HomeMy WebLinkAbout0232 WHITE OAK TRAIL - Health 232 White Oak Trail
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T11E COMMONWEALTH OF MASSACHUSETTS Entered in computer:
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PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for Mi!40016pgtem Conelruction Permit
F, Application for a Permit to Construct( . j Repair(VlUp grade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
lq2 l' —6
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
orb-o1��'-�
-7 7>=9 �� MF>, o 9//IlL Mom.
Type of Buistling: L
Dwelling No.of Bedrooms _ Lot Size ��5� sq.ft. Garbage Grinder(X4
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design.Flow gallons per day. Calculated daily flow gallons.
Plan Date // / o�j Number of sheets f Revision Date cu
Title
Size of Septic Tank r�"y 0/9 'Sock A/&``` Type of S.A.S. _ LE'064 F'lt-r
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: 12 o
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued
Signe VJ,
Date `S
c�
Application Approved by �' . Date
Application Disapproved for the following rea
Permit No. Date Issued
iNO. D \ �i` "F e� " 4L%
( JTHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r
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g PUBLIC HEALTH DIVISION -TOWN.OF BARNSTABLE., MASSACHUSETTS
01ppYication for 0i.5pogar *p! tem Con5ftu'etioui 3permif
Application for a Permit to Construct( )Repair(�/S Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Addressor Lot No. Z 3 Z (U14 1 L 'C�k� ' Owner's Name,Address and Tel.No.
rt. yin rev, ii ,.�,. �r �l �7Z�y� J< 7-7/ VZ5 7
Assessor'sMap/Parcel _
Installer's Name,Address,and Tel.No,
Designer's Name,Address and Tel.No.
i Type of BuMmi g: '" r
Dwelli%ng No.of Bedrooms_ Lot Size L sq.ft. Garbage Grinder( (4
f, Other Type of Building No.of Persons Showers( ) Cafeteria
Other Fix"tunes
Design Flow gallons per day. Calculated daily flow --gallons.
Plan Date 1'Sr Za`/ Number of sheets / Revision Date
Title
Sizeyof Septic Tank TYPe of S.A.S. � ' ''� ! ''> f
Description of Soil /y,1 'S �'� ���k
4
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:w
/? ��' C
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system inoperation until a Certifi-
cate of Compliance has been issue�,�tl'is oard-of H lth
Signe lie Date < /
a
Application Approved by xv _Date
Application Disapprove or the following rea
Permit No. — Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance /
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired (vl Upgraded( )
Abandoned( )by� COI�TTJ A/,71-a a&ev ;A—,
at Z Z GvhI' ,2e 1--er �/ C'h�x°/v� / e has been constructed i ,accordance
with the provisions of Tuttle 5 and the for Disposal System Construction Permit No dated 1
Installer \ Q�c-�(e� 0 Designer
The issuance of this pem shall�not be construed as a guarantee that(the yste . �111] nction as designed.
Date �1) t t� 7 Inspector_ i � �.Jl_�1 .=�•
-.�,—ems- �
-- ---
- . No.—— — — Fee-- -�=E�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Ii.5pozar 6p5tem Con!5tructiou Vermit
Permission is hereby granted to Construct( )Repair( )Upgrade )Abandon
System located at Z�,3 G�-�i/?%f" ���' %C9/
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 m i st be co pleted within three years of the da e of th�s-permTt.
Date y ) Approved b r y
_
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TOWN Of BARNSTABLE
OCATION W���L DA T4 SEWAGE # 9 I�
LAGE ���'� ASSESSOR'S MAP & LOT
'INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / OU D
LEACHING FACILITY: (type) � � l�X� � I �� (size) �d�
1
Nti.OF BEDROOMS
BUILDER OR OWNER 17
PERMIT DATE: 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 leachi�g facility) Feet
Furnished by Z/1 SpG�T I!!n -J7 FO J/G
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TOWN OF BARNSTABLE
LC?.CATION OZ30. A1,4,,7Z2-cl.A,,r_ 77Z4-/4_ SEWAGE # s- I�
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VILLAGE ASSESSOR'S MAP & LOT �,ee2
INSTALLER'S NAME&PHONE NO. 1-f1!L<aJ tb-*Istr "»/ Y/ 4
SEPTIC TANK CAPAC= O'D 0
LEACHING FACIL=: (type) VI/T-S (size)
N"0.OF BEDROOMS -.-'3 1
BUILDER OWNERS soft qn
PERMITDATE: COMPLIANCE DATE: 4 ZZ4 AS-
Separation Distance Between the:
Maximum Adjusted.Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any.`wells exist �.
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
L
Furnished by
0
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;LOAT ION 3 � K'� ,S� �W� E PERMIT N
if VILLAGE (�
V I LLB
UNS .�A LLER'S NAME & ADDRESS
B U D,E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 1Q' .7aw ��
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Tv, i\c-Toro
Town of Barnstable
I"E l°w Regulatory Services
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Thomas F. Geiler,Director
Baie.YSTesr.�. � .
Public Health Division
1619.
rEai. Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date:
Designer: S�+-'- A 11J t µG Od C Installer:
Address: POZ, Address:
On S�2� 5� was issued a permit to install a
(date) , A�Z Co (installer) C ki Tff ZV�L LE
septic system at Z 62-\d i T—c C' V-7 CA,I L based on a design drawn by
(address)
SvLL\VA0 IE�AG LAC_ dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic systern referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State& Local Regulations. Plan revision or
certified as-built by designer to follow.
N OF
PATER
suuivNa
talle ' ignature) 00.29733
CIVIL
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLLANCE NVILL NOT BE ISSUED UNTIL BOTH THIS FORD AND AS-
BUILT CARD ARE RECEIVED BY THE B_4RNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Desiper Certification Form
SULLIVAN ENGINEERING , INC .
January 13,2005
Thomas A. McKean,Health Director
Barnstable Health Department
200 Main Street
Hyannis,MA 02601
SUBJECT: 232 White Oak Trail
Septic System Expansion
Dear Tom:
For your consideration, we are forwarding you information regarding a proposed
expansion at 232 White Oak Trail, Centerville, MA. The property has been inspected by
James Ford, a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310
CMR 15.000). His findings indicate that the system passes and according to our analysis of
the system design, there is a total leaching area capacity of 834 gallons per Section 15.301(5)
=_ System Inspection. The proposed expansion from three (3) to four (4) bedrooms would
require less capacity than the design capacity under the 1978 Code. The analysis also
identified that no garbage grinder was proposed in the past, nor for the future at this
property.
Sincerely,
Peter Sullivan,P.E.
CC.: Timothy Acton
Moore Survey Associates
Enc.: Design and Plan
•
Official Title 5 Inspection Form
7 PARKER ROAD, P. O. BOX 659, OSTERVILLE, MA 02655
TEL: (508) 428-3344 PSu11PEQao1.com FAX: (508) 428-3115
Sullivan Engineering, Inc.
7 Parker Road -P.O. Box 659
Osterville, MA 02655
Project: [23i2
mothy Acton Mailing: Timothy Acton
White Oak Trail 232 White Oak Trail
enterville, MA 02632 Centerville, MA 02632
Septic Design Analysis:
Residential Flow: Bedrooms 440 gal
110 x 4 =
Septic Tank Requiements: 660 gal
440 x
Existing 1,500 gal Tank(H-20) minimum
Leaching Area Provided(Existing Leach Pits):
Pit Stone Pit
Radius Radius Height #of Pits
3 1.5 5 2 Area
x 2 = 127.23
Bottom 63.62 --- "' 2 = 282.74
Sidewall 28.27 x 5 x
Total Area= 409.98
Check: SF Prov. Factor
�1 �127.23�gal. =
12723 x 1
282.74
x 2.5 = 706.86 gal
Total based on 1978 Code 834.09 gal
Indicates a capacity for 7 bedrooms 770.00 gal
Two Existing H-20 Leach Pits Capacity OK
OF
W.3�11.UVA�
civil733
Leaching Chamber Provided:
r-
COMMONWEALTH OF MASSACHUSETTS
UV EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 232 White Oak Trail
Centerville,MA 02632
Owner's Name: Timothy Acton
Owner's Address:
Date of Inspection: December 6, 2004
Name of Inspector:(Please Print) James M. Ford
Company Name: James M.Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signatur\sub
a!� Date: December 8, 2004
The system inspector sa copy of this inspection report to the Approving Authority(Boar&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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 232 White Oak Trail
Centerville MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
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:
2
�. Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 232 White Oak Trail
Centerville,MA
Owner: Timothy Acton
Date of Inspection: December 6. 2004
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 t 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:
3
sad
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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''/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for 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 System:
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.
4
F
t Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6. 2004
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 thi's inspection?
✓ — Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ — Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ 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 15302(3)(b)].
5
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 232 White Oak Trail
Centerville,MA
Owner: Timothy Acton
Date of Inspection: December 6. 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
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): n/a [if yes separate inspection required)
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2003- 147.000�eals.:2002-171.000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): ______gpd
Basis of design flow(seats/persons/sgketc.):
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
Source of information: Unavailable
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
✓ 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:
Installed on 6126195-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11 .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6. 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _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: ✓ (locate on site plan)
Depth below grade: 8"
Material of construction: ✓ 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: 1000 Qal.
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
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: 10"
How were dimensions determined: Measurinf stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage
GREASE TRAP: . None (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.):
7
Page 8 of 11
or
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 232 White Oak Trail
Centerville,MA
Owner: Timothy Acton
Date of Inspection: December 6. 2004
TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D box was level and clean No solids were present Speed levelers were present.
PUMP CHAMBER: None (locate on site plan)
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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6. 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
One leach nit 01)was dry. The bottom to Qrade was 9'. The cover was 32"below Qrade. The other pit(92)had 3.5'ofliqui
on the bottom. The scum line was approximately 4'up from the bottom. The bottom to—grade was 9.5'.
CESSPOOLS: None (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: None (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.):
9
V e
' Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 232 White Oak Trail
Centerville. MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
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.
ASAL,k a,
A 13 0
1 /06 i/` a
a 19(0 A/b
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y
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6. 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40+/- 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: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps the maps were showing approximately 40'+/-to groundwater at th
site. Using the Cape Cod Commission technical bulletin,the high ground water adjustment for this site(MIW 29 Zone C 10/0,
was 4.4'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees,either expressed,written or implied,relating to the system,the inspection and/or this report.
11
TOWN OF BARNSTABLE
LOCATION �3e� 44 0,67 ,,,s(- SEWAGE#.2Q0J--0 VJ-
-V"_`.LAGS ��rJ��r'yr��P ASSESSOR'S MAP & LOT
1 TdSTALLER'S NAME&PHONE NO. 17,g AAA,' Y.17 P9.t6
SEPTIC TANK CAPACITY oao /J7�a 6a
LEACHING FACILITY: (type) �� (size)
1'0. OF BEDROOMS
BUILDER 0 WNER
PERMTTDATE: 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 a ching facility) Feet
Furnished by , sv
OOO
O'
+ Ol ,
ti
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
�AIa oil? DECEIVED
DARLEI
G_o) _ _ JAN 0 4 2005
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEFT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 232 White Oak Trail
Centerville, MA 02632
Owner's Name: Timothy Acton
Owner's Address:
Date of Inspection: December 6, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: December 8. 2004
The system inspector shall sub lac.py 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 232 White Oak Trail
Centerville. MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
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:
2
t
ro -
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
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 CAR 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.
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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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 ''/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for 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 System:
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 11 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 232 White Oak Trail
Centerville. MA
Owner: Timothy Acton
Date of Inspection: December 6. 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
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): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2003-147.000 gals.;2002- 171.000 Qals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,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
Source of information: Unavailable
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
✓ 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:
Installed on 6126195-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of i l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION(continued)
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _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: ✓ (locate on site plan)
Depth below grade: 8"
Material of construction: ✓ 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: 1000 gal.
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
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: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were_present. The liquid level was even with the outlet invert There did not appear to be any signs of leaka e.
GREASE TRAP: None (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.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Commments(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.):
The D-box was level and clean. No solids were present Speed levelers were present
PUMP CHAMBER: None (locate on site plan)
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.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 232 White Oak Trail
Centerville. MA
Owner: Timothy Acton
Date of Inspection: December 6, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: _2-6'x 6'(1000 ag 1.)
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.):
One leach nit 0l)was dry. The bottom to grade was 9' The cover was 32"below grade The other nit(92)had 3 S'of 1Lguid
on the bottom. The scum line was approximately 4'up from the bottom The bottom to grade was 9 S'
CESSPOOLS: None (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: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 232 White Oak Trail
Centerville, AM
Owner: Timothy Acton
Date of Inspection: December 6, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
l F6 Ir a
a /9� ly6
3
y 3�
10
Page l l of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 232 White Oak Trail
Centerville, MA
Owner: Tintothv Acton
Date of Inspection: December 6, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40+/- 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: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable to o ra hic and water contours maps, the maps were showing a roxintatel 40'+1-to ground water at this
site. Using the Cape Cod Commission technical bulletin, the high ground water adjustment for this site(MIW 29 Zone C 10104)
was 4.4'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees,either expressed,written or implied, relating to the system, the inspection andlor this report.
11
�6NJE EGRESS
DOW&
DOW WELL
16'-3' 1 T-8"
VENTS
t I �
UNFINISHED _Z-8"
FURNACE. PLAYROOM BEDROOM
AREA r cLG r cLG
t—SMOKE ALARM -
— — I -
SMOKE ALARM
UNFINISHED
STORAGE AREA WORKSHOP
T CLG
4Alf
'-3"
UP 6'-9"CLG O SMOKE ALARM
SMOKE ALARM--.Q
t - Up _ - a NEW WALL
1
EXISTING �
_72 I
BULKHEAD El EXISTING WALL
PROPOSED BASEMENT RENOVATION PLAN
ec`NTc rZ1lLCL<-
IMF}
ASSESSORS MAP NO°
No .T�.._~_..�8Y . PARCEL NO:
. C9��e
FE
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration fur Di-tipuiul Works Tvatitrurtion 11rmit
Application is hereby made for a Permit to Construct ( ) or Repair ( L.�'ah Individual Sewage Disposal
System at:
W ------- :�.��... --------------- ----=---..----------------------------
----------------------------
Locati Address or Lot No.
(t O".ner Address
.........................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms-----------------------------------------.-_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
p'' Other fixtures
d ------------------------------------------------------------
w Design Flow--------------------------------------------gallons per person per day. Total daily flow.------------------------------------------gallons.
W Septic Tank—Liquid capacitv_......._._gallons Length________________ Width..---___---.__. Diameter-_--.-_-.--_-. Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet-------------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------- ----------------------------------------------------------------- Date----------------------------------'----
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_.......................
O04 ---------------------------------------'---'----._.._.....------"----'-'-'-----'--"------......---'----""---'--............---------'--------...........
Description of Soil--------------'---------....-----'------...-------------------'-----------'----'-----------------------------------....------....-'---------..................--------..
x
w
x --------------- -----'
U Nature of Repair or Alterations—Answer when applicable.-- ........D.Qb---- 1
AA
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health. I
c -�...� C •\—moo..... .....
-- ....._. ....._6 l
Application.Approved By ....
Application.Disapproved for the following reasons- --------------------....---....------------------------------------------------- -----------------------------------
.......................... ......... ........... ...................... ........ ......--------------------------
.............._._....... --------------------------------------
Dare
..
PermitNo- ------ --------------------------------------------------------- Issued -------------------------------------------
Date
—__— _——————
99
FB$ .. J......
THE COMMONWEALTH OF MASSACHUSETTS k
BOARD OF HEALTH `J '
TOWN OF BARNSTABLE,
Ap.pliration for Diinpu al World Tomitrnrtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( L4-,Ia-n Individual Sewage Disposal
System at:
c.d ...............--------------------------------••-•----•••--••••••-•-•-
Loca"ot -:'`ddress� �"` or Lot No.7..D
W Owner Address
C`C-------C'D�S�-U� ---off..) '
istaller Address
UType of Building Size Lot............................Sq. feevy
.-� Dwelling— No. of Bedrooms_ __________________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _------------------- ------ No. of persons----_____---..__-_--___.-_-_ Showers ( ) — Cafeteria ( )
Q Other fixtures -------••---------------•-------•------
llnr
R: SSes is Tank—Liquid ca acitv.._......._.g llo-ss P Len tlon per d---Width1 daily ---Diameter_ __-.-._._-_ Depth- gallons.
x Disposal Trench—No- -------------------- Width..._................ Total Length--._---_______-_---_ Total leaching area--------------------sq;;Mft.
Seepage Pit No...................... Diameter-----._-_.-.._--.-- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---------- --------------------------------------------------------------- Date....................................
Test Pit No. I.---_-_----._..minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.__----______-____- Depth to ground water----------------- .......
C� ............
-------• ----•..................................•-••-•-•---•---•--••----•-•----•------------•-•------•--•----•----------•--------•--------......
Descriptionof Soil.. -....................•-----------------------•-------------------------------------------------------------- ....-•--------
U ------------------••--•-----•--•------•-•--•-------------------•-•-----•---------••----••---•--------------------------•-------------•----•---------•
W ->,.
x ---...--••----
U Nature of Repair or Alterations—Answer when applicable.__ `�..._:._G ,.-
,!° --�_!�....----`-`.. .............................................__.Y"" _._.... )c/S 77^!L' Sj�S � ._._..... .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the boa d of health.
Signed 0-.4_ 23
.... .
f e
Application.Approved BY ....._C.�"°�-t..`-��--------------------_ 2 �
Dare
Application.Disapproved for the following reason.t: - -------------- -------------------------------------..------------------.._-----------------------:-..........
-------------------------- -------------
Dare
Permit No. f
Issued -----es_-.-.---.-
--- - ......................... -..... -
r/ Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T(O��WN OF BAR��TNSTABLE
ILQrtifi ate of Tomplii nre
THIJIS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
t by 1�l e�L c--'-t �'or�s /
Installer
at 23 �1-1 T'ti, b A\L- - N't'Lii1l_•
--..._..---------------- ---------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ----------------------------------_............ dated -----------------------............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEP AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Ins e
- =
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�f S -IS84, TOWN OF BARNSTABLE
No......:.................. FEs_ ....
�i��ro�ttl or�� C��n�#r�r#ion �erttti� ,
" t4 eon
Permission is hereby granted.._._...-�C. Y- •--------
to Construct ( ) or Repair ( an Individual Sew>age Disposal System Cam`
atNo......2Z w S ------------oup.-'- ------- ........ ..........----------------...._......--------------•--------=----------------...._-_`___
Street
1.
(_�
as shown on the application for Disposal Works Construction Reltmix_No-�_--- S y
--- Dated----. �1�.�._�. .._.---••-- '.
: . -------------------------------------------•-----------...----------••-•----
1v/ � Board of Health
DATE...........(! •-------------------------------------=
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
j
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated -A p , concerning the
r
property located at 232, c� �7� aA y Q meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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