal 8ystem•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7
Property Address
Info Is ner Owners Name
required for every
page. Cityrrown State Zip Code pate 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: .
❑ 2 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.
❑ 0� 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 6 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,OOOg pd,
❑ The system &Llg, i have determined that one or more of the above failure
criteria exist as described in 310 CM 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 16,000 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•3n 3 Title 5 official Ins pec bon Form SuMflace Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
s Subsurface Sewage Disposal System Form - Not for voluntary Assessments
/3 le L,9,u L_iY
Property Address
Owner Cw
information Is ner's Name
required for every Ge 0 41,Vi/�e
page. Wr own Slate Zlp Code Date of I specton
C. Checklist
Check if the following have been done. You must indicate'yes"or'no" as to each of the following:
Yes o
�❑ Pumping information was provided by the owner, occupant, or Board of Health
El21 Were any of the system components pumped out in the previous two weeks?
llcl' ❑ 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?
L�l ❑ Was the site inspected for signs of break out?
l� D 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:
l� 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)1
D. System Information
Residential Flow Conditions:
Number of bedrooms (design); Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example; 110 gpd x #of bedrooms): 330
f5irr 3N3 Tile 50fecidIrispeefionFormSubsurlaoeSewageOlsposelSyslom•Pagef10117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
g Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
(Ile 6QW 1, e4-
Property Address
Owner Ow ner's Name //
information is � eV,,` ,e �0
required for every
page. City/Town State Zip Code Date of fnspehon
D. System Information
Description: / /Voo
Number of current residents:
Does residence have a garbage grinder? ❑ Yes Er-'No
Is laundry on a separate sewage system? (Include laundry, system inspection [] Yes No
information in this report.) ,,.__, .��✓✓
Laundry system inspected? El Yes l-'No
Seasonal use? ❑ Yes
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes 9 N��o
Last date of occupancy: C 64 f ev.
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 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:
t5ns-3113 Tine 5 Official ins pecton form Subsurlme Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/3� I!✓ea2� µ Z
Property Address
,QO I2
ON ner ON ner's Name
information is CPN ��/��
required for every ''L
page. City/town State Zip Code Date of In ctlon
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? 65 Yes ❑ No
If yes, volume pumped:
gallons /i CAJr
How was quantity pumped determined? J
G/,1 71ekI
Reason for pumping:
Type of Sy em:
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):
Ors•3113 T&501flciFi InspactlonForm SUIDUMce SeVMSDlaposal System•Pape 8017
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
L2
in is owner's Nam �J O
19
e required for every GeN J /Vy!1 -e �� �r�& 3.�
page. CityRown State Zip Code Date of I spec Ion
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information: Q70b4",
7—a�!v 0 ���,r✓I .S �-. /lam�✓ � �Od -- -5,.9,5'
Were sewage odors detected when arriving at the site? ❑ Yes ❑— o�o r
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron �40 PVC ❑ other(explain):
Distance from private water supply well or suction line: f o /
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Dept h bel ow g ra de:
feet
Analonstruction:
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: -5 -X
Sludge depth: C2 / -
t51ns 3113 Title6Official Inspection Form Subsurface sewageDiepoeal Syatem•Page 9of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13Y G✓eaLtc, au� �it- Z-
Property Address gole,
'
Ow ner Ow ner's Name //
information Is
required for every C'h ✓tif -e /O /3
page. Cityffown State Zip Code Date of I pection
D. System Information (cont.)
Septic Tank(cont.) </
Distance from top of sludge to bottom of outlet tee or baffle — o�
Scum thickness
Distance from top of scum to top of outlet tee or baffle X/
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? en----
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
U ond r h o 4 2 dll�'C ti v49 C
co")J, J�0✓J, �(/ ZCrH►r
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
t6lns•3/13 Tine 5 oteclel Ins pecbon Form subsurtme sewage Disposal system•Page 10 a 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Cw ner Av ner's Name
Information is ��� ✓y! `/� /�,� Da63 l 6
required for every
page. City/Town State Zip Code Date of Inspd tion
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:
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
tens-Y13 TiO501flclal InspecoonForm Subsurfwe S"eolsposal System Page 11 d 17
Commonwealth of Massachusetts
Title19 �/a a�ve'
U
5 Official Inspection Form
law
e Di osal System Form •Not for Voluntary Assessments
Property Address /f
/S O
oN ner Cw ner's Name
Information is �p�,,�¢y�/ -e A/ /0 A/3
required for every State Zip Code Date of irfspecwn
page. City/Town
D. System Information (cont.)
Distribution Box (if present must be opened)(locate on site plan)^
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
C&
4y
Pump Chamber(locate o"ite plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
tyre W3 Tide 6Officiei irupectionForm Subsurface Sewage Dispose,System.Pepe 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address /
ON ner Owner's Name � //__ /
information is (/jPN7�✓yl`/-e /�/7�f
/o /3
required for every
page. City[Town State Zip Code Date of In ection
D. System In rmation (cont.)
Type: �� Z h-'i//71---�. �f S7Uv�e,
❑ leaching pits number:
I` j ❑ leaching chambers number:
0
d ❑ leaching galleries number:
� ❑ leaching trenches number, length:
L ��r i ❑ leaching fields number, dimensions:
❑ overflow cesspool number:
.�.p ❑ innovative/alternative system
Type/name of technology:
I_
I��✓r � Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
��VTe 1�r �9_
7'1- �7 do-4 C,
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth-top of liquid to Inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
15ns.3/13 TiOe 5 Official Inspection Fam Subsirfec®SewageDlsposel System Page 13cf 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage (Disposal
/System Form - Not for Voluntary Assessments
H-C
Property Address
610
ON ner Ow ner's Name )
Information is �t"de✓ya (J�63 �o /3
required for every
page. City/Town State Zip Code Date of I pectbn
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:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t51ns•W13 T1050f6cial Iris pecknForm Subsurface SewageDisposel System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/SY C✓e a�P Q � �-�
Property Address
d
ON nor Oar ner's Name
ation is Inforr
requir ceN 4✓✓/ �� r 6 �� � /O 13
required for every
page. Cityfrown State Zip Code Date of In o ection
D. System Information (coot.)
Sketch Of Sewage.Disposal System: Provide a view of the sewage disposal system, including ties to
at least two p anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where pu water supply enters the building. Check one of the boxes below,
❑ and-sketch in the area below
drawing attached separately
t6ro•3113 Tice 5Orncial Impectlon F am Subsurface Sewage Disposal System-Pepe 15 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
's Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
eQUj
Property Address
0
ze-
ON ner Ow ner's Name
information is CQ y ���`� / j� cd� _— . �O
required for every
page. OtyrTown State Zip Code Date of 10 pectf n
D. System Information (cons)
Site Exam:
0 Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells /0 , AT
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health- explain:
/40S' f 7-es�t f 10 s
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
4h T` �2 l.✓� /Si7 ��
e 'Agv Cc
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Oro 3/13 TI0e5Offcial Ins pec;bon Form Subsulace Sewage Disposal System-Page IS 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7
Property Address �O
Ow ner Cw ner's Name
information is
p Cep ✓��
page.
State Zip Code Date of I s ectlon
page. City/Town p
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Ird Sy em Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
thins-V13 Tltle5olAclsl Inspection Form Subsurface Sewage Disposal System-Pape 17 d 17
q Page 10 of I I
r _
Ji
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUB,'SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan & Carron Trafton
Date of Inspection: July 2,2007
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.
°lS
vent
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a
Water
Service
Wequaquet Lane
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
6�•
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 134 Wequaquet Lane
Centerville MA 02632
Owner's Name: Dan&Carron Trafton
Owner's Address: 294 Milano Drive
Carey IL 60013
Date of Inspection: July 2,2007 Job 4 07-141
Name of Inspector: PATRICK M.O'CONNELL —
Company Name: SEPTIC INSPECTION SERVICES CO. yl r-a
r�
Mailing Address: 189 CAMMETT ROAD -9- �P,_
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
`ram
CERTIFICATION STATEMENT co
I certify that I have personally inspected the sewage disposal system at this address and that the informat on reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed base 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:
_X:_ Passes
,_ Conditionally Passes
__ Needs Further Evaluation by the Local Approving Authority
Fair
Inspector's Signature: �; Date: 7/2/07
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 shal I 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.
Notes and Comments: Tank needs to be pumped,Liquid level in infiltrators is 2-Y below inlet pipe.
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection: July 2,2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CW[R 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
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:
I
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection: July 2,2007
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 noit functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspoc l 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 I of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection: July 2,2007
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
—X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X— Any pon:ion 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection: July 2,2007
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period ?
_ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS,located on site?
_X_ _ 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?
_X_ _ 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:
Yes no
_X_ _ Existing information.For example,a plan at the Board of Health.
_X_ _ 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(3)(b)]
9 ,
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection: July 2,2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Two years total: 190,000 gal.=260 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTR IAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgR,etc.):
Grease trap present(.yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available: _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: None
Source of information:
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(y-.-s 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 alil components,date installed(if known)and source of information:
Compliance date for leaching system:2/3/04
Were sewage odors detected when arriving at the site(yes or no): No
I
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection: July 2,2007
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 2'
Materials of construction:_cast iron _X-40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 2'
Material of construction:_X_concrete_metal_fiberglass_polyethylene
_other(explain)_
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:8.5'long x 5.2'wide—1000 gal.
Sludge depth: 10"
Distance from top of sludge to bottom of outlet tee or baffle:20"
Scum thickness: 8"
Distance from top of scum to top of outlet tee or baffle:6"
Distance from bottom of scum to bottom of outlet tee or baffle:4"
How were dimensions determined: STICK WITH HINGE FLAP.
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 needs to be pumped,tees are intact.
GREASE TRAP: No (locate on site plan)
Depth below grade:__
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
l
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection: July 2,2007
TIGHT or HOLDING TANK: No (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (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.):
Trace of solids observed,no hieh stains.
PUMP CHAMBER: No locate on site Ian
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
d
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection: July 2,2007
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
—X_leaching chambers,number: Five infiltrators.
leaching galleries,number:
leaching trenchies,number, length:
leaching fields, number,dimensions:
overflow cesspool,number:
_innovative/alteirnative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): Liquid level in infiltrators is 2-3"below inlet pipe SAS is at 75%capacity.
CESSPOOLS: No (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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
I
I
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUB,'SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection: July 2,2007
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.
rr
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Wequaquet Lane
Page 11 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Wequaquet Lane,Centerville
Owner: Dan&Carron Trafton
Date of Inspection.: July 2,2007
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to€;round water: More than 20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el.35 and topo map shows property above el.60.
r
TOWN OF BARNSTABLE
UCATION 1_ 34/ W .� qyQ�T LQ SEWAGE#—�r�y.�
ILLAGE �.'r����(� ASSESSOR'S MAP&PARCEL
S NAME&PHONE NO. r�°�1L V Ccs,.xkUf WO-
SEPTIC TANK CAPACITY /000
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
OWNER 'Z)�,,y\ `rj yrs..P,1,(3 n
PERMIT DATE: DATE:--X,SP. "7
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
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f
Water
Service
`Wequaquet Lane
ff
o.... ... 2 FEB....10V�,.........
THE COMMONWEALTH OF MASSACHUSETTS
Q BOAR® OF HEALTH
.r!�-..........OF..........
�
Appliratiou for Uisvvii al Workii Tumitrnrtinn ramit
Application is hereby made for a Permit to Construct (t,<or Repair ( ) an Individual Sewage Disposal
System at:
Location-Ad sI or Lot No.
Owner Addre s-
�? .�
Installer Address
Type of Building Size Lot.Z•3,Z .....Sq. feet
Dwelling—No. of Bedrooms................ ......................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures ...
w Design Flow....................S-_................gallons per person per d2ly. Total daily flow__-_.-_-_ -_--�U 4P.................gallons.
WSeptic Tank—Liquid capacity./O_(✓.Qgallons Length__. . Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------/---------- Diameter._J.Z.�—.1.". Depth below inlet--_.67 Total leaching area_1lSr..17.sq. ft.
Z Other Distribution box Dosing tank ( )
`-' Percolation Test Results Performed by__. /'L _ ` G►!!�?lyi� ` Date..... ............
/p/97Z.Test Pit No. 1__ ;•.....minutes per inch Depth of Test Pit-------- L...._.. Depth to ground water...�l��l�_..
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ........................................................ ,
O Description of Soil................................................3----�'D.rn_......,% ......
x
w
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
•------------------------------------------•------••----......-------------•-•------...---........--•---•---••-•----------------•--------------------------------.......------------....--••••---...----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of H,'MLE. 5 of the State Sanitary C de— The and signed further agrees not to place the system in _
operation until a Certificate of Compliance has be is /th oard of health.
s = 7A. ...
- 1- e
Application Approved By................ .................. ........................................................
Date
Application Disapproved for th oll wing reasons:-----•-•...........-•--•--•-•--•---•••----•-----------------••-----•-•••-------------••----••--------...._----•-
-------------•------••-•-••-•------•--•-....•----••-••---•-•-........•---••••----•----•---••---•--------•••-------•••-••-------••--•-•---•-------------------•---•-------------------------....._---...
Date
PermitNo...............•--•-•--•.._..............-------•.-•---. Issued.---......------......................................
L
Date
1�0.... ....... FRic Or.,. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
HEALTH
0...........OF.......... -! ' Vle..................................
Apptiration for Dhipogal Works -Tomitrurtion thrutit
Application is hereby made for a Permit to Construct. (V_15' or Repair an Individual Sewage Disposal
System at:
...... ........................... ........................ .............. ...........................................................
Location-Address7s 4� y or
7� 6;tr- 7/
Lot No.
.......................................................... ................................... ......... ... -700'�'..........__-
Owner Add,e'ss
—71 c_ 2
..........................
........... .........
Installer Address
Type of Building Size .....Sq. feet
Dwelling—No. of Bedrooms.................. ..............Expansion Attic Garbage Grinder (
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria (
P4
P-1 Other fixtures ---------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow____________________'. :_._.___________._gallons. per person per day. Total daily flow.._....__.__._..3... .................gallons.
9 Septic Tank—Liquid capacity h.:"4gallons Length..-�?!V. Width________________ Diameter_.._..._.._____. Depth_.__._______._..
Disposal Trench—No. .................... Width_____...___....._.._ Total Length._:_..._________.___ Total leaching area....................sq. f t.
Seepage Pit No--------/........... Diameter..K;_'-<e!_'_'_. Depth below inlet___. Totdl leaching area3..t�t_e7.sq. ft.
Z Other Distribution box (.v) Dosing tank
/X
Percolation Test Results Performed .................................. Date.... .............
Test Pit No. .....minutesperinch Depth of Test Pit.._.__. Depth to ground water.A
Test Pit No. 2................minutes per inch Depth of Test Pit._.__..._____._.____ Depth to ground water..____.._..____._._._---
.............................................................................................................................................................
0 Description of Soil...............................................................................................:. ............ .............................
---------------------------- -------------------------------- ---------------------------------------------------------------------------------------------
----------------------- .............................................................................................................................................................................
Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------------------.........
........I...............................................................................................................................................................................................
Agreement:
The undersigned agrees- to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of-TTLE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issued by the board of health.
..................................................................................... ................................
Date
ApplicationApproved By.................... .... .......................................................... ....................Date....................
Application Disapproved for t fo_ wing reasons:................................................................................................................
........................................................;........................................................................7......................................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF...................................................................................
(Infifiratr of Toutpliam
I CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
.......................................
.............. .............
-----------------------------------------------------------------
by...........o.. �..,:.ta ler
... .. ..... .... .................................
at................................................. ....... ...................... .........................................................................
has been installed in accordance 'th the provisions of '1�7,, The State Sanitary o� e.a scribed in the
t ----- ... . ........................
application for Disposal Works onstruction P------- - -- --------- ................. da ed
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A` UARANTEE THAT THE
SYSTEM WILL. NC ON SATISFACTORY.
DATE.......... ....... ............. Inspector................. .................................................................
---------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ay . I_wr", .... ......................................OF..............................................................................................:,.' .
ss h eby granted...14
Permissionw* ar ---
...........................................................................
......
to Constr rRe air n Indivi a o germ sal System
at No...
........... .............t ....................................... ....
__;. ..................
Street
... ...!
b'sal Works Construction Permit No.......:............. *e(4
as shown on the application for Di .................
........................................... ..........................................................
rd of Health
DA4TE...... ---------------------------------------------------
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
LOCATIONCr/ u� ue SEWAGE PERMIT NO.
VILLAGE
(,7yiS�77' 4 s,
INSTA LLER'S NAME & ADDRESS
BUILDER OR OWNER
tiDATE PERMIT ISSUED
® DATE COMPLIANCE ISSUED
r
to `l /
Its
y� q/
Sy
BENCH MARK: TOP OF FND. /N 5
ELE.= O 7a 1 (SAS) SHALL BE ��,`� 3ti LOWS
O MANHOLE COVERS TO EXTEND TO a I � 11 05 WIDE G a� �
WITHIN 6 OF FINISH GRADE 10' DEEP �3'
2% BAFFLE REO'D
7' C USE
�sT' C,7.0 D.B. 2' PEASTONE TOPPING
-- - -- --
i� CAP ENDS GENERAL NOTES: -.-.
is 1. '• , 6, , .
`T'a►�DK 3 �O = _ - = _ - \_3/4' DOUBLE WASHED — ELEVATIONS SHOWN BASED ON U.S.G.S. DATUM.
EL-b�.6 7 STONE ALL AROUND SYSTEM PIPE SHALL BE EITHER C.I. OR
SCHEDULE 40 P.V.C.
—t — THE BOARD OF HEALTH SHALL BE NOTIFIED
20' MIN:
1.5 3125• 1.5, PRIOR TO BACKFIWNG CF SEPTIC SYSTEM.
T�S T a � � �• — SEPTIC SYSTEM STRUCTURAL COMPONENTS
USE FIVE (5) INFILTRATORS ` 1 SHALL BE CAPABLE OF WITHSZNDING A
SOIL TEST LOG PROPOSED SEPTIC SYSTEM wrr 1 4.o OF STONE o.a OF STONE • ENDS (� , ((o H-10 LOADING, UNLESS SPECIFIED OTHERWISE
PERC RATE-< 2 MIN/INCH NO SCALE — SEPTIC SYSTEM UNDER DRIVEWAYS SHALL
NO STONE AT BOTTOM
COMPLY WITH A H-20 LOADING.
DEPTH' ELEV.-
EL —THE DESIGN AND COMPONENTS OF THE SEPTIC
k SYSTEM SHALL BE IN COMPLIANCE WITH THE
A LQAMY SAND i ont
!OI` A SMIO 7 N v0 �0.E-�� r STATE OF MASSACHUSETTS SANITARY CODE
I3 OCJS�'X 1fC� TITLE V. AND SHALL BE IN COMPLIANCE WITH
Nd THE LOCAL BOARD OF HEALTH RULES AND
.O I
REGULATIONS.
THE CONTRACTOR SHALL BE RESPONSIBLE FOR
s. LOCATION OF ALL UNDERGROUND U nUTIES AND
MA P ZSd SHALL NOTIFY DIG - SAFE PRIOR TO �
TEST 6 Y .T. P EA,I L I K PAAC&-L ��J — NO GARBAGE GRINDER
No .. �"y�' 1�,. 4 DESIGN CRITERIA:
�t
LEGEND "; .o DESIGN FLOW
(pj 3 BEDROOMS AT 110 G.P.B. / DAY 330 G.P.D.
EXISTING CONTOUR
WATER SERVICE VIF—W— � �j REQUIRED SEPTIC TANK:
GAS TEST HOLE
G G �" SEPTIC TANK PROVIDED
BENCH MARK raBN sk �. ,: DESIGN PERC RATE <2--MIN/INCH
SIZE OF REQ'D (SAS) AREA = 330 0.74 - 446 S.F.
Ef'ST• 5Q*T etre-v.. = Coe .O
SIDEWALL ffl%83)(34.25)+(2)(O.83)(11)= 75.12 S.F
BOTTOM 4.25) - 376.75 S.F.
SIZE OF LEACHING FACILITY PROVIDED:
376.75 S.F. + 75.12 S.F. = 451.87 S.F.
y ` = 334.4 GP
NOTE: „
PRIOR TO INSTALLING THE NEW (�) THE 0 1 �C� DEPTH: 10"
N1 L A4 µ_�.r EFFECTIVE LENGTH: 34.25'
CONTRACTOR SHALL PUMPOUT ,�,, � �. �„
AND BACK FILL WITH CLEAN MEDIUM SAND EFFECTIVE WIDTH: 11.0'
iF LG AcA P f T ARE ENCOUNTERED IN THE '
i
O AREA "Ey SHALL BE REMOVED OUTBACK ENGINEERING
�00
I l9� S .106 WEST GROVE STREET
PLTH OF M,ds c^ MIDDLEBORO. MA 02346
0
(508) 946-9231
o ,LAMES A. yGm ' L� PROJECT SEPTIC SYSTEM REPAIR
PAVLIK FnP:
CIVIL N34 r'
O 3 srxc AS SH WN °rAm w
JP
L o9 9 ISTE o 21 0 MAPZ5,0/ LOT 15�} �se
_ e
s NAL 3� ` OWN : SQSAnI TRAIPTOW
L A.
GN TOL\1(
LLE
SITE PLAN T YPICAL PROFIL E
SCALE — / _ ��' 1=�. c �, �.-� =;
NOT TO SCALE
/B STD. L T WGT C.I. MH COVER
�-
4"C.I. PIPE 4"BIT FIBER PIPE TIGHT JOINTS
p
OUTLET LEVEL FLOW LINE O TO FIRST ✓O/NT �- - - -- -
DWELLING
o�
I m
./. TEEC.I TEE 4,Z STANDARD PRECAST �-
c _ CONCRETE cuOGALLON
SEPTIC TANK 01STRIBUTION Box
TO BE INSTAL L ED ON
LEVEL , STABLE BASE.
SEPTIC TANK �� 1
t `�✓ `� �o TO BE INSTALLED ON
LEVEL , STABLE BASE
P. L'v,x iCP. tw'MP-CA 4T GOA 4 -
�,�� loot/ IaAL
I G r T I L 'rA A,4 W. 2' - l/B TO //2 WASHED PEA STONF�J ALL AROUND FREE OF IRONS, FINES LEACHING PI T
AND DUST IN PLACE BASE TO BE LEVEL
• �` ,4 /
Y �o BRICK a MORTAR COURES
AS REQUIRED TO BRING 3/4" TO I-//2" WA SHED CRUSHED
r ND FREE OF
� �• 3� COVER TO GRADE. 24"C. I. MH COVER STONE ALL AROU
AND FRAME IRONS, FINES ANO DUST IN PLACE
---------
7l rh 1 r
1 yyV\�
-�
4 J _ —� LEACHING PIT SEC TION—
I.NL ET_ __ ____ B' FLOW L INE - _ _�_
6� P/PE I. CONCRETE TO BE 4000 PSI 28 DAYS
-�,. 2. REINFORCED WITH 6" x 6'' NO. 6 GA W.W.M.
—! - 3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREATER
0 DEPTH REQUIREMENTS.
L O 7 4- 1 � f OPENING WITH 4 //B 4. NUMBER OF PITS REQUIRED
Z Z�9 .5 t L OUTER DIAMETER 8 ��
3" f I vi " INS/DE DIAMETER NOTE. EXCAVATE TO ELEVATION OR LOWER AS
l-3/4•; � _ t � 'O ' 3„
REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH
PIT REPLACE EXCAVATED MATERIAL WITH CLEAN
t p \ I GRAVEL TO DESIGNED GRADE
r
15 136 f - --- —-� - - - - — — ----- I
r i
I L ' Cam 7 I. ,. �
MIN.
EFFECTIVE DIAMETER
1 I (NOT TO EXCEED 3 TIMES EFFECT/VE DEPTH/
J -- �--�.v WATER TABLE- -- ----- — ------- ----- -
SOIL AND FERC. DATA GENERAL NOTES
PERC. RATE : 2L MIN. /IN . NO HEAVY EQUIPMENT TO RUN OVER SYSTEM
SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD
TEST BY: ��LJG� N�LP �Wlil, M. bU.,df2l[aIGK �' ��`��• ,- PRECAST REINFORCED CONCRETE UNITS
WITNESSED BY. J"Ef" �� 4co[-5! _ I'j . Pj , ,� , 1 ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE ,
TESL PIT GR EL. �� .0 DATE '- = , ���' MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF
TEST PIT NO. 1 Pl�j'�4 TEST PIT NO. 2 SANITARY SEWAGE EFFECTIVE I JULY 1977.
0 0" ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE
3, To ue,loXlPr,.'., ;off/'SUfO/GonnP. 6AQ r, BO) .RD OF HEAL7 H.
GoA6ZS6 SAND/&,QA AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE
BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
D PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATED
lo'
12 I2, Elms 5 ,& IJD CL r,4,, OTHERWISE.
f-i v w A. f•2
DESIGN DATA
BEDROOMS —�_ DISPOSAL_---I
EST TOTAL DAILY EFF. __ �' f U__GALS.
L EGEND _ SEPTIC TANK GAL
SIDEWALL AREA f f_GAL /SO. FT
BOTTOM AREA _ I ' c GAL./SQ. FT SEWAGE
0x0C EXISTING GRADE LEACHING REQUIRED zos.�� SQ.FT. S w GE DISPOSAL SYSTEM
ZONE' _ Co 40D
FINISHED GRADE ACTUAL LEACHING AREA SO.FT. FOR _
DOMESTIC WATER SOURCE r o ' I a• oo INVERT ELEVATION /�ivv/�iL „ ��
LoT 41 1uC- G2LJA6Q LJCcT L- �. t. !
PROPERTY LINE -t+ OF �a,ss G�f�J' RV II_(~ � , �.�,G2�J 57 4. pL�, MAS`�
PLAN REFERENCE ' ►- `}' p 5 �- +. -
- --- MEAN HIGH WATER SCALE' AS INDICATED DATE 7/ 14/�3
BENCH MARK DATUM: '� v M V h _ T 4---) p a s "• � ;I
MARSH ( WM. M WARWICK a ASSrCIATES
z p ° BOX 801 - NORTH FAL,L101J7-H
MASSACHUSETT,- 02556