HomeMy WebLinkAbout0091 WILD GOOSE WAY - Health 91 Wild Goose Way
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COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
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RECEIVED
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350 MAIN STREET MAR 1 8 2003
WEST YARMOUTH,MA
508-775-2800 TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 167 PAR 042
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner's Name: MELTZER,ZACHARY
Owner's Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Date of Inspection FEBRUARY 17,2003
Name of Inspector:(please print) JAM ES D. SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yannouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall sub /t 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 tot he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: ✓
I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to detenmine 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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in leaching 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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this fonn.)
NO (Yes/No)The system fails. I have detennined 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 detennine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a
mapped Zone 11 of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ Pumping infonnation 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 nonnal 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 infonnation on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
✓ Existing infonnation. 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)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of infonmation: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
./ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1996 PERMIT#96-172
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 18"
Materials of construction: Cast iron P40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 26"
Material of construction: ✓ concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,500 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: I,,
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: ASBUILT AND TAPE
Comments(on pumping.recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL.TANK AND COVERS 26"BELOW GRADE.OUTLET TEE,NO SIGN OF
LEAKAGE OR OVERLOADING.
GREASE TRA
P(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Fonn 6/15/2000 7
try
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alann level: Alann in working order(yes or no):
Date of last pumping
Comments(condition of alann and float switches,etc.):
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 IS 16"X16",34"BELOW GRADE.ONE LINE IN,THREE LINES OUT.BOX IS CLEAN,
LEVEL AND SOLID.NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
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:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS THREE FLOWS WITH Y STONE.FLOWS ARE 36"BELOW GRADE. 1"WATER IN FLOWS.
NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Title 5 Inspection Form 6/15/2000 10
Page I I of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 91 WILD GOOSE WAY
CENTERVILLE,MA 02632
Owner: MELTZER,ZACHARY
Date of Inspection: FEBRUARY 17,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 9 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation 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:
HAND DUG TEST HOLE. 9' NO WATER. TEST HOLE 4'6"BELOW BOTTOM OF FLOWS.
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I �J/TcM 1
Title 5 Inspection Form 6/15/2000 1 I
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wild Goose_Way r
Property Address
Dick Fairbanks
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20
required for every .._ _ _ _
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information / -
.
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
Key.
363 Whites PathVQ
Company Address
South Yarmouth Ma. 02664_
City/Town State Zip Code
�;Xw 508-477-8877 S114430
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 ``"�a�u�ut�n�u,,,�
2. ❑ Conditionally Passes •� \'�H�F MAssgcy
MICHAEL N
3. ❑ Needs Further Evaluation by the Local Approving Authority o; SEARS
* No.SI14430
4. ❑ Fails ��j•°FRrtF�``�'��,
%''' ,�IiN SPG`
3-6-20
Inspector's Sig na a Date T
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 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
J� 91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-6-20
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:
® 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:
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.
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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Disposal System Form -Not for Voluntary Assessments
Subsurface Sewage sp y Y
91 Wild Goose Way
Property Address
Dick Fairbanks _
Owner Owner's Name
information is
required for every Centerville Ma. 02632 3-6-20
page. City/Town 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.7/26/201a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
is
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
_ le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v-
91 Wild Goose Way
Property Address
Dick Fairbanks_
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20
required for every _ —
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
El 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
M1}i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-6-20
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%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.
❑ z 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 II of a public water supply well
t5insp.doc•rev.7/26/2018 r- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
6P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Dick Fairbanks _
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20 required for every Ce
- _
page. Cityrrown 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?
® ❑ 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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-6-20
page. Citylrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
Number of current residents: 2
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 ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available last 2 ears usage d 2018- 131000gal
g ( y g (gp ))' 2019- 142000gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: present
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M � 91 Wild Goose Way
Property Address -
Dick Fairbanks
Owner Owner's Name
information is required for every Centerville _ Ma. 02632 3-6-20
page. City/Town 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: NA
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined? —
Reason for pumping:
t5insp.cloc-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
n �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-6-20
page. Cityfrown 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:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 34"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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c , Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-6-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2'feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
1"
8„
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Tape, sludge gudge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
both covers at 2' below grade Inlet and outlet tees __..
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20
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 ❑ polyethylene ❑ 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
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
V - -
Property Address
Dick Fairbanks
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-6-20
page. City/Town 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.):
D Box is 16x16 with 3 outlets, cover at 31" below grade Sprinkler line over cover
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
91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20
required for every
page. City/Town 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:
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
r
I
f
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20
required for every --
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.):
3 Flow diffusors No sign of failure _
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
s Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
u-
Property Address
Dick Fairbanks_
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20 required for every _
page. Cityfrown 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.):
sem•Pa e15 of 18
t5inep.doc-rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal Sy t g
• c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
. s 91 Wild Goose Way
Property Address
Dick Fairbanks _
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20
required for every -_
page. City/Town 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20
required for every
page. Cityrrown 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: 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:
Hand Augered 10' below grade
bottom of leaching at 5' T
4' 6" no ground water
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Fig Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Dick Fairbanks
Owner Owner's Name
information is Centerville Ma. 02632 3-6-20
required for every _
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
15lnsp.doc•rev.7/261201a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
b
Page 2 of 3
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file:///T:/Public/Asbu i Its/Centerville/91%2OWild%20Goosc%20Way.gif 2/26/2020
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolln
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC
Company Name
rab P.O.Box 763
Company Address
Centerville Ma. 02632
remm City/Town State Zip Code
(508)428-4028 S14454
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
1/02/2008
In ect gn u r e 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.
91'wild goose•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wild Goose Way
M
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section b
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
B) System conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
91 wild goose•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public.health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
91 wild goose•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
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
El ® 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.
91 wild goose-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 91 Wild Goose Way
M
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ . ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
.E) Large Systems: To be considered a large system the system must serve a facility with a,
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"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
El : El the
— IWPA)or a mapped Zone Hof 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.
91 wild goose-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
C. Checklist .
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
r
❑ ® 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)]
91 wild goose•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c^M 91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
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
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry,system inspected? ® Yes ❑s No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage (gpd)): 2006:213,000
g ( y g 2007:359,000
Sump pump? ❑ Yes ® No
Last date of occupancy: 1/02/2008
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
91 wild goose•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Nicole Corson
Owner Owners Name
information is
required for Centerville Ma. 02632 1/02/2008
every page.. City/Town State Zip Code Date of.lnspection
I
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Capewide Enterprises,LLC
Was system pumped as part of the inspection? ❑ Yes 0 No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
System installed 1996
Were sewage odors detected when arriving at the site? ❑ Yes ® No
91 wild goose•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
20'+
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
2'
Depth below grade:, feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1500 gallon
Sludge depth:. 0
Distance from top of sludge to bottom of outlet tee or baffle na
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle na
Distance from bottom of scum to bottom of outlet tee or baff
le e na
How were dimensions determined?
tank pump at inspection.
91wild goose-12/07 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
° M 91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be 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
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):
91 wild goose•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'01 Wild Goose Way
Property Address
P Y
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has 3 outlet laterals with equal distribution.No evidence of solids carryover.No
evidence of leakage into or out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order ❑ Yes ❑ No
91 wild goose•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type.
❑ leaching pits number:
® leaching chambers number: 3- Flowdiffusors
❑ 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.):
Sandy soil.No signs of hydraulic failure.No ponding or damp soil.
91 wild goose-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
- W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code' Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
/
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
91 wild goose-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Map a Page 1 of 2
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i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wild Goose Way
Property Address
Nicole Corson
Owner Owner's Name
information is required for Centerville Ma. 02632 1/02/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 15'
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:
As-Built Card
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Used:Gaherty& Miller model 12/16/94 ground water elevations.USED:USGS Observation Well
Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of ground water elevations.
91 wild goose•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
THE Town of Barnstable
OF 1p�
yP� Regulatory Services
„STABLE Thomas F. Geiler, Director
s�
9
6 Public Health .Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
No. Fee
— THE COMMONWEALTH OF MASSACHUSETTS
g���PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MAS ACHUSETTS
application for Migool *pgtem Congtructiou 30ermit
Application is hereby made for a Permit to Construct(X)or Repair( )an On-site Sewage Disposal Syst at:
Location Address or Lot No. Af V /67 /azh.t e_EZ clL Owner r and
Instal NqM, de an e1.No. ,o Designer's Name,Address and Tel.No.
P,ji �%�(/ 57 �u ff 1-t- °tS ,arc
993 ,e'av7Z-- 6,+,
Type of Building: Sad
Dwelling No.of Bedrooms Garbage Grinder(,vo)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �3`0 gallons per day. Calculated daily flow �� gallons.
Plan Date r & 9<® Number of sheets Revision Date —'
Title ii� S yS ��a 1r _ •�/ Geld rJ 1� �0��
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions 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 t B and of Health.
Signed Date
Application Approved by
Application Disapproved for the llowing reasons
Permit No. / h 17�L Date Issued
No. t t Fee
THE COMMONWEALTH OF MASSACHUSETTS
g PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for 3igpoof *psstem Construction Permit ,
Application is hereby made for a Permit to Construct(X)or Repair( )anrOn-site Sewage Disposal Sys te at: .
i
Location Address or Lot No. Af.V &07 Pete.eT cj/L Owner 1d r and Q �/ h/
4/ cv y —D 4rros rewz6
/7c/.
Install fie, dre s,and Tel.No. Designer's Name,Address and Tel.No.
A), C-41 Sr ,yam A rrr +s , vE u
923 ZcvTz- 6,4, "A, 1
8i3Z azU,S
Ty Sbe Type of Building: 36z "
Dwelling No.of`Bedrooms 3 Garbage Grinder Oo)
Other Type of Building No. of Persons Showers(+ ) Cafeteria(
Other Fixtures
Design Flow 3D gallons per day. Calculated daily flow _ 330 gallons.
Plan Date S !. !. Number of sheets / Revtiion Date
Title 57f15TZ--,-f 2>4s�4iy F\ax �f�1 yL t�yae (1p�-�•
Description of Soil 6i?x_)1>
i
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions 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 t B and of Health.
Signed r Date
z
Application Approved by.
Application Disapproved for t Bowing re sons.
q
Permit No. Date Issued
's
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( I or repaired/replac d on( )
by for t� � ,d 4G- - za :46
as 2 owAA has been constructe in accordance
with the provisions of Title 5 and the for Disposal System Wristruction Permit No. —dated,,; —
Use of this system is conditioned on compliance with the provisions set forth below:
No. `lam Fee Q
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS
Zigosal *pstem Construction Permit
Permission is hereby granted to
to construct(><�repair( ) n On-site Sewage S stem located at
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.
All construction must be completed wi 'n two years of the date below.
Date: Approved
< 2
ti
' TOWN OF B,W STABLE C�
SEWAGE#
VILLAGE ASSESSOR'S MAP&LOT&7
INSTALLER'S NAME&PHONE NO. e
SEPTIC TANK CAPACITY /-fA�pC
P
LEACHING FACILITY: (type) (size) .�� g
NO.OF BEDROOMS
BUILDER OR`6WNl✓k
PERMTTDATE:- — 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 bys9 � _
tulK .ej
,4 Z7 4 L ,..
8 ,5
3G, ,�
A � ��; 32`
f�G
AG= 1,13
TOWN OF BARNSTABLE OP 10" %
L;=JCf iiO?F/ 1MAJ 6o0a L,,n-L SEWAGE #
VILLAGE 992005 L e y1 Te r v,1 k ASSESSOR'S MAP &LOT 7*'e
INSTALLER'S NAME&PHONE NO. R.S c V I le, OR
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) P; 1 (size) 1 C�CX1
NO.OF BEDROOMS
BUILDER OR OWNER S,w. Mv r P�f
PERMTTDATE: yL COMPLIANCE DATE: 74'
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 oAlchi ng f//��ciliry) Feet
Furnished by �.c �� -
ouY �.
Lo�
15 '
c v P`^
G��-I
o o �
4-
�3. h�
!_ S
_ COMMONWEALTH OF MASSACHUSETTS g
EXECUTIVE OFFICE OF ENVIRONMENTAL FAIRS b
DEPARTMENT OF ENVIRONMENTAL PRO CTION �O
ONE WINTER STREET, BOSTON MA 02108 (617) 292- 0
81998 ~ Y CORE
VILLA=I F.WELD -,`Q2',` Secretary
ti
ARGEO PAUL CELLUCCI
D / . STRUHs
am**+issioner
Lt. Governor 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO
1 V7 PART A
CERTIFICATION
Go7" o�L
Property Address: Address of Owner: C1�
Date of Inspection: q(r i�c1ca (If different)
Name of Inspector: tC�nr.t� � � C:
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: T Mailing Address:� i—i rr
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and
complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance
of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails S
Inspector's Signature: Date: t S CJ
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
VVI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any
failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y. N. or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the
septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure
is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 04/15/97). Page I of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property'Address:
Date of Inspection' ;�
BI SYSTEM CONDITIONALLY PASSES (continued) a
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or
to a broken settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health).
Describe observations:
�j broken pipe(s) are replaced
" � obstruction is removed
distribution box is levelled or replaced y
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection
if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
Cl 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 the
public health. safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMrq-ES THAT THE SYSTEM IS NOT FUNCTIONING IN A
. MANNER WH3,CH Ni'ILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE E\'VIRONMENT:
_ 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) SYSTEAI WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETER,NUNES THAT THE SYSTEM IS FUNCTIONING IN A DIANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank�and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.'
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
Method used to determine distance (appro)imation not valid).
3) OTHER
(raised 04/25/97) Page 2 or io
h
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
e
Date of Inspection:
DJ SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Yes No
Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System. cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds. ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/15/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART B
CHECKLIST
Property Address: Ott W%kA GjoC,0-.,
Owner: Q *-'W
Date of Inspectio ,tt15�
6
Check if the followingdone: You must indicate either "Yes' or "No" as to each of the following:
have been
es No
Lion was provided b the owner, occupant, or Board of Health.
Pumping informs Y
— P g P
— None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
v t been introduced into the system recently or as pan of this inspection.
Burin that period. Large volumes of water have no b Y
g P 6
�poses�
— Ai-bttilt plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
— The system does not receive non-sanitary or industrial waste flow.
— The site was inspected for signs of breakout.
)( — All system components. excluding the Soil Absorption System, have been located on the site.
— The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of.baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge. depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
— Existing information. Ex. Plan at B.O.H.
— Determined in the field (if any of the failure criteria related to Pan C is.at issue, approximation of distance is unacceptable)
(15.302(3)(b))
(revised 04/u/97) Page 4 or to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Q( tW%1A
Owner: Copw0 j
Date of Inspection. C`„\ A$
l` \ e
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 33c p.d./bedroom for S.A.S.
Number of bedrooms: 0'6
Number of current residents:
Garbage grinder (yes or no): ft
Laundry connected to system (yes or no): t,
Seasonal use (yes or no):-t—j
Water meter readings, if available (last two (2) year usage (gpd): P-->
Sump Pump (yes or no):�
Last date of occupancy: 11i
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GE\'ERAL INTORNIATION'
PUMPING RECORDS and source of information:
System pumped as pan of inspection: (yes or no)_
If yes, volume pumped: Gallons
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)�u
(revised 04/25197) Page 5 of 10
{ b�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: W,\�
Owner:
Date of In�pecfi�o,- �,
BUILDING SEWER: \
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: 4
4C S
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal. list are _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: �00
Sludge depth: �,u t�
Distanct from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 1" a
Distance from top of scum to top of outlet tee or baffle: S �t
Distance from bottom of scum to bottom of outlet tee or baffle: 4
How dimensions were determined:lA/l o ►►n
Comments:
(recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet i vert, structur inte city.
evidence of leakage, etc.) ��^ 111 N
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity.
evidence of leakage, etc.)
r
i
(mvised 04/25w7) Page 6 of 10
r r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: j wi Q
Owner:
Date of Inspection:
TIGHT OR HOLDING, TANK: kA-) (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in workine order _ Yes. _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches. etc.)
rISTRIBUTION BOX: WA
(locate on site plan)
Depth of liquid level above outlet invert: Q.&
Comments:
(note if level and distri utipn s equal, a idence of solids carryover, evidence of leakage into or out of box, etc.)
a[ � � �C�U, .d�/�►Y-- r� Wf S �� R M CI�.�QNL I cr L31L�.�d 1�ti
PUMP CHAMBER:—t_�-o
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(rertsed Osr3/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: I1 1u--4 C-AcoS—
Owner•.:
Date of Inspection: G t tjkl
,SOIL ABSORPTION j SYSTEM (SAS): l S
(locate on site plan, if possible. excavation not required, but may be approximated by non intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:ay
leaching galleries, number:
leaching trenches. number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
e etati tr, etc.)
(note condition of il. signs of hydraulic failure, level pon 'ng, ndition of v
a
CESSPOOLS:.
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 04125/97) Page 8 of 10
X
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ( W.0 F700&Q•,
Owner:
Date of Inspection:
a
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
V
a a
At ` tq'Y" .fit- iy '�►,
qu bt-- 33 "
(revised 04/25197) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: ceg"t-i"
Date of Inspection:
Il ( o
Depth to Groundwater t I�Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
uObservation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed) 1
�f,5,s.¢a�a5cr Surnc�s� U1�y�o�tG � 11�1 (( 1S (�.14, �`�Z �34 ,
(revised 04/25/97) Page 10 of 10
TOWN OF BARNSTABLE
LO '$ '1'ION v� 1 w k (_)00&&_ W SEWAGE #
VILLAGE `�,`�- ASSESSOR'S MAP & LOT 1(0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ►SOO
LEACHNG FACMITY: (type) r�0bi Ut ('IASSO*_5 (size) 3
NO.OF BEDROOMS 3
BUILDER OR OWNER CA0W0,!I
PERMTTDATE: 16115ACOMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility + I Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) . +j(A Feet
Edge of Wetland and Leaching Facility(If any wetlands exist �91 �, Feet
within 300 feet of leaching facility) .
Furnished by I_Lo_ C a�4D
1
A
Q44n.,
u 1
t
� 3
9
Al- ►S`� ,g1` �`�����
�-ab
A BZ
A3
'
2
,� „ a
s
TOWN OF B STABLE C�
LOCATION/$ � 9 SEWAGE#
VILLAGE_ �2y
ASSESSORS MAP&LOTAK
1 INSTALLER'S NAME&PHONE NO. e
i
y SEP'�C TANK CAPACITY cp-
j� P
LEACHING FACII,TTY: (h'Pe) Ce� �� r�si ' (size) �.f'� `3��d
kk
NO.OF BEDROOMS
BUILDER OR e i-Vag 4.'A
PERMTTDATE:'�"'�/b COMPLIANCE DATE:
i
Separation Distance Between the:
i
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 leachin facility)ty) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
j Furnished by_ 1,YA 4 41",jj
But KV tj
A 1 = ADS 14
q' yp'
33
GENERAL NOTES : I N VER , ELEVATIONS : DES / GN CR / TER / A
ACCESS COVERS MUST BE WITHIN 9' MINIMUM. INVERT AT BUILDING: _1QQyQ DESIGN FLOW:
1. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION 6" OF FINISH GRADE
104.50 3 ' MAXIMUM COVER INVERT IN SEPTIC TANK: _.1S2Q. D0_ -�BEDROOMS AT II() G. P. D. PER
OF THE SEWAGE DISPOSAL SYSTEM ONLY. FIRST 2' TO
BE LEVEL, j MIN 2' OF PEASTONE INVERT OUT SEPTIC' TANK:_ 99,Z5 _ BEDROOM EQUALS 2__G. P. G.
2. ALL CONSTRUCTION METHODS AND MA TER/AL S AND
i -- INVERT I N D I S T. BOX:
MAINTENANCE OF THE SEPTIC SYSTEM SHALL --`_:._,=-4�-PVC 3/4' - I l/2" D/A. NO GARBAGE GRINDER
CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SCHEDULE 40 - o ;rL! -= ---- ---WASHED STONE INVERT OUT DIST. BOX: __��1._ZQ___
BOARD OF HEALTH REGULATIONS. /00_-50 j -1S �yy00 $ �' 97 O
_loo. oo ; 4 -A �_ INVERT IN LEACH CHAMBER : 99. 00
ass eaFFLE � ----�----_" SEPTIC TANK REQUIRED
3 OUTLET 3-4 'X 8' FLOWDIFFUSORS BOTTOM OF LEACH CHAMBER : 97. 00
3. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER - - v-- X 200% - 660 GAL •
l0' MIN. _1_500 D-BOX W/3' STONE AROUND. l ' UNDER ADJUSTED GROUND WATER :AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER _ � � N/A
----_ ---- -- GAL \ - ------- SEPTIC TANK PROVIDED:____-- 1500 GAL .
THAN 3 ' IN DEPTH SHALL BE CAPABLE OF WITH- SEPTIC TANK 6' CRUSHED STONE OR OBSERVED GROUND WATER: N/A
STANDING H-20 WHEEL LOADS. MECH COMPACTED BASE _
BOTTOM OF TEST HOLE: 9I . 0 SOIL ABSORPTION SYSTEM REQUIRED:
4. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR PROF l L E : NOT TO SCALE DESIGN PERC RATE ---�--5_MIN/INCH
APPROVED EQUAL. SOIL TEXTURAL CLASS
5. BEFORE CONSTRUCTION CALL 'DIG-SAFE'. IRRIa4T/ON 104 28 EFFLUENT LOADING RATE - 0-74 GPD/SF
1-800-322-4844 AND THE LOCAL WATER DEPT. +IOJ.s WELL 4�` -.JO_GPD /-__0_7_4 GPD/SF
FOR LOCATION OF UNDERGROUND UTILITIES.
�`i► i PRO V I DED: I FFUSORS w_t3._
6. VER T I CAL DATUM I S: ASSUMED �1 C \ ` _
roJ.s� ST0NE-ARDUND---1.-'--UNDER_._ A-460 S,..F,___.�
7. FOR BENCH MARKS SET. SEE SITE PLAN. +100.1 +102.3 8� 46 31 'E
`�I ,/ N 4.
12 . 1 SOIL TES T P I T [%A TA �
8. NO DETERMINATION HAS BEEN MADE AS TO ,/ � 1
COMPLIANCE WITH DEED RESTRICTIONS OR ZONING // 1
/ 1
REGULATIONS. IT SHALL REMAIN THE CLIENTS ;/ ,/ 1 INDICATES INDICATES
RESPONSIBILITY TO OBTAIN ALL PERMITS. SPECIAL i 1 PERCOLATION = = OBSERVED
r 1 TEST - GROUNDWA TER
PERMITS. VARIANCES ETC. FOR THIS PROJECT.
L O T 4 1 I ►� TP• I -- TP• z -
9. IT SHALL REMAIN THE CLIENT'S RESPONSIBILITY Ii 1OZ.0 P-8685 l02. 0
0 2/704 + S. F. n I GRND EL. GRND EL.
TO HAVE THE PROPOSED BUILDING FOUNDATION / G. W.EL. N/A_ G. w.EL. N/A
DES/GNED TO ACCOUNT FOR THE EXISTING GRADE 101.s /
AND SOIL CONDITIONS AT THE LOCATION OF THE + Y �'+ HORIZON TEXTURE COLOR - OTHER - HORIZON TEXTURE _ COLOR_ OTHER
PROPOSED BUILDING, 0' - -- -- 102. 0 0' -�---- - 102.0
103.4
J-4•X S' FLOWDIFFUSORS 1 -} 0 0
I j �
\ W/J' 8 TONE AROUND. I' UNDER 102.e I i 4' ............................................................ 101. 7 4* ........................................................... 1101. 7
i/ �, c MED I UM /0 YR MED I UM l O YR
102.107 ! G SAND 411 SAND 411
\ Isov C \\ /" 5• ............................................................ 101.6 51 ........................................................... 1 1101.6
\\\ - sfprrc TANK \ 33't_- - J.e 1 O D LOAMY IOYR R LOAMY IOYR
D
SAND 5/8 SAND 5/8
\ 1� I D-Box '---- \ 24• ....C..... ...... oo.0 24 . ......... ... ... . ... ................................. aa. o
\ 1 I ; l
COARSE I DYR GRAVEL C If COARSE IOYR GRAVEL
\ poSED
1 SAND
\ \ I ......................................... 95.0 84 ........................................................... 5 0
L 6 6 SA 6/6
Tp#? pRopoSED THREE
3 aEDRooW DWELLING 12 MED l UM C2 MED I UM
ao ToF - 104.50 c SAND SAND
M l DEGt( \ u I
-- CID
oz m t 103.2
�0 `,` A< f
WATER
132 NO WATER------- _ 91.0
EXISTING
DWELLING
' 102.s I ►. DA TE: MAY 3. 1996
• �� TEST BY• STEPHEN HAAS
:.. I. a` QARAGE /of ' `-- -- -- ----------
l o'-I' \\ + Ut • 101.97
-• % 102\A u, � W'1 TNESSED 8Y: EU BARRY
�1or.o ! PERC RATE:---- ------- MIN/INCH
ao':
� I
/01.SJ S T / C' S y' S T EM D E S / G'A/
CATCH BASIN
RIM-101.47 ca / W / L D GO O S E W,-1 Y
101.36
^ CR/DH=1102.34 1
1 ��\ _ `�, , SA R /V S TA B L E . t can/ TER v I L L E- ; "A .
R 10 71
1 lol.vl
/'ILIA R K V4//0 O O C O R
F9� r� 99.3 CB/OH-100.O7 99.
a + S B7• '31 'W CB/DH-1o2.20 / / O B R EEO S H / L L R 0,4 O U/V / T / O H Y,4 /V/V / S MA
--- - ---- -----
Ilk
100 100.55 S (:,-,4 L E . - ? O MA
--- 99.so
aw L OCUS ,-
�' rt .
CATCH BA51N � YI14�G 1'��G I NFFR I NG , I�'G'0 L NCUDDER GY PA 7.N r90 3 R n Zl t o CA
NAY a�
y
L
CfA4 }'a r 17Z 0 u t h ® r t M�3 � 2 6'7 5
4/
------ 5 ® � > 32 -- 5 3 3 3
L 0CUS 11A P JOB NO: 96-259 FIELD:RVB/PDR CALC: SAH/CFW CHECK: CFW DRN: SAH