HomeMy WebLinkAbout0018 WHITE PINE LANE - Health `>..
_...18 WHITE PINE LANE, CENTE- s, RVILLE
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UPC 12534
No.2-153LOR
4ASTINGS. UN
Commonwealth of Massachusetts Ig'7' 03&
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 White Pine Lane i
u'
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. Citylrown State Zip Code Date of Inspection'
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms �A. Inspector Information 5/ir P qap
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return
key. Company Name
52 Rivers End Road
� Company Address
Teaticket Ma. 02536
City/Town State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5:.
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10/02/2020
Inspector's Signature
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
c , Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This 4 bedroom home has an H-10 1500 gallon septic tank with a D-Box feeding (3) 500 leaching
chambers with stone. At the time of the inspection no visible failure criteria was found.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain. t
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ 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):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
cam !% 18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 of a public water supply well
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is Centerville MA 02632 10/02/2020
required for every -
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
Z ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ali Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
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 plus
GPD
Description:
Number of current residents: 0
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
❑ Yes Z No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d town water
9 ( Y 9 (gP ))�
Detail:
In 2019-55,000 gallons were used and in 2018-90,000 gallons were used.
Sump pump? ❑ Yes ® No
Last date of occupancy: 2 weeks ago
Date
t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,r-P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 White Pine Lane
V
Property Address
Charles Maher
Owner Owner's Name
information is Centerville MA 02632 10/02/2020
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Per Owner tank was pumped apx 1 month ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 4411
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain): 2 pipes
Distance from private water supply well or suction line. town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c !% 18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. Citylfown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 36"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:
H-10 1500 gallon
1„
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
35"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined? sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�� - Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is Centerville MA 02632 10/02/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
concrete metal fiberglass❑ ❑ ❑ El polyethylene El other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Iti Title 5 Official Inspection Form
<� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u—
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is Centerville MA 02632 10/02/2020
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u—
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection no visible failure criteria was found.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 White Pine Lane
V�
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
. Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 White Pine Lane
u—
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Assessing As-Built Cards https:Htownofbamstable.us/Departments/Assessing/Property_Valu...
TOWN OF BARNSTABLE
LOCATION;'Y SEWAGE# 9-1 o_
VILLAGE r rrl /i/ci: ASSESSOR'S MAP&LOTJj O.'G
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /f 00
LEACHING FACnM:(type) 3• 0
NO.OF BEDROOMS y
BLMJ5EROROWNER
PERMITDATE: I/- -99 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 feu of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 fTe}of leaching f ty) - Feet
Furnished by
f"
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1 of 1 10/2/2020,9:15 PM
Commonwealth of Massachusetts
�n ►` Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is Centerville MA 02632 10/02/2020
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12 plus feet
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:
I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 White Pine Lane
Property Address
Charles Maher
Owner Owner's Name
information is required for every Centerville MA 02632 10/02/2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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TOWN OF BARNSTABLE
LOCATION /g Gl�LiiTF SEWAGE # 9q' 2
VII.LAGE lfr'kinfeVI/11 ASSESSOR'S MAP &LOT/87-O3e, '
INSTALLER'S NAME&PHONE NO. u'I'I-O;?
SEPTIC TANK CAPACITY
LEACHING FACIIITY: (type) 2!1u 14AE11 (size) 33 k l 3
NO.OF BEDROOMS y /
BUILDER OR.OWNER
PERMTTDATE: f/, 219 COMPLIANCE DATE: //- c/-91
Separation Distance Between the: .
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility: Feet ;
Private Water Supply Welland Leaching Facility (If any wells exist .,
r{ z on site or within 200 feet of leaching facility) Feet a
y Edge of Wetland and Leaching Facility(If any wetlands exist
' l within 300 fee of leaching face'ty) Feet
Furnished byi �: y
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t TOWN OF BAMSTABLE O
LOCATION /g ��i rF p//�/-G l 4kv e, SEWAGE #
VILLAGE fir_-hT-i-✓1119 ASSES G
ASSESSOR'S MAP & LOT -03
INSTALLER'S NAME&PHONE NO. 1/77- 4 d b.S`6R- O-e- R an-,Y 5
SEPTIC TANK CAPACITY zrVo
LEACHING FACILrrY: (type) I'S00 Gel,19,11 (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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 faci 'ty) Feet
Furnished by
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No. Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprtcatiou,for Miq;paaf *pgtem Cougtructfou Permit
Application for a Permit to Construct( epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /Q G*jrl�- 101% .e_ LLi3 q e- Owner's Name,Address and Tel.No.
Assessor's Map/Parcel /s, d
Installer's Name,Address,and Tel.No. Ll,7,7-O:5 q q Designer's Name,Address and Tel.No.Type of Building:
Dwelling No.of Bedrooms 5/ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of epairs or Alterations(Answer when applicable) nlS r`i // �F.S.f/0r�81 t
oL3 U s L;rW61 4I'<a
el ' `7n e «iceg/i av -
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of He th.
Signed _ es ate Z/- 2 yp
Application Approved by ® ate
Application Disapproved for th ollowing reasons
Permit No. Date Issued
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
i Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpprication for Dtgool *patent Con.5truction Permit
Application for a Permit to Construct( air( )Upgrade( )Abandon( ) ❑Complete System ❑Individ a1.Components
Location Address or Lot No. /Q' Vh;,rl: .16 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
�= L
Installer's Name,Address,and Tel.No. C,17�J- 03 V 9' Designer's Name,Address and Tel.No.
" Type of Building:
Dwelling No.of Bedrooms Lot Size --" sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons` Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
A Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
k Description of Soil
Nature of epairs or Alterations(Answer when applicable) F�/� Fx/Sti'l7ri �h.s.s,/�a®/.s Zvi
'o
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
_ in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thi Board of Health.
Signed o ate//- 2
Application Approved by 611" Date
Application Disapproved for th ollowing reasons
Permit No.M ! Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(---"Repaired( )Upgraded( )
Abandoned( )by J s r� 0:4
at f 49 i = i 0-t L/4,W rfl=wrlsF,-tlllle has begrn constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. alhated
Installer /0 " 6,0.1101105 Designer "'A
The issuance of this p s alhnoT be construed as a guarantee that the sy em will function/as designed/ p it Jam)
Date �'� Inspectorf^? �1 .I �.f r� A //1/Vtli(�, `
z�
No. M Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
1=igpo2;ar bpgtem Construction Permit
„ w Permission is hereby granted to Construct(4--y Repair( )Upgrade( )Abandon
System located at /$ Gc/Li 1,711 A c 4,441-e-
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
" comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must a co p ted within three years of the dateter mit Date: Approved b l'
s
I/6199
NOTICE: 'This Form Is To Be Used For the Repair Of Failed
,Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS C-0-NSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, o `i_���c l��r�os , hereby certify that the application for disposal works
construction pe:rtnit signed by me dated 11— .2 99 concerning the
property located at /g al�iT� meets all of the
following criteria:
I
f/f'he failed;y,;tem is connected to a residential dwelling only. There are no commercial or business '
uses associated with the dwelling. j
4
4--the soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. , w
ere are no wetlands within 100 feet of the proposed septic system 1
1
4- There.are no pnvate wells within.150 feet of the proposed septic system
The is no increase in flow and/or change in use proposed
Ther arno
rariances requested or nexded
e bottom of the proposed leaching facility will not be located less than five feet abo
ve e the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable] —
• If the S.A.S. Mll be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facil;:,y will got be located less than fourteen(14)feet above the ma�cimum adjusted
groundwater table elevation, !
Please complete the following:
A) Top of Ground Surface Ie:vation(using GIS information) I
B) G.W, E.1evation
f�
_+the VAX. High G.W. Adjttstment j�_ �a
DERF:r10E BETWEEN A and B
SIGNED : �d�e��
(Sketch proposGe-;'plan of DATE.q:two folds_ system on back]. —
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