HomeMy WebLinkAbout0117 WILD GOOSE WAY - Health 117 Wild Goose Way
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cam, Commonwealth of Massachusetts
�u Title 5 Official Inspection Form
lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r
117 Wild Goose Way 4
u
Property Address r t
Jeanne Hynes
Owner Owner's Name `
information is required for every Centerville Ma. 02632 8-20-20
page. City/Town State Zip Code Date of Inspection -
r i
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.
fmngoutf Important: A. Inspector Information �1# �y�&9
filling out forms
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 Path
r� Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 SI 14430
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
`\```��H OF Rq
2. ElConditionally Passes q�y
MICHAEL .N
3. ❑ Needs Further Evaluation by the Local Approving Authority `o. SEARS
No.SI14430 •0
4. ❑ Fails %*' riF�``�
N SrPG````���
8-20-20
Inspector's S 19pilure 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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
I
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
+- �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� 117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name,
information is
required for every Centerville Ma. 02632 8-20-20
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 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
{ _ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V
� 117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is Centerville Ma. 02632 8-20-20
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not,functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
page. Citylrown 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 aye triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
cam, Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
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
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ E 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
❑ El Area
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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1,
117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
page. Cityfrown 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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z ❑ 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
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
�1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 2018-124000ga12019-171000ga1
Detail
I
Sump pump? ❑ Yes ® No
Last date of occupancy: NADate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
iIb Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
G � 117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
page. Cityrrown 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: 2018
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 8 of 18
c Commonwealth of Massachusetts
i� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�—
117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is Centerville Ma. 02632 8-20-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1999 #95-705
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
8'6"
Depth below grade: 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
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Wild Goose Way
u�
Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
page. City/Town , State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
7, 8„
Depth below grade: feet
Material of construction:
® concrete ❑ metal . ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:.
1500
Sludge depth: NA
Distance from top of sludge to bottom of outlet tee or baffle NA
NA
Scum thickness
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? NA-due to depth of tank
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 gal tank outlet cover under blue stone patio with outlet tee in place
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
+- I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 Wild Goose Way
u
Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
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 El 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
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
�0 Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is Centerville Ma. 02632 8-20-20
required for every
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 2 outlet pipes box is at 91 with cover at 26" below grade
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Wild Goose Way
u—
Property Address
Jeanne Hynes
Owner- Owner's Name
information is Centerville Ma. 02632 8-20-20
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:
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
page. Cityrrown 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.):
SAS is 2- 1000 gal pits both pits appear to be clean and dry, used camera and saw 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.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
tiI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Jeanne Hynes
Owner Owner's Name
information is Centerville Ma. 02632 8-20-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of,vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
i
c , Commonwealth of Massachusetts
Title 5 Official Inspection Form
Dis Disposal System Form -Not for Voluntary Assessments
I� Subsurface Sewagep y Y
a�
117 Wild Goose Way
u� Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
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
ater
Service
/ ♦ ♦ ♦ / / / / ♦ r / / / / / I / A r r / / r
\ ♦ \ \ 1 \ \ \ \ ♦ ♦ ♦ \ \ \ \ ♦ ♦ ♦ ♦ 1 \ \
♦\/\/�r\, \ � ♦ ♦ \ ♦ \ � ♦ \ \ \ ♦
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.1, \ \ \ \ \ \ \
7% %
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Irr / / / r\/`/`r\r\♦\r`/�/�/`/`/`/�r`/�/i`/
%'%'\'�'�/ r / / / r ♦ r rrrrr r
/ / ♦ r r r r r r r r / r r r r r\r`r`r /`/`/
r 1
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Ret. wall
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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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Wild Goose Way
u
Property Address
Jeanne Hynes
Owner Owner's Name
information is required for every Centerville Ma. 02632 8-20-20
page. City/Town 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: 30+
feet
Please indicate all methods used to determine the high ground water elevation:
Y ❑ 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:
Yard drops 30'+, no ground water
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form Not for Voluntary Assessment
117 Wild Goose Way
,u—
Property Address
Jeanne Hynes
Owner Owner's Name
information is
required for every Centerville Ma. 02632 8- 0-20
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 attach d
For 15: Explanation of estimated depth to high groundwater included
..k
Ib'
'VO G^OvO wizfe "
t5insp.doc•rev.7/26/2018 - .'Title 5 Official Inspection Form:Subsurface Sewage isposal System•Page 18 of 18
r
Commonwealth of Massachusetts
. - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
"t 117 Wild Goose Way
' Property Address
Terry Ford
Owner Owner's Name
information is y
required for Centerville MA 02632 May 28, 2008
every page. Cityrrown 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 Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
r� 189 Cammett Road
Company Address
Marstons Mills MA 02648
reon Citylrown State Zip Code
508-428-1779 SI 12855
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
May 28, 2008
Inspector's Signatu. 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.
08-137 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
d - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is Centerville MA 02632 May 28, 2008
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Tank is not in need of pumping at this time leaching pits show no evidence of backup into d-box.
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
08-137 Ford.doc-08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is required for Centerville MA 02632 May 28, 2008
every page. Cityrrown 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
160 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.
08-137 Ford.doc-08/06 Title 5 Official Inspection Form:Subsurface'Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
rV-
w 117 Wild Goose Way
Property Address
Terry Ford _
Owner Owner's Name
information is required for Centerville MA 02632 May 28, 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
❑ ® 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_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.
08-137 Ford.doc•080 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
a - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is required for Centerville MA 02632 May 28, 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
❑ to Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
08-137 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'< 117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is Centerville MA 02632 May 28, 2008
required for
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® El information
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)]
06 137 Ford.doc•08l06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'• 117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is required for Centerville MA 02632 May 28, 2008
every page. City/town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
0
Number of current residents:
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 ❑ No
Seasonal use? ❑ Yes ® No
_
Water meter readings, if available(last 2 years usage(gpd)): 282,000 gal.386 gpd.
Sump pump? ❑ Yes ® No
Unknown
Last date of occupancy: 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):
08-137 Ford.doc•0=6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 115
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is required for Centerville MA 02632 May 28, 2008
every page. City[fown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: None
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-137 Ford.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is required for Centerville MA 02632 May 28, 2008
every page. City1rown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
8'
Depth below grade: 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.):
Septic Tank(locate on site plan):
8'
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: 10.5' long x 5.8'wide- 1500 gal.
Sludge depth: 6
Distance from top of sludge to bottom of outlet tee or baffle
27"
4"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Measured
08-137 Ford.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'< 117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is required for Centerville MA 02632 May 28, 2008
every page. Citylrown 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.):
Liquid level was found at bottom of outlet invert and tees are intact.
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):
08-137 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
i
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is Centerville MA 02632 May 28, 2008
required for
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):
0.1
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box is 6-8 feet deep with no risers and was video inspected through tank outlet pipe. No
solids or high stains were observed, liquid level was found at bottom of both outlet pipes.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
08-137 Ford.doc-08106 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
r 117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is required for Centerville MA 02632 May 28, 2008
every page. Citylrown 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: Two 6x6 pits.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching pits show no signs of hydraulic failure, due to site conditions leaching pits were unable to be
opened.
08-137 Ford.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is y required for Centerville MA 02632 May 28, 2008
every page. Cityrrown 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
I
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.):
08-137 Ford.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w '. 117 Wild Goose Way
Property Address
Terry Ford -
Owner Owner's Name
information is Centerville MA 02632 May 28, 2008
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
ater
Service
1W ,As
IN N
g 45
17
8
Ret. wall
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
s o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 Wild Goose Way
Property Address
Terry Ford
Owner Owner's Name
information is Centerville MA 02632 May 28, 2008
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to round water: 30
p g 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:
Surface water of salt marsh adjacent to rear of property is 30-40 feet lower than bottom of leaching
pits
08-137 Ford.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Town of Barnstable
PROF tHE Tp��
Regulatory Services
BARNSTAB E, i Thomas F. Geiler,Director
9� s63.
a Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
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 or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations 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 Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disdaimer Private Septic Inspections.DOC
OWN OF BARNSTABLE
LOCATION UJ`I� V-t om— wev SEWAGE# Tn5 f
VILLAGE��(UAlQ ASSESSOR'S MAP&PARCEL
INSTA tERS NAME&PHONE NO. c,ST f$C.1� ��,� y� �-f
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) /000
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
t
ater
Service
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p 9 45 '
17
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
4
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
4
�Y
I� 6V�y
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A 7
CERTIFICATION 379
Property Address: 117 Wild Goose Way
Centerville MA
Owner's Name: Terry Ford
Owner's Address: Same t
Date of Inspection: May 19,2006 Job#06-132
tir;
Name of Inspector: PATRICK M.O'CONNELL �=r
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648 r" T
Telephone Number: 508-428-1779 CD
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
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: `��`` . F JA
X Passes :�� •S yam;
Conditionally Passes PAT I m c
Needs Further Evaluation by the Local Approving Authority
Fa 'C t c
` •;Q*
' Signature: Date: 5/19/06 �.,��� F �
Inspector's S g �4i FS INS' ri
rni tuM��``
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.
Notes and Comments: Recommend pumping tank. Leaching pits show no evidence of backup into
distribution box.Due to site conditions leaching pits were not able to be excavated.
****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.
i, ;
' Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
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.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.)
_No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
_X_ Has the system received normal flows in the previous two week period
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
_X Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_X _ Existing information. For example,a plan at the Board of Health.
_X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
I
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):No
Water meter readings, if available(last 2 years usage(gpd)): Avg gpd including irrigation: 445 gpd.
Sump pump(yes or no): No
Last date of occupancy: Intermittent weekend use for past year.
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: None
Source of information:
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped:`gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(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:
Permitted in 1995/Occupied in 1999.Compliance date unknown.
Were sewage odors detected when arriving at the site(yes or no): No
• Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 8'
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints;venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 8'
Material of construction:_H-10—concrete_metal_fiberglass__polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10.5'long x 5.8'wide—1500 gal.
Sludge depth: n/a
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 5"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle:8"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Observed traces of solids in outlet tee,recommend oumuine to avoid simificant solids carryover.
Tees are intact and liquid level is at bottom of outlet invert.Tank is too deep to measure sludge death.
GREASE TRAP: No (locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass__polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
1 t
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: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
D-box is 7-8'deep with no risers and was video inspected from outlet wipe of tank. No solids or hieh
stains were observed and liquid level is at bottom of both outlet pipes.
PUMP CHAMBER: No (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.):
i
Page 9 of 11 r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: Two 6x6 pits.
_leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): Leaching pits show no signs of backup into d-box.Death of nits and site conditions did not allow nits
to be opened,liquid level is unknown.
CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.
ater
Service
X.
XXXX
9 17 45
8
Ret. wall
Page 1 I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 117 Wild Goose Way,Centerville
Owner: Terry Ford
Date of Inspection: May 19,2006
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 40 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
_X_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:
Tidally influenced open water 400'+/-from site is 30 40 feet lower than system.
L TOWN OF BARNSTABLE
LOCATION ��p� w�lu' l t-4 SEWAGE #'YA
am- 1'`
-VILLAGE & er ulft ASSESSOR'S MAP & LOT AL 7 0
NAME&PHONE NO.
SEPTIC TANK CAPACITY D
LEACHING FACILITY: (type) e9 PitD (size) � °� .�ec�
NO. OF BEDROOMS L
BUILDER OR ��' QrJ
PERMITDATE: 094 DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i��. � �y _
� �«
�� ys
a
- 4
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
' DEPARTMENT OF ENviRONMEdrTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: _%/7 olA b 6,vs'a may/ ERECEIVED
Owner's Name: /�ii?�� �i��� 3Owner's Address: ABLEI7►ate of Inspection: i / 3
Nance of Inspector:(please print) 146 Q1 "AtSgjul
Company Name:
Mailing
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 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 S(310 CMR 15,000). The system:
<✓Passes
Conditionally Passes
Acopy
ds Further Evaluation by the Local Approving Authority
s
Inspector's Signatur . D$$e; — > p 3
The system inspector shall suis inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of i I
M
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: / /4� feed/-ki)
Owner:1))i,jgk (,1 S k4
Date of Inspection:_ T c 3
Inspection Summary: Check A,B,C,D or /ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 3I0 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner
h!113P-g- -fie.. �►�_
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is 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(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
i
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: l f"2 4-41-7�0 109pe,6e ijA-1
Owner: A)
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
y�ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
v Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
dogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ iquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
o.•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.
_ ny portion of a cesspool or privy is within a Zone I of a public well.
OAA ny 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 collform 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.[
I4 64 (Yes/No)The system fads. 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 now of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page b of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:LL `7 tojj-i:�, 6 adc"tZ- e.sw
14 jA�A
Owner:_j3iA ; - _
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): A/y0
Number of current residents:\—
Does residence have a garbage grinder(yes oror ,o —
Is laundry on a separate sewage system(yes o _ [if yes separate inspection required)
Laundry system inspected(yes or no):—
Seasonal use: (yes o
Water meter readings, if available(last 2 years usage(gpd)): l(f
Sump pump(yes or no):
Last date of occupancy: T
COMMERCIAL/INDUSTRIAL
Type of establishment:
Desien now(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): _
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no): _
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):.
- GENERAL INFORMATION
Pumping Records
Source of information: 0La A,ti; 1Z.
Was system pumped as part of the inspection(yes or no):_&6
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE F SYSTEM
LSeptic 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 s Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
IVsi 24L-942- Q - J 7 --9 9
Were sewage odors detected when arriving at the site(yes or no):LAO
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:__/ 1 `7 Lei it e !;;Fr
�.bl�"�-yilfd.Lt=' dine l�
Owner:f1p A4Zt?_d
Date of Inspection:
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
L Vlrere 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
P P P
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes
_ Existing information.For example,a plan at the Board of Health.
_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
f
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:---
Materials of construction: cast iron !✓d0 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:—(locate on site plan)
Depth below grade:- r+
Material of construction: nCrete metal_fiberglass_polyethylene
_other(explain) —"
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 1q
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: t� .
Distance from bottom of scum to bottom of outlet tee or baffle: f
How were dimensions determined:_i�h jr9!a2jg:X�
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: f/`) 4QQQ5' �- -,
Cte(i " %. ��
Owner: ' s
Date of Inspection: 19
TIGHT or HOLDING TANK: (tank must be pumped at time of inspectionxlocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level:_ Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
. ® . .��2-y' ��G .LIB 1J,Z� d - � �. = •,�
PUMP CHAMBER: (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.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: //'7 /y-j'2 &mom E WW
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
L;Ieaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): f
CESSPOOLS: (cesspool must be pumped as part of inspection)(iocate 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: (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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: I%7 (V/,cp de22g�" 4a+ /
Owner:/7)A2,V,-
IDate of Inspection: 3
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
Z—j
0
Jai - .2 ? 3 ' i3I
I
Page I 1 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: -11-7 L>>6j-) & 4 g Lsj!g*
Owner: _ -
Date of Inspection: 8 3
SITE EXAM
Slope
Surface water
eck ce
S allow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
_ Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
C}�ecked with local Board of Health-explain:
pecked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
11V-4 ffl�_ ASSESSORS MAP N0: 1,
P
THE COMMON�GF�%YQOF_MAC SSACHUSETTS
�!.✓ BOARD OF HEALTH
7ocv�2...................
Appliration for Dispaual Works Tonstrudion Vrrutit
Application is hereby made for a Permit to Construct (I,-<or Repair ( ) an Individual Sewage Disposal
System at: ,
..i. 7.. /.�:.... se /-►/c� 1�,1� fe It/ale �.?... �...•. .............
•------°O ........... .....
Location-Address or Lot No
.........---
-
r Owner �� d r
j .�.
U rhstall.r
Address
Type of Building Size Lot.Z2/__0.0.�Z_Sq. feet
U /
..� Dwelling—No. of Bedrooms................` /...................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Buildill
a Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other/fix/tu�res ......... ------•---•-•----------------
W Design Flow............f.i�0......................gallons per person per day. Total daily flow........ 11' 0............--.......gallons.
W Septic Tank—Liquid capacity-1500gallons Length..../Q...... Width:--`-,•..-._4q. biameter................ Depth... ...-.12,
u
x Disposal Trench—No. .................... Width............:_...... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.....2.......... Diameter......... Depth below inlet........ R....... Total leaching area-531t.�tsq. ft.
Z Other Distribution box (1 ' Dosing tank (
aPercolation Test Results Performed by........c:_...1'Q-!//27-... .. 'R�F?>�.._ Date....3- l -- 710
Test Pit No. 1 G. ......minutes per inch Depth of-Test Pit.../. ��. Depth to ground water/2Q./29%..rfRC.
L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---•-------------------------------------•-•---.....---.....--•--..........--•-•••••......--•----•.----- ....•........:_. ...;.
O Description of Soil...49.0.11.n.30!!..4A14M_ . Sv>��5 Ail�t.. O .._/�4.
.��..C�Q 'S e.......
W -
-----------------------------•--......-----........_...._..-------••--••--------•--•---......•••-•--••-----------•-•-•---•-......•••--------.................-----•-------••••--•••.......----••-•---••-
U Nature of Repairs or Alterations—Answer when applicabl ..............................:
e.
....-•---•-•--•-------------------------------------------------------------------•--...................-••-•................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of h '
Signed... e.._..... ..5 ....
-Q- -..._...... Date
Application Approved By........... ----- ...... ... . .............
Date
Application Disapproved for the following reasons:....................................................................•......•............................ ._.._
-----------------------•---•---•-----•-...............--------........... .------•-•------•-----•--............-------------•--•-------•-----..........--- .......... .............................
aft
Permit No... :. ........... .........
,�--� ' ---- -- Issued............ ...... ...............
Date
THE COMMONWEALTH OF MASSACHUSETTS
/0BO ARD
OF H?E�ArTH
1 ....` ..........................................OF.....!�/.... G ''�`••t'•••••.
.... QCdI..........................
(Irrtif irab of Toutplionrr
I I �OC RTIFY, That t Indiv'd Se a Disposal System constructed or Repaired
.... . ... .. Q...... ............... ....._. .............................._..............(........
Instal
P--------------------- 1-0-0.V
has been installed in accordance with the provisions of TIT F 5 of he S Sanitary Coe a ribed in the
application for Disposal Works Construction Permit No. '�� _ to dated-.:. .
THE ISSUANCE OF THIS CERTIFICATE SHALL/� ED AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ;�r r
DATE.......................•••-•-.......---•--------•----•......•-----••.........--• Inspector....................................................................................
Nol, _.• l .
; THE COMMONWEALTH OF MASSACHUSETTS(j
;BOARD OF HEALTH
� ltrttti �i fnx Uiiipoiial Vorkii Tonstrurtiun"_Prrmit
Application is hereby made for a Permit to Construct (V)or Repair ( ) an Individual Sewage Disposal
System at: / /
............,l1�c! {r-✓lf/11-e /_074
Location Address
' or Lot No
................ ,/ `70 ,PVC G i
Owner
rW.7 1 K / 1 �/l�G'//34,..-!k �f_./J r � •2 :�;= - %C_,_X_. ? h r,/�iX Addr
J
r Installer Address
�'. Type of Building Size Lot.-Zn: /2t_7C7 S feet
.. Dwelling—No. of Bedrooms......•......... .':...................Expansion Attic ( ) Garbage Grinder ( )
aa Other—T e of Buildin
YP g ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures .................................. .........--.-•----•----•••••••••---•••-•••--•-•--••••••....................................................
WW Design Flow...........•/,/-�-1........................gallons per person per day. Total daily flow........44."0......................gallons.
A4 Septic Tank—Liquid capacityY5042gallons Length....I<.%_..... Width:�.-4. biameter---------------- Depth..:a
_Disposal Trench—No..................... Width......-............. Total Length.................... Total leaching area....................sq. ft.-,,, '`
3 Seepage Pit No......:;�......... Diameter......12�2...... Depth below inlet......�2....... Total leaching area.' t esq. ft.
Z '} Other Distribution box Dosing tank ( )
aPercolation Test Results Performed by........ ...Y�!h/r... f /:u /� ��!2!� ... Date.... 1-J.._.....
Test Pit No. 1'"-.Z.....minutes per inch Depth of Test Pit...l. ..... Depth to�ground watery OW.e...ifY/,1.
rs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----•------...--•--------------------------------- ---------•---...-------
•----- -------------•-----.-
O Description of Soil...4'�A........_30.. f�,�r�!? 7s�c/�/ �/l eai .,_�C.. /�"� " Cc.. v ...
--•-
VW .....----••--------------- ------------------------------•----------------------------------•------•----•---•----------•------=------...---•------.....------------------..........••..........---.••... ,.
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
i
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with,
the provisions of TITU!- 5 of the State Sanitary Code— The undersigned furthe-r agrees not to place the system in'? �
operation until a Certificate of Compliance has been issued by the board of health:
Signed•• ..d..a !f `"'? �� �(
..� ;................
,F1..s./��. /f� Date
ApplicationApproved By.. '`� // ../../....-•-•...................--�-------•--- ........................................
Date
Application Disapproved for the following reasons:..............................................................................................................
` .....................1............... ..............." •- "-----••-----.......••---•-•-•-'--••--•---••------........................••..----I--------A•-------- ......:........
Date
Permit ---------- . • .. Issued.......... � l ..
Date
R'l...e..=e#........wJO` ..f...*.Ong......r O..>T 1bn _ ..._!q^.'d..........•T....m T•........4..►®»s V SM...T. •T.1!
THE COMMONWEALTH OF MASSACHUSETTS
/0aWBOARD OF HEALTH
//� f
..................................... OF....... .../!..Y............ ................f..................................
Trrtif irtt#r of Tomphattre
T IS IS TO CERTIFY, That the Individual Sew,lge Disposal System constructed ( ) or Repaired
4 � ( ................................................) ..............
K ,( )
� �Installer
I
at > '' Ca{/.......................... -- r __ /. _....-.: 1 1- �--�F--- ---------------••-•---•--•----
has been installed in accordance with the provisions of TIT-LE 5 of he State Sanitary Code
as described in the
application for Disposal Works Construction Permit No.__.� ..-i dated_.... .r .. ��..............
I -p Q �.....
THE ISSUANCE OF THIS CERTIFICATE SHALL [ �BCGONS RUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. / � .� �,•--��
DATE................................................................................ Inspector...................................................................................
----- ------i.e-------s --------- tom-. -----------s+-------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0.1 ..............L.1./ �'!:/.®V. .OF.....!") /4 C /•I`I ................... I
NO...• FEE..TA-=
19isposal Works' Tons#rur#ion f rrmit
Permission is, herebyranted_. M"4 .P�G�G,�..( E-!° f...........
.d.....:.....•--"-............. ..........w_............. ...._..............__..._......
to Construct ( ) or Repair ( ) an .Individual,Sewage Disposal Systemr
at No....... C/��f(._ - �' �G f �A y..... ..e.l� t% � / .....
• .......... ---.....--•---...
l Street [0'1) !.�'" ..
as shown on the application for Disposal Works Construction Peri 't;No (.__.. _.... Dated...:......... ....t.�.�...........
.. • ..............�=---oars...-_-.-.....--------------•---....>.-- . —
� l ' � Board of Ilealth C
DATE.............. = ;� r.......... ............•-•-----•----....._
TOWN OF BARNS ABLE /ILI
LOCATION I ' SEWAGE # vJ
WVILLAG of r ASSESSOR' MAP & LOT l __ t®
INSTALLER'S NAME&PHONE N0.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (ty ) - (size(L)
NO. OF BEDROOMS ,
BUILDER OR OWNER
PERMITDATE COMPLIANCE DATE:
Separation Dis ce l etweM
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
L
Private Water Supply Well and Leaching Facility (If any wells exist !'
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
1
-62 Q' ��
"41 T B_ � % I�
TO OF B STABLE
LOCATION + ���� I A V SEWAGE # VS
Js rILLAGE r U ASSESSOR MAP & LOT r
r /
6�7-
INSTALLER'S NAME&PHONE N0. .�,
SEPTIC TANK CAPACITY
LEACHING FACIL=: (ty ) (size(4Q X 6X 6;
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE S COMPLIANCE DATE:
Separation Dis ce between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet.
Private Water Supply Well and Leaching Facility (If any wells exist
on'site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by.
ra TOWN OF BARNSTABLE
LOCATION SEWAGE #
A ►VILLAGE ASSESSOR
'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS -
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by j
I I
1
i
1
142 432 t �,,
TO OF BARNSTABLE
LOCATION I Q, Se, SEWAGE # �S
VILLAGE r u ASSESSOR MAP & LOT
INSTALLER'S NAME&PHONE NO. J
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (ty ) (size(2) �'x �:
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE S COMPLIANCE DATE:
Separation Dis ce 9etween the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on Isite or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
'r within 300 feet of leaching facility) Feet
Furnished by
Jr
,r
�V0 —StA
1
Ti
2 24 I
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