HomeMy WebLinkAbout0020 WINDLASS LANE - Health 20 VVindlass Lane
Centerville P
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UPC 12543 •
No.5._.3LOR
HASTING9. UN
lqTown of Barnstable P#
Department of Regulatory Services
Public Health Division Date
sue.
200 Main Street,Hyannis M:r.
Date Scheduled13 )9 TimeFee Pd.
- /61
-"' Soil Suitability Assessment for Sewage Disposal
Performed By: Witnessed By:
LOCATION& GENERAL INFORMATION
Location Address aO W;,7j)-a,55 Owner's Name 50,,1 Sw,fp
I_ '
Address 'L o �:r+3<st SS C-e.-Jev�
Assessor's MaPtParcel• (C Engineer's Name a\ CE�a;�la thf,��`�es
®�J / 1YQ
NEW CONSTRUCTION REPAIR V Telephone# SOg
Land Use 1es oAkvk�—t�G• 1 Slopes(%) f' Surface Stones- A IA
Distances from: Open Water Body t� ft Possible Wet Areaa�ft Drinking Water Well?t�— ft
Drainage Way ft Property Line 16 ±f <ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
Cr
Vj\NV�SS
Parent material(geologic) C-CI^0 Depth to Bedrock /\j.f A
.a Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater J 3 Z
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in, Groundwater Adjustmeet €t.
Index Well# Reading Date: Index Well level�., �.�, Adj.factor- Adj.Groundwater L.evet
PERCOLATION TEST Date Time.
Observation
Hole# d a Time at 4"
Depth of Perc [ Time at 6"
Start Pre-soak Time @ J LZS
End Pre-soak 2`� �o lG v�S
Rate Min✓Inch
2-
[(
Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100'of wetland,you must first notify the. - -
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:\SEPTICIPERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole# I
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency, ravel
— A S to y
-3 s L le 15-1
ci 1"1- C S�✓i. Z.S. �/ 20 v.9
DEEP OBSERVATION HOLE LOG Hole# Z,
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling .(Structure,Stones,Boulders.
Consistency.%Gravel)
d --� A SL. LO �yIZ
-3 fe, 3 S ( to y 9-574
3(6-7( Ck M-C SC4 �/ r
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
ConsistencZ%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No_ Yes "
-U Within l00 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
g Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? y --
t] j If not,what is the depth of naturally occurring pervious material?
Certi_ficati°n �^
I certify that on L �� L (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 310'CMR 15.017.
� Signature Date
Q.\SEpTIMERCFORM.DOC
I
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
a
a'
TITLE 5
OFFICIAI. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 20 Windlass-Aw-
Centerville MA 02632 t 5
Owner's Name: John Sapp
Owner's Address: Same 1
Date of Inspection: July 25,2007 Job#07-157 Z I
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
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 experien,.e 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: F
Passes
Conditionally Passes c--; �_rD
__ Needs Further Evaluation the Local Approving Authority
Ji
Fails c'' '
CD ..3
Inspector's Signature: Date: 7/25/07
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board o Health or
r.� r-:
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flo of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional o ice 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: Leaching pit is full to top of structure.
****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.
i4,1.,,.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CM:R 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:
r
Page 3 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 20 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
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 I of a public water supply.
_ The systeem 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:
r
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 20 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
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 3AS 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"Lone 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 forma
Yes (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.
I
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 20 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
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.
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))
Page 6 of 11
OFFICIAI. INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: :t0 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:4
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)):
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALAN DUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow i;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:
i es
Was system pumped as part of the inspection(y or no): No
If yes,volume pumps:d:_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:
1980's
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: 20 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
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: 1'
Material of construction:_X_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:8.5'long x 5.2'wide—1000 gal.
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle:24"
Scum thickness: 4"
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:9"
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.):
Tank has no evidence of leaks and appears to be structurally sound.Replace concrete baffles with
PVC tees at time of irepair.
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.):
Page 8 of 1 I
OFFICIAI, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: :20 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
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:
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.):
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 I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: One 6x6 pit.
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.): Liquid level at top of structure,pit is in hydraulic failure.
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 I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
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.
19
... ... .... 242
...................... ...... ..
................................... .... .......
53
. ....................................
..............
45
Water
Service
Windlass Circle
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Windlass Road,Centerville
Owner: John Sapp
Date of Inspection: July 25,2007
SITE EXAM
Slope Non:
Surface water None
Check cellar Dry
Shallow wells Nome
Estimated depth to ground water: n/a
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
*4416
TOWN�O/FF BARNSTABLE
JCATION S' u Gv+ncd C� A66 SEWAGE# -�0� "3`?�'
ILLAGE (yen f A4 L,c `it ASSESSOR'S MAP&PARCEL /9 ; — oko
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY /0 oU
LEACHING FACILITY:(type) ,2 el to Sby (size) /3 X 3
NO.OF BEDROOMS �?j
OWNER .9 Oh v\ SIrA {)
p
PERMIT DATE: T_n, 2-00-2 COMPLIANCE DATE: Z,oO-
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Mato I Feet
Private Water Supply Welland 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 BYQ�v. �I /p�% Gj L-C L:
'c
So J,# or-
At 11,v
112 as:-7
R3 3a, 0
q
0,5'
/1 6 �a
alr0
No. .01-W 3- ° Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for ig onl 6p5tem Con5tructf ott Permit
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) El Complete System ❑Individual Components
I
Location Address or Lot No. ao t)�'Ij(als5 loyu_ Owner's Name,Address,and Tel.No. �'_TvL vi S'A
Assessor's Map/Parcel 0 g L p 1�0
Installer's Name,Address,and Tel.No. "(e � �'�''' P �� Designer's Name,Address and Tel.No.
v. 13ox -763 /2,Wejr eySf��
�(2� �ozk &vihwWe mA oZ(,3.t ` -77 53# 3 fi)yWrv4te 441
Type of Building:
Dwelling No.of Bedrooms Lot Size +S/ L� + sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33o gpd Design flow provided 3 3 [ •7 gpd
Plan Date S'V)—2,oQI7 Number of sheets ?i Revision Date
Title 2.o W a-j�l .5
Size of Septic Tank f Ono 64/ Type of S.A.S. (Z) Sba �Zj42- �•�. �`S fit
Description of Soil �n�p/191 �(—
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: t ,gJ,fi Zci>7
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Datey�—
Application Disapproved by: Date
for the following reasons
Permit No. X 0 0 —- Date Issued
}Perms
---------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,,MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded (Lj)
Abandoned( )by
at 20 (A! 11Jt gt:%S �i�Y�,c C L! (( C has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. a� '?j�� dated
Installer. r_*a't ',6L 04e_t/p!', S e S C_C C Designer f J vtrPJtit a 1,�g12 KJ `
v
#bedrooms Approvejde','i')n flow / gpd
The issuance of this permit shall t b c•ns,ue as guarantee that the systengti• . as designed.Date Inspecto r
� v t
No. go 37 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
aigoml 6p!5tem CongtrUction ermit
Permission is hereby granted to Construct ( ) Repair ( ) Upgri _de ( , Abandon ( )
System located at 'Z O t,J,, h� Lot).) (�r� C.s.•z,,,---y,,t 14
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes I'syher duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of erm'
.,:. Date "0� Approved by
AV
No. T 44 Fee
THE COMMO WEALTH OF MASSACHUSETTS Entered in computer: Yes���
t A
PUBLIC HEALTH DIVISION'- TOWN_OF,BARNSTABLE, MASSACHUSETTS
Application for �Digonl *pgtem Con0truction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade k/Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. a O �i neI 1 a155 IA AA Owner's Name,Address,and Tel.No. Tv(,vi 5A r
Assessor'sMap/Parcel
C•7(�c�w,�l� 01 fcrQ�' Designer'sn�;1 tJzvt�c 11
Installer's Name,Address,and Tel.No. � S Name,Address and Tel.No. �
Pc7. djg 763 1 /1 uJ�1r(loSS(�%(
C,I �,,-Nile mo QL63i y7"j S3� 3 j�rrsr0✓}1� Ma)
Type of Building: C
Dwelling No.of Bedrooms :3 Lot Size f S 1/p + sq. ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33o gpd Design flow.provided 3 3 1 gpd
Plan Date $ ,Z 1 -ZZ7 Number of sheets Revision Date
Title '7 o W,Aj E0&S
Size of Septic Tank /00c) 6,41 -Type of S.A.S. (Z, Too lie
Description of Soil J i, 64 (W Yf/ 3(,ill
Nature of Repairs or Alterations(Answer when applicable) tx,Ch 1W hI 7b /441-1 7-I�ae
Date last inspected: ►a,S j Zct�7
Y
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance.with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed t. Date �" Z 9 LOo7
Application Approved by Date
. x
Application Disapproved by: Date
for the following reasons �.
O 0 -3 7 Date Issued ��^�
Town 0f .2stable
Thomas F,Color,]D yr
lic HMO D o11
Thomas:McKega,DlroMr
2M Mwa Street,H?&UW5,MA,0W1
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Dma: I �d s
_ SOW Pit# + ? -3"7 s �q` �-0 Pl C7
A sensors Map\
P�✓i GL` 7YtilS ter:
Ae`' >> ;was issued a.pcncpit to iztSW a
(iutalier)
fad0esa)
based on dew dt .by
dated
1'L�C a-7
„ . .peptic s3►ateta teif ced above w" insWl eel;s�ubttiaill� a5acor�to
w la may inchzdc r approved changes such is lateral re oc (M ON
IMx atxd/or septic t>mk
f
Abe
septic rlctmmced above was installed with
�J l+atarsi Feon of the SAS or
:.w )but in aCCv attY vertical r+eiiQcatai y.. t
cc with State &Local Re�1>�ct M., PW ivm
„MvI�dosiper to fogor
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WENTEE
CIVIL y
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SEWAGE P'fRMVT NO.
Ujj"ot,455 LN . <z? S - -797
L L A G E
1EN ? C[ 2y!LLt�:-
INSTALLER'S NAME i ADDRESS
CARS H, LAMPi
S U I L D E R OR OWNER
-30�i N Ms- At-Pi N�
DATE PERMIT ISSUED
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OAT COMPLIANCE ISSUED
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4
U9COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RIC D
APR 1 2 2005
TOWN OF 13ARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION AP
q'Z
Property Address: 20 Windlass Lane -ARCEI
Centerville. MA 02632
Owner's Name: Carolyn Keane
Owner's Address:
Date of Inspection: April 1. 2005
Name of Inspector: (Please Print) Janes M. Ford
Company Name: James M. Ford `
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: April 3. 2005
The system inspector shall sub'rt
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
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Windlass Lane
Centerville. MA
Owner: Carolyn Keane
Date of Inspection: April 1. 2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Windlass Lane
_ Centerville. MA
Owner: Carolyn Keane
Date of Inspection: April 1. 2005
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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Windlass Lane
Centerville, MA
Owner: _ Carol
vn Keane
Date of Inspection: April 1, 2005
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that'one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 20 Windlass Lane
Centerville, MA
Owner: Carol
vn Keane
Date of Inspection: April 1. 2005
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)J.
5
I
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 20 Windlass Lane
Centerville. MA
Owner: Carolyn Keane
Date of Inspection: April 1, 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/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: Pumped in November 2004-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed on 10129185-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Windlass Lane
Centerville. AM
Owner: Carolyn Keane
Date of Inspection: April 1. 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge.depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Windlass Lane
Centerville. MA
Owner: Carol
vn Keane
Date of Inspection: April 1, 2005
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Windlass Lane
Centerville, MA
Owner: Carolyn Keane
Date of Inspection: April 1, 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The leach pit had 5'ofliauid on the bottom. The scum line appeared to be at the same level There did not appear to be any
s_iQns offailure. The cover was 30"below grade. The bottom to grade was 8'6"
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Windlass Lane
Centerville, MA
Owner: Carolyn Keane
Date of Inspection: April 1. 2005
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 wit in ee . Loc -- a er supp y erife—rs the building.
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Page I of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Windlass Lane
Centerville, MA
Owner: Carolyn Keane
Date of Inspection: April 1. 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours mans
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps, the maps were showing approximately 30'+1-to ground water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied,relating to the system,the inspection and/or this report.
11
Tr
OF BARNSTABLE
LQCATI odd (itll/I �t, SEWAGE #
VILLAGE CCA'r(ry% �� ASSESSOR'S MAP & LOT a �0
INSTALLER'S NAME&PHONE NO. /
SEPTIC TANK CAPACITY UnUD
LEACHING FACILITY: (type) p",T �X 6� (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE: 1
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 leachin�facility) Feet
Furnished by /1SPG , Iiun
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. ........................OF.....................................
Appliratiun for Dhipoutti Workii Tonutrur#'tun Prrutit
Application is hereby made for a Permit to Construct (--10)'or Repair ( ) an Individual Sewage Disposal
System at:
...........-°I- - ................... ............�a..... ...i.-4-.........................................................
Location Soh. .. ..... P�_�..p. ....-..A..ddress }...--t--No .:
t
........ .
� L
Iac........ . 4 ...... r-----�n....-:
s .--•-..W&;.;..:......Owner.......................................... .. A dresW
....
0.4 Installer Address
UType of Building Size Lot..... -_..Sq. feet
Dwelling—No. of Bedrooms.....................3......_...__......Expansion Attic ( ) Garbage Grinder ( ) WO
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ----•-•-------•---------------------------------------------------------------------------------------•-----------------..._.......
w Design Flow.................r?. .....................gallons per person per day. Total daily flow...........3_.3 0._._.___..._.........gallons.
WSeptic Tank—Liquid capacity.�9Q�._gallons Length................ Width................ Diameter................ Depth.......
x Disposal Trench—No..................... Width.._......r_..._._.. Total Length.............. Total leaching area....._..__.____..._.sq. ft.
j----
Seepage Pit No..............I..... Diameter............I..... Depth below inlet........6A......... Total leaching area....aAP....sq. ft.
Z Other Distribution box (&oj Dosing tank ( )
aPercolation Test Results Performed by.... d.... -f.................... Date................1.......................
Test Pit No. .1.1-•.lr1..a_minutes per inch Depth of Test Pit.......IA?....._. Depth to ground water_.&P....W-.'L-fr r-
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil...---D--....�.........................
--------------- ----------D-�i!!'1. ' � `-�� ...
x - -
U ....................I....._••-•-..........S-Ln.c !j---....�.t'm y. .1..........•--•-----•-----••-••---•............•-•-- ..........................................................
w
U Nature of Repairs or Alt ions Answer when apVlicable...............................................................................................
-• --•-•-----•-••••••-------------•---••-----•--••---------••------•-••••-•-••-----•--•--••••--•-----._...•••.
Agreement
The un Igne gr e t install the fore escribed Individual Sewage Disposal System in accordance with
the provisions of TLH1E of h —
p S the State Sanitary Code .The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
igned...................................................................................... .... . ....................
Application Approved BY---------- .`.rtS...=.-----•---•-•...............•-----•-•----••- -•-•--..Q at
IDate
47 --•---
Application Disapproved for the following reasons--------------------------------•----•-------•--..............................................................
----------•--•--.......--•-•-•---•-------...-•------------------------------•------------------------•--.-••------•-----•--•-•••••--•••--•-•----•••-••----••-••••-•-•---••••••••----•••••---•--------••-
Date
PermitNo....................................................... Issued------------------------------•---=-------•----------.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ .... ........Fa" ;OF.....................................................................................
(Irrufutt#r of faomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (<) or Repaired ( )
by...................................••-•---•-.................._...._•-•---._............. ...-- i................................................................................
Installer
at.....................................................................................
..... - ...
-:. --••-_.....77-•.. dated.....-- -
has been installed in accordance with the provisions of TIT F f The State Sanitary Code s described in the
applicatior'for Disposal Works Construction Permit 1�'0.__.. `""S --4�t'` ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT.B.E CON TRUED AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
Inspector........... ..
DATE...........i Q -�.�....�_g�� ........................... - •----••----•-
THE COMMONWEALTH OF MASSACHUSETTS
q
BOARD OF, HEALTH
No... OF.........:...................... Fes.......'.. ...
x 11ispasid 19orks Tons#rudi art Prrmi#
Permission is hereby granted----.----- G;:Ai k.---•--.4.-.to 1k1.--•--•--.......---•---•---••.............•---......---•---•--.........................._..
to Construct ( X) or Repair ( ) an Individual Sewage Disposal System
at No...........L O -T•-•-•#-:al.m......-.W_c !.1�k!k:S 5:.._J..�t!1!! ........ .................................................�` 1C 2 V 1 L Ls
-,--.--.._-•----•.......---••••........
Street ' /
97
as shown on the application for Disposal Works Construction Permit No. .�:...� . Dated....._.... /"I .
DATE............. -...12._..R5 Board of Health.----•----------------------•=--•---.....
FORM 1255 A. M'SULKIN, INC BOSTON
No FER
�-.;`THE COMMONWEALTH OF MASSACHUSETTs
BOARD OF HEALTH
...................................0 F.........................................................................................
ApVliration for Disposal Works Toustrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
o L q
L o, ..0 ,1.1 ±... . ................... ..................................................................................................
Location-Address 'Lot No.
'111Y.................................................. 'i r L-k"Al C.-
.... .........................................�a.%j.............................
Owner
AddreiLl
.................... ....... .............. ...Installer Address
. .................................. ... ..................
Type of Building Size Lot....../"7.....././.?'....Sq. feet
U
`4 Dwelling—No. of Bedrooms.....................:-..................Expansion Attic Garbage Grinder 'LO
P4 yp Other—T e of Buildin g ............................ No. of persons........................... Showers sCafeteria
Other fixtures
Design Flow.............. ......**.............gallons per person per day. Total daily flow........... 330 ..........gallons.
Septic Tank—Liqui'd"capacity.ZP.�-.'��.gallons Length................ Width................ Diameter...-.._.........*........... Depth................
Disposal Trench—No. .................... Width.........
'('*.....11 Total Length...............r.... Total leaching area....................sq. ft.
Seepage Pit No...............I..... Diameter.............Y.... Depth below inlet.......L.......... Total leaching area.... ...sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by .c.........d.....b.j..e e ................... Date............._.....___.............._...
1.4 1 . ... .... ... 4 0.4 Test Pit No. IJ....in..a.minutes per inch Depth of Test Pit........L2....... Depth to ground water..2Y4'....
Test Pit No. 2................minutes per inch Depth of Test Pit.._................. Depth to ground water........._.........._...
......................E.....................................................................:Y....... -----------------------------
0 Description of Soil.....-D.........-................... ..... ..........
UW ........................................... .........
.................................................................................................................
(71
......................................................................................................................................................................................................
U Nature of Repairs or Alte tions—Answer when ap�licable...............................................................................................
_
........... .. .... ............................ .. ..........................................................................................................
A�-----------
eement-'
The un lgn agree t install the fore escribed Individual Sewage Disposal System in accordance with
the provisions of TLITA 11- 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 health.
igned...................................................................................... ... . .....................
�,v
ApplicationApproved By................... ....!�....... ................................................... ...........
Date
Application Disapproved for the following reasons:..........................................................................................................
..................1...................................S....................................................................................................................................................
Date
-No.' .......Permit L._'L ................................ Issued L.......................................................
Date
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5UevL—_( 4 T"r- OFFSET; -5"DoL1D 1.1or $E USA APPC.tGAuT ,� ,(
To PETEREt1� L LoT UMEX. �Ul.,ftil Mfci i�..(�IF�C
LEGEND aLonn
x 76.95 EXISTING SPOT GRADE Co n Cftl9 R
EXISTING CONTOUR e°
r Pen U
TEST PIT
W EXISTING WATER SERVICE 06
��
G EXISTING GAS SERVICE
\ ad —OHW— EXISTING UNDERGROUND WIRES
y
o
\ BENCHMARK
BENCHMARK:
RIGHT FRONT CORNER c °��e� LOCUS
OF CONCRETE SLAB. LOCUS MAP N.T.S.
ELEV. = 100.00 (A55UMED)
,/ APN 192 - 080 -
/ %, nj� 15,1 18 5F f DECK
EXISTING SEPTIC TANK
h�� ��• r _. wl •C�.�; �fi TO REMAIN
EXISTING S.A.S.
TO BE PUMED AND FILLED GENERAL NOTES:
, WITH SAND. W17H UT SOILS
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
f / NO. 20 / ASSOCIATED WITH THE EXISTING BOARD OF HEALTH AND THE DESIGN ENGINEER.
� / ,� S.A.S. (SEE NOTE 11)
I/2 STY.)l /� I �,•ti •-., I 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
�� OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
/ TOF t 100.68 / / �; ; / -w _ LOCAL RULES AND REGULATIONS.
' ✓ ` /� '� / : C`n 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
O AI. F/ / 20 i:.',... .� DESIGN ENGINEER.
` 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
9` FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES.
0 S'�9' 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
� NSI LE FOR THE FAILURE OF 6. THE DESIGN ENGINEER IS NOT RESPO B
•.,, I � \.,.;.�%��, � -- THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
I o HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
L)?';J LVVAY _ - O ��S• 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
0i~1G TP-1 TP-2 B. THERE ARE NO ABUTTING WELLS LOCATED WITHIN 150' OF THE S.A.S,
9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
~ TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
1U CONTRACTOR TO
IT SHALL BE THE RESPONSIBILITY OF THE CONTRA VERIFY
,q -,,t ~4 f THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
o $ �� - 9� CONSTRUCTION.
R-199.86 — 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
S
N �``�•. .- 'd' L
00
-" r� IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S.
L=197. 14' AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3).
~` 9 CONTRACTOR SHALL CONTACT THE BOARD OF HEALTH FOR INSPECTION
9CP00 OF STRIPOUT HOLE PRIOR TO BACKFILL WITH SAND.
Mqs 12. CONTRACTOR SHALL EVALUATE STUCTURAL INTEGRITY OF EXISTING
O i �Q�� s9ry SEPTIC TANK PRIOR TO CONSTRUCTION.
I N D LASS o PETER T.
LANE MCENTEE PROPOSED SEPTIC SYSTEM UPGRADE
o CIVIL
No. 35109 20 WINDLASS LANE, CENTERVILLE, MA
ft OCR_ �E6/SiER�� �Q Prepared for: John Sapp, 20 Windlass Lane, Centerville, MA 02632
NAB G\ Engineering by: Surveying by: SCALE DRAWN JOB. NO.
Engineering6Porks HOOD SURVEY CROUP 1"=20' P.T.M. 207-07
12 West Crossfield Rood 18 Route 6A
Forestdale, MA 02644 Sandwich, MA 02563 DATE CHECKED SHEET NO.
(508) 477-5313 (508) 888-1090 8/27/07 P.T.M. 1 Of 2
, I
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} NOTE: TO PREVENT BREAKOUT, THE PROPOSED
T.O.F F.G. EL: 99.5t FINISH GRADE SHALL NOT BE < EL:96.5
(EXISTING) FOR A DISTANCE OF 15V.. ' AROUND THE
EXISTING F.G. EL: 99.4t(EXISTING) F.G. EL: 99.4t PERIMETER OF THE S.A.S.
MAINTAIN 2% MIN SLOPE OVER S.A.S. 4 SCH 40 PVC PERFORATED PIPE WITH
SCREW CAP SET TO WITHIN 3" OF FINISH
INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER D-BOX TO
2-500 GALLON LEACHING CHAMBERS IGRADE TO SERVE AS INSPECTION PORT.
TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL SIDES
INSTALL RISER OVER CHAMBER
• L=3' L=10' SHOWN ON PLAN AND SET COVER
WITHIN 6" OF FINISH GRADE
4" SCH 40 PVC 4" SCH 40 PVC
-11 is 2- LAYER OF I4" ® S= 1% MIN. a ®® e® DOUBLE WASHED STONE/2
(MIN.) 0 S= 1% (MIN.) aaaaaaa OR APPROVED FILTER FABRIC
EXISTING ®®a aea
48' LIQUID 2' EFF. DEPTH aaaaaaa ( )
�,;, ,•,; LEVEL INV.=96.80 INV.=96.63
EXISTING ADD GAS PROPOSED DI-BOX 4' 5.2' 4' DOUBLE
1 A
BAFFLE DOUBLE WASHED
INV.=97.00f ( EFFECTIVE WIDTH = 13.2' STONE
EXISTING GALLON SEPTIC TANK EXISTING
INV.=96.00
1
TOP CONC. ELEV.=96.8 -BREAKOUT ELEV•=96.5
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING INV. ELEV.=96.00 a®i a0•B
PIPE INVERTS PRIOR TO CONSTRUCTION. 8sa�®�iB®B�Ba a
2) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=94.00
GRADE ON A MECHANICALLY COMPACTED SIX t 3' 2 x 8.5' = 17.0' 3'
INCH CRUSHED STONE BASE, AS SPECIFIED IN {310 CMR 15.221(2). 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 23.0'
, T.P. EXCAVATION OR G.W.
3) INSTALL INLET & OUTLET TEES AS REQUIRED. LEACHING SYSTEM SECTION
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE. y NO G.W. ENCOUNTERED AT EL.=88.4 z
SEPTIC SYSTEM PROFILE
N.T.S.
(
(3) 5" DIA.OUTLETS 1
E--- --1�2" DESIGN CRITERIA
i SOIL LOG
O
12" NUMBER OF BEDROOMS: 3 BEDROOMS
Lj 2L 1s.5" s" t. e" DATE: AUGUST 13, 2007 (P-1 1,91 1) SOIL TYPE: CLASS I
SOIL EVALUATOR: PETER T. MCENTEE P.E. DESIGN PERCOLATION RATE: 5 MIN./IN.
~ 2' WITNESS: DONNA MIORANDI-HEALTH AGENT DAILY FLOW: 330 G.P.D.
H-10 LOADING S6, DESIGN FLOW: 330 G.P.D
D-BOX / i 2• Elev. TP- 1 Depth Elev. TP-'2
/ _� Depth GARBAGE GRINDER: NO
"'Ts 99.4 A SANDY LOAM A SANDY LOAM 0" 99.4 0" LEACHING AREA REQUIRED: (330) = 445.9 S.F.
ssr 10YR 4/2 10YR 4/2 74
98.9 6,. 98.9 6..
_ SANDY LOAM B SANDY LOAM EXISTING SEPTIC TANK: 1000 GALLON CAPACITY (ESTIMATED)
rEE3 O ®®®® /
®®®®®®® 33" / / / / / \ 10YR 5/6 10YR 5/6
®®®®®®® ' 323 �� \ 9s.s 34" 96.4 36" USE 2-500 GALLON LEACHING CHAMBERS IN SERIES
0.2' ?0 \o, y SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F.
�O \ M-CiSAND 48 M-C SAND BOTTOM AREA: 13.2' x 23.0' = 303.6 S.F.
102" 5•�' \ 2.5Y 6/4 PERC 2.5Y 6/4
>207.GRAVEL 60" >20%GRAVEL TOTAL AREA: 448.4 S.F.
4" KNOCKOUT - \\ /��` 93.1 C2 76" 93.1 C2 76" DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D.
20' DIA. COVER
KNOCKOUTM-C SAND
O/4" KNOCKOUT 82" 2-Y 6/6 2.5Y 6/6 720
ROPOSED SEPTIC SYSTEM UPGRADE
5-10%GRAVEL 5-109 GRAVEL
4" KNOCKOUT WINDLASS LANE, CENTERVILLE, MA
�
Prepared for: John Sapp, 20 Windlass Lane, Centerville, MA 02632
88.4 132" 88.4 132"500 GALLON CAPACITY, H-10 LOADING I Engineering by: Surveying by: SCALE DRAWN JOB. NO.
NO GROUNDWATER OBSERVED EngineelingWorks HOOD SURVEY GROUP N.T.S. P.T.M. 207-07
CHAMBERS PERC RATE <2 MIN/IN. 12 West Crossfield Road 18 Route 6A
NJA S.A.S. LAYOUT Forestdole, MA 02644 Sandwich, MA 02563 DATE CHECKED SHEET N0.
(508) 477-5313 (508) 888-1090 8/27/07 P.T.M. 2 of 2