HomeMy WebLinkAbout0238 WHITE OAK TRAIL - Health 238 White Oak Trail
Centerville P
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
JAN 0 6 2004
TOWN OF BARNSTABLE
TITLES HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 238 White Oak Trail 9
CPntPrville� MA
MAP -.... ,
Owner's Name: ,Tenn F..1 stern PARCH
Owner's Address: LOT
Date of Inspection: 0
Name of Inspector:(please print) Wi 1 1 i am E_ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
I certify that 1 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 Sgction 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: 4V V Date: ",3--0 3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthvr
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 6/152000 page I
Page 2 of 1 I t
OFFICIAL N I SPECTION FORM—NOT FOR VOLUNTARY ASSESSM
ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 238 White Oak Trail
Centerville, MA
Owner: Jean Elston
Date of Inspection;
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S item Passes:
71 have not found an information which indicates that an of the failure criteria
y y na 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
repa ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Ans r yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
expla .
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the
existin tank is replaced with a complying septic tank as approved by the Board of Health.
"A me 1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicat ng that the tank is less than 20 years old is available.
ND ex lain:
bservation of sewage backup or break out or high static water level in the distribution box due to broken or
obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approv I of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND a lain:
e system required pumping more than 4 tomes a year due to broken or obstructed pipe(s).The system will
pass in pection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is V=nd
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 238 White Oak Trail
Centerville, MA
Owner.. Jean Elston
Date of Inspection:.
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 1ailing 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. Sys em 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:
_ I e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surfacce 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 P p i ate water supply well.
e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fronl a
priv to water supply well" Method used to determine distance
*' is system passes if the well water analysis,performed at a DEP certified laboratory, for colifonn
--bad eria and volatile organic compounds indicates that the well is free from pollution from that facility and
th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
f lure criteria are triggered.A copy of the analysis must be attached to this form.
3. then.
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 238 White Oak Trail
Centerville, MA
Owner: Jean Elston
Date of Inspection:jg-63 -Q 3
D. ,System Failure Criteria applicable to all systems:
Yo must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface
water supply.
y portion of a cesspool or privy is within a Zone I of a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Kato
upply well with no acceptable water quality analysis. (This system passes if the well water analysis,
erformed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds
ndicates that the well is free.from pollution from that facility and the presence of ammonia
itrogen 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.]
(Y /No)The s 310 Cystem fails. 1 have determined that one or more of the above failure criteria exist as
described inMR 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: Lar a Systems:
To be c sidered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd•
You in st indicate either"yes"or"no"to each of lite following:
(Tlte f llowing criteria apply to large systems in addition to die 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 We Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you h ve answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in ection D above the large system has faikd.The oxna at operator of arty large system considered a
significan threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.T e system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 238 White Oak Trail
Cent ry; 1 P MA
Owner: Jean E1 Gt-nn
Date of Inspection: IX—63—ej 3
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Ye No
_ _ Pumping information was provided by the owner,occupant,or Board of Health
V 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 tan1:manholes uncovered,opened,and the interior of the tank inspected for the condition �
of the b_affles 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 /
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(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: 238 White Oak Trail
Centerville, MA
Owner: Jean Elston
Date of Inspection: 0 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3
Number of current residents:
Does residence have a garbage grinder(yes or no): O
Is laundry on a separate sewage system(yes or no):0 [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):A-
v
Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 2—4 8, 0 0 0
Sump pump(yes or no):/1�1 U 2 0 01 —6 6, 0 0 0
Last date of occupancy: 1�3—v3
COMMER IAIANDUSTRIAL
Type of estat lishment:
Design flow based on 310 CMR 15.203): gpd
Basis of desi p flow(seats/persons/sgft,etc.):
Grease trap j resent(yes or no):_
Industrial w to holding tank present(yes or no):_
Non-sani waste discharged to the Title 5 system(yes or no):_
Water mete readings,if available:
Last date o occupancy/use:
OTHER escribe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:1"-10 allons,--How was quantity pumped determined?
Reason for pumping: .f V e I W-L
TYKE 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):�v
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: 238 White Oak Trail_
con rville MA
Owner: aean F1 -,ton
Date of lnspectlon: / %"^,s
BUILD SEWER(locate on site plan)
Depth bel w grade:
Materials f construction:_cast iron _40 PVC_other(explain):
Distance om private water supply well or suction line:
Common (on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_v(locate on site plan)
Depth below grade:
Material of construction: /concrete metal fiberglass_polyethylene
_othcr(explain)
If tank is metal list age:_ Is age confirmed b
certificate) I t y a Certificate of Compliance(yes or no): (attach a copy of
r
Dimensions: e V
Sludge depth: 4/—G '
Distance from top of sludge to bottom of outlet tee or baffle: ,p.T'
Scum thickness: % 6"
Distance from top of scum to top of outlet tee or baffle: c�
Distance from bottom of scum to bottom Aoutlet tee or baffle: )C1 * P
How were dimensions determined: 0 PC-- L o v
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evi ence of leakage,etc.):
CREASE P:_(locate on site plan)
Depth bolo grade:—
Material of onstruction:_concrete metal fiberglass_polyethylene other
(explain):
Dimensions-
Scum thic ess:
Distance fir m top of scum to top of outlet tee or baffle:
Distance fr m bottom of scum to bottom-of outlet tee or baffle:
Date of la s pumping:
Comment (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: 238 White Oak Trail
ri-ntarvi 1 1 a_ MA
Owner: jean E1 Qi-nn
Date of Inspection: c)3
TIGHT or OWING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below ade:
Material of construction: concrete metal fiberglass_polyethylene other(explain).
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm presc (yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last umping:
Comments ondition of alarm and float switches,etc.):
DISTRIBUTION BOX: y(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: (9
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.):
y�
PUMP HAMBER: (locate on site plan)
Pumps ii working order(yes or no):
Alarms i i working order(yes or no):
Comme is(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8 J
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Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 238 White Oak Trail
Centerville, MA
Owner: Jean Elston
Date of Inspection: I
SOIL ABSORPTION SYSTEM(SAS): V(locate on site plan,excavation'not required)
If SAS not located explain why:
Type
aching pits,number:_ 3 leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,'condition of vegetation,
etc.):
CESSPO LS: (cesspool must be pumped as part of inspection)(locate on site plan) t
Number a d configuration:
Depth—to of liquid to inlet invert:
Depth of s lids layer:
Depth of s um layer:
Dimension of cesspool:
Materials f construction:
Indication f groundwater inflow(yes or no):
Comment (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Material of construction:
Dimensi ns:
Depth o solids:
Comm is(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: 238 White Oak Trail
Centerville, MA
Owner: Jean Elston
Date of Inspection: .47- C) 3
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.
,K
0
., lit-
10
Page l 1 of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 238 White Oak Trail
Centerville, MA
Owner: Jean Elston
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 1 feet
Please" dicate(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:
P g
/Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: 6,S yr!
Checked with local excavators,installers-(attach documents on)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
6 6 S 1,17
11
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-a
238 White Oak Trail f'
Property Address ram?
M
Diane Kovanda (-
Owner Owner's Name
information is
required for every Centerville Ma 02632 5/8/2018 R
page. City/Town State Zip Code Date of Inspection '
63
�j
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
Title V Septic Inspection
Company
Na
� Company Name
74 Beldan Ln.
Centerville Ma 02632
Cityrrown State Zip Code
774-2484850 smjonestitle5@gmail.com S14522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5/8/2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 238 White Oak Trail Centerville is served by a Title V septic system consisting
of a 1000 gallon septic tank, distribution box, existing leach pit and 3 Infiltrators. The system was
found to be in proper working condition at the time of inspection.
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):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owners Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El ® 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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,..°� 238 White Oak Trail
Property Address
Diane Kovanda
Owner Owners Name
information is required for every Centerville Ma 02632 5/8/2018
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owners Name
information is required for every Centerville Ma 02632 5/8/2018
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of.design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is Centerville Ma 02632 5/8/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
system repaired 4-8-97
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth: 611
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
3"
Scum thickness
3"
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? opened covers, took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
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
t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,..'° 238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Distribution box was in good condition, no rot, water level was even with outlet invert.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
® leaching chambers number: 3 Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
s.a.s. consists of the original leach pit and 3 infiltrators installed 4-8-1997. The leach pit was video
inspected and found to have 5'of standing water. The Infiltrators were video inspected and was found
to be dry with no sign of past overloading.
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , 238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M yy� 238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
<�\\
/� Ar 6
3
° ,
!3( yB 6 °
z
AZ ZD•6
62 s�
A3
L3 30'�
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
w u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
238 White Oak Trail
Property Address
Diane Kovanda
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/2018
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r -i •l
TOWN OF BARNSTABLE
I.6CCATION �23� l,�l,(a� f3� 1 SEWAGE # �'��
1.17
V; LAGE wZ ASSESSOR'S MAP & LOT oav•_�
INSTALLER'S NAME&PHONE NO.�� r M �6 �9S-�s 7 7
SEPTIC TANK CAPACITY .16 6 �
a
LEACHING FACILITY: (type) —�� f�t. (size) 4' I o-
NO.OF BEDROOMS
BUILDER OR OWNER L,,I�
PERMIT DATE: 3 C COMPLIANCE DATE:
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
Furnished by
113
IY
JiJ �
9 Fee
�
No. 2- 50.00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpphratton for Miopozal *p!tem Congtrurtton Vermtt
Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
238 Vhitc 03k 'mil Cataville Jean ELsbm
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. �JiT)s�I Septic
P.O. Box 1089
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( r)cj
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 Sa WC1ra _1
Nature of Repairs or Alterations(Answer when applicable) Tnst011 d—brx and
3 stmTa1 kfi C U J+e! .s
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Co e and not to place the system in operation until a Certifi-
cate of Compliance has been issued y t ' �doaltlhi
Z�� n
Signed L Date .�~
Application Approved b Date
Application Disapproved for the following reasons
Permit No. Date Issued
LOCATION TOWN OF BARNSTABLE
�
VILLAGE SEWAGE #
_� ,, 7
INSTALLER'S N ASSESSOR'S MAP a LOT
NAME a PHONE —'N0.
SEPTIC TANK CAPACITYLEACHING FACILITY: (type)
NO.OF BEDROOMS (size)
BUILDER OR OWNER Zs
PERMTTDATE:
COMPLIANCE DATE:_/
Separation Distance Between the:
M um.Adjusted Groundwater Table and Bottom of Leaching Facility Private Water SuPPIY Well and Leaching Facility g �ty Feet
on site or within 200 feet of leaching facility any wells exist
Edge of Wetland and Leaching FacilityFeet
within 300 feet of leaching facility)
(If an y wetlands exist
Furnished by
. Feet
a}�
Jv
L -
—L.._..........—---——
ori
Y a , 50.00
No.9 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppYication for Mioogar *p5tem Construction Permit
Application for a Permit to.Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System, ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
2M 6+litre Oak Tcm1 a3tan&Ue jem EGM
Assessor's Map/Parcel
Installer's Name,Address, d Tel.No. Designer's Name,Address and Tel.No.
l.�.W.E. rxm Sepbo
I . p.O. B3C 1089
E Type of Building: ,
Dwelling No.of Bedrooms 3 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 S WCA-dw1- {
Nature of Re airs or Iterations(Answer when applicable) IrstaU d-bm and
Date last inspected:
Agreement: '" {
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Env'ronmental Co e and not to place the system in operation until a Certifi-
cate of Compliance has been issued y t ' d ealth.
Signed _ / Date
'k Application Approved by_ r' Date
Application Disapproved for the following reasons -
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 X Upgraded
N g P Y P � ( )- Pg ( ) '
'i Abandoned( )by W.E. lld*is t1 ftdb Smdm
at C�lc has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 19 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. J
Date t_! _ U 7 Inspector
i
No. �7` ���----------------------------
Fee �.Q0
y
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi5pogat *pgtem Con.5truction Permit
Permission is hereby ranted to Construct( )Repair( X,�QUpgrade( )Abandon( )
System located at 6Ute OE k TmU �"'
by W. ELL Rt&a al Septic
fand as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to 1
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: 3 126167 7 Approved-
NOTICE: This form is to be used for the repair of failed
septic systems only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS).
I,William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated 3`� "� ; concerning the
property located at 238 White Oak Trail, Centerville 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 obseved 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: e/' 1 ��.(� DATE
6.
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60
is h.r
(Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification
plot plan,this plan should be submitted).
. .fi
•yy
0
i
�A
i
4% d ,� )
03?
5EWo,64E PERMIT MO,
IW5TQLLER'S 1 &NAE ADDRESS
- IV- - - - - - -
- _ .BUILDER 5 ADDRESS
DQTE .P.ERNAT ISSUED
-DATE COMPLI &MCE ISSUED ;
D Fof 3
5 LIb�✓t v�ti1�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H EA T
--..--.oF ...... .. ... ...................................--...........
Appliration -for Uiipoial Works Cnonutrurtion Vrrngit
Application is hereby*made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......................................./ •-•-- -••.••......................f.__...------�----------•--------------P-•-•.....------•---
Location•Addres or Lot N�
S !---------------------------------- ............................ S�.1 � .._..................._.
Owner ,Address
Installer Address C U Type of Building Size Lot...... _. --__`_----------'Sq. feet
Dwelling—No. ,of Bedrooms------------ _______________________Expansion Attic (,,Li) Garbage Grinder (�^
pa, Other—Type of Building ---------------------------- No. of persons........f!------------------ Showers ( ) — Cafeteria ( )
0.' Other fixtures`------------------------------ -
W Design Flow......�..............................gallons per person per day. Total daily flow............. g Z�'-'t1--------------------gallons.
WSeptic Tank�.iquid capacitv.IUW---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-------...__....__..---.
Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground
" L
w�ralter-_.-..._.--_'-----.__..--.
--------- --------- . .... . ....... ......... �7__
'd"+� G.""
------------- --- --- - -. .................----- --_----.--..-----------------------.--------- -
V .O Description of Soil.- <
W
VNature of Repairs or Alterations—Answer when applicable.---------------------------------------------------------------------------------.------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
76`Signe _ 2-�—.....................
.....
Date
Application Approved BY . { -
Date
Application Disapproved for the following reasons________________________
--------•------------•----------•------•---••----------------------- --------------
.....------•-•-----•----•---•••-•••--•••••-------•-------•----•-----••-••----------••-•••------••-•-•-•--I-----------------------------------------------------------------------------------------------
Date
PermitNo..................................... ................ Issued.... ... -. ..........
Date
Date
No.........a
....... FEE /I) ................
........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H(E 4� LT
..... ............ ................................
-----OF........��_d . _
Application -for Bhipoiial Works Tonfitrurfilin Vrruift
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
.............................. 4- ---------........ ... ............ .............-/.� I ..... ...................................
Location-Address or Lot No
............... -------le�, ............. ..........................
1�0 --------------*---------------"......... ------------------ Address
W , ..5.......................... ................... I I
............................. . .�n.............Z ...............................................................................
Installer Address
Type of Building Size Lot...�J--j...C-.(-Vq-.Sq. feet
U Dwelling—No. of Bedrooms.--.--..... L................._._...Expansion Attic 4/ Garbage Grinder
Other—Type of Building ---------------------------- No. of pe.rsons.......i---_-------------- Showers Cafeteria.
Otherfixtures -------------------------------------------------------..............................................................................................
Design Flow--_--_ ...........................gallons per person per day. Total daily flow_________Z,_C--0-----------_-------gallons.
P4 Septic TLn44Liqtiid capacitykA-----gallons Length------tA........ Widtli__4.......... Diameter_____...._..... Depth----------------
Disposal Trench—No_ -------------------- Width___-----_---_-_-.--- Total Length--_--_-_---_--____.. Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter._...._............. Depth below inlet.....;?�........... Total leaching area------------------sq. ft.
Other Distribution box ( ) Dosing tank ( ) 0/ A-11 .- Cq- / V- 7-1-1,
Percolation Test Results Performed by-------------_ ......................................................... Date---------------------------------------
Test Pit No. I----------------minutes per inch Depth of Test Pit..-__-_--____--_--.- Depth to -round water------------------------
rX.1 Test Pit No. 2................minutes per inch Depth of Test Pit......_............. Depth to ground water-..-..-.-_--._---__--.-.
.; -1 1 ---7;,------------------------------------------------------------
0 --- -------- ......... .
Description of Soil-=..... ...... I , Z. 7........ .... . ..
--------- --------
-------------------------------
---
U ------------ ----- ..
. ....... ............ ....... --------------------------------------------------------
- ----------------------------I------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of healt�
----- -- ------
Signed kk---------1Z, ------ -----------
--
Date
Application Approved By..--. ..........
Date
Application Disapproved for the following reasons:................................................................................................................
............................------------------------- ........................................................................................................ -----------------------------------------
Date
PermitNo.-- ..................................................... Issued---------------------- .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... ..............OF...... ................................
'T.Wrtifirate of T"'limpliaurr
T,VI5j,LS-�TO CERTV; Y, That the Individual Sewage Disposal System constructed or Repaired
...........................................................................77...........................................................
JJ
In alter
at ----------- ----------------------------------------------------------
has been installed in accordance with the provisions of "Lk�t'i I XI of The State Sanitary Code as described in the
I '_'------2-5�/
application for Disposal Works Construction Permit NO.-_7__ -------------------------- dated ty-- 7
. ............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL C T ATISFACTOR�.,
DATE------------- .... ..... ....... Inspector....
-- ------- -- --------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(L7 J)
091 .....r& OF ........... ................................................ -d
No......................... '* .......**. .........* FEE.&................
Di.spaiial Norkq Tonfitrurtion Prrmit
I
Permission is hereby granted. Y_-e 1 f-
-- ,
9V...........................................................................................
to Constr c1 ®r Repai Vn..,Indidua sewage Disposal System j
... .......................................................Street
as shown on the application for Disposal Works Construction ermit .......... Dated-'-P-
.. .........................
//------------------------------------
7J7 Board of Healx
DATE.- .. ..............................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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