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Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 0-7-1(o
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.
ComWhites Path
Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes `����punn►rui�,
ZH OF�9S��i��i
2. ❑ Conditionally Passes °y� •"" •.s9'�•,
MICHAELN'
3. ❑ Needs Further Evaluation by the Local Approving Authority _"o; SEARS :M S
No.SI14430 rn
4. ❑ Fails
o
;N
6-3-21
Inspector's SignaWfe 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
m io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. Citylrown 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:
System is in working order
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Rio Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is
required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
I
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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Ins p ection Form
I
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
�u
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes"or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
V�
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 2019- 35000 gal
2020- 30000 gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r;
39 Woodvale Ln.
u�
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
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:
Nerw SAS 9-2-05 #2005-435
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
i
Depth below grade: 14"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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 4"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle 12
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Sludge judge, tape, plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 gal tank with inlet tee and baffle outlet in place, both covers 2" below grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
u�
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
_ gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16x16 with 3 outlet pipes, box is 10" below grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is Centerville Ma. 02632 6-3-21
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: K Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is in working order
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 12'x40'
❑ 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
F. Title 5 Official Inspection Form
�e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is a 12'x40' leaching field, field is clean and dry with no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Sewage Disposal System Form -Not for Voluntary Assessments
I� Subsurface Se a
9 p Y rY
u
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is Centerville Ma. 02632 6-3-21
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
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
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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
_ i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
39 Woodvale Ln.
V�
Property Address
Christopher Isaac
Owner Owner's Name
information is required for every Centerville Ma. 02632 6-3-21
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: 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. 12-6-04
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:
No ground water per plan
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
i
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Woodvale Ln. _
u� Property Address
Christopher Isaac
Owner Owner's Name
information is Centerville Ma. 02632 6-3-21
required for every — -
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
FA LED 1�j . ....`CTION S� Zoo
COMMONWEALTH OF MASSACHUSE-rT{$S}p
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EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL°RROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 39 Woodvale Lane
Centerville.MA 02632
Owner's Name: Bill Porter
Owner's Address:
Date of Inspection: September 30, 2004
Name of Inspector: (Please Print) James 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
✓ Fail
Inspector's Signature: Date: October 6, 2004
The system inspector shall sub t a copy of this inspection report to.the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent 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 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 39 Woodvale Lane
Centerville,MA
Owner: Bill Porter
Date of Inspection: September 30, 2004
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: 39 Woodvale Lane
Centerville,MA
Owner: Bill Porter
Date of Inspection: September 30, 2004
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: 39 Woodvale Lane
Centerville, M4
Owner: Bill Porter
Date of Inspection: September 30, 2004
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.]
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 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 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 39 Woodvale Lane
Centerville,MA
Owner: Bill Porter
Date of Inspection: September 30, 2004
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)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 39 Woodvale Lane
Centerville,MA
Owner: Bill Porter
Date of Inspection: September 30, 2004
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: 2
Does residence have a garbage grinder(yes or no): Yes
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
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): end
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-.—Unavailable
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:
Unknown
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: 39 Woodvale Lane
Centerville, MA
Owner: Bill Porter
Date of Inspection: September 30, 2004
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: 6"
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: 1"
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.):
The liquid was even with the outlet invert. There did not appear to be any signs of leakage Cement tees were present
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: 39 Woodvale Lane
Centerville,MA
Owner: Bill Porter
Date of Inspection: September 30, 2004
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 The pipe between the tank and the D-box had standing water due to a slight belly
in the pipe.
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: 39 Woodvale Lane
Centerville, MA
Owner: Bill Porter
Date of Inspection: September 30, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
✓ leaching trenches,number,length: 1-4'x 30'x 2'(per information from last inspection)
leaching fields,number,dimensions:
✓ overflow cesspool,number: 1
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 trench was drv. There did not appear to be any signs of failure The cesspool was S'W x S'T x 6'bottom to grade
Liquid was above the inlet pipe. The cover was to grade The cesspool was 12'away from wetlands and approx. 1'below the
water level in the wetlands.
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: 39 Woodvale Lane
Centerville,M4
Owner: Bill Porter
Date of Inspection: September 30, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provi s o permanen re erencelandmarks or
benchmarks. Locate all wells w' in 10%th Locate where public wat supply enters the building.
A r39 3
A I- ag
a ) _ 33- as
Ga- '39
� fay
wcrlmA�s
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 39 Woodvale Lane
Centerville,MA
Owner: Bill Porter
Date of Inspection: September 30, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow 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)
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:
The bottom of the cesspool to grade was 6'. The wetlands were approximately 12'away The bottom of the cesspool was
approximately F below the water in the wetlands.
This report has been prepared and the system inspected and failed 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 andlor this report.
11
i
TOWN OF BARNSTABLE
IL70CA'1110N
UJCpC VALL /AA-L. SEWAGE #CLL ft+ f I L ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. A It
SEPTIC TANK CAPACITY 1
t
LEACHING FACILITY: (type) C�`T col + 4Gn LA (size)
NO. OF BEDROOMS p
BUILDER OR OWNER 13,1 f Dew
PERMITDATE:` COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well 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 le hi facility) Feet
Furnished by LI►S' f-7i0.1
1
R '
1
A a8
(91 - 31 as
pia,_ yq
r3a- 39
� fa.
wer/A^ s
No. li'I'v� Fee
THEyCOMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ye
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zfppliration for �Digooal bp$tem Couttruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.°\3 q wv%a�F _ _ .Owner' a Address
/and
Tel.No.
Assessor's Map/Parcel q✓�/'j/ vim�/�-���,,�: �Lv• `�' ►�—
I N ,A es , LTeNo. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures \
Design Flow D gallons per day. Ca culated daily flow 1 l gallons.
Plan Date Number of sheets Revision Date
Title �' '�
Size of Septic Tank cLrri S Type ofS.A.S.
Description of Soil �-67 `°!- �` � Uy`-�s� SM-,L.
Nature of Repairs or Alterations(Answer when applicable)( �S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b f lth.
Signe + Date
Application Approved by Date
Application Disapproved for the following reaso
Permit No. Date Issued
ate- -- � ' ?�� �
No. � '` Fee ,
AllTHE COMMONWEALTH..OF MASSACHUSETTS �``Enfeied in computer: A
Yes
PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLE., MASSACHUSETTS ` ,,.
�ti � ricatiou for Di.5pont, *p.5tem Con.5truction Permit
Applies tdon for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ( �VCt_ Owner' Address and Tel.No.
Assessor's MaplFarcel G 0 ^� ay d ✓"__
er N A o
ress, Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow —3 3gallons per day. Ca culated daily flow t gallons.
Plan Date Number of sheets Revision Date
Title �_�_._
Size of Septic Tank Type of S.A.S. c_GkA fit---_ ,,•••• nn n
Description of Soil �-6) 10%_�,f 5",
e
Nature of Repairs or Alterations(Answer when applicable) _ �'tow S
,ter'
Date last inspected:
Agreement: t '
The undersigned agrees to ensure the constructionand maintenance of the afore described on-site sewage disposal system
- in accordance with the provisions of Title 5 of the Environmental Code.-and not to place the system in operation until a Certifi-
cate of Compliance has been issued by-this-B-oard o alth. _
Signe Date
Application Approved by G ` Date
Application Disapproved for the following reaso
Permit No. ,. , Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIF�t 1the On site Seew�age Disposal System Constructed( )Repaired( )Upgraded(�
Abandoned( by d r
at Cl U.)cockj W-0—Lc_ C-E W-Ve."'A has been constructed i in accordance
with the pro v ierr f itle 5 and the for Disposal System Construction Permit No. 5-q 35 dated 9 / 0'1
Installer CC 4.,—�, Designe
The issuance of this perttiliallnpt be construed as a guarantee that t e syste i J n �ion a design
Date W Inspector
%., — I a�_
No. 4/�0,5oz X
THE COMMONWEALTH OF MASSACHUSETTS
f jr f PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Dig;pont *p5tem Cott.5truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( bandon( )
System located at
� C�•b0 V
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Consi cti'on m st be completed within three years of the date of thi e t.
k
Date:_.. Approved by /
Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
• BAMSTABLB,
MASS. �0�' Public Health Division
'FD 1A. th Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: C[2
Designer: Shay Environmental Services, Inc. Installer: �-
Address: P.O. Box 627 Address:
East Falmouth, MA 02536
On t'' 2An_-� was issued a permit to install a
(date) (installer)
septic system at 1 k1, , (k^C . based on a design drawn by
(address)
Shay Environmental Services, Inc. dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
rd
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
(N OF MASS
q �
CARMEN
( a re) E.
0': SHAY
NO. 1181
r op GISTS Vk-0�
(Designers Signa r (Affix Desi p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
l
OFs DA E:
FEE: S
II * IARNSTAB Y
MASS.
RE BY
1
A
own of Barnstable
SCHED. DATE:
Board of Health
1f?1`
200 Main Street,Hyannis MA 02601
('r Office:1508-862- 644 (Susan G.Rask,RS.
FAX: '508-790-004 iSumnerKaufman,M.S.P.H.
s. I Wayne A.Miller,M.D.
i
' I VARIANCE REQUEST FORM
s,.
LOCArIION I
Ir Property Addr 9's:
i'. Assessor's Mal and Parcel Number: 0-Io Size of Lot: , 4bQ �1�
e ,
Wetlarids With 300 Ft. Yes V Business Name:
No Subdivision Name: r
! APPLICANT'S NAME: `� i(41r � C" Phone .LQ(-}-- -'apt¢- 99( _
lj Did the owner cfthe property authorize you to represent him or her? Yes, No
I, PROPE �RTY O R'S NAME CONTACT PERSON
Name:. Name: C��Z�N►>✓t� I� �,y .
t u '
Address: N-j�oc Address:
Phone — - Phone: 5 39
VARIANCE FR Ni REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed)
z Z oy 6—
S JIs
NATURE OF NVORK House Addition 0 ????? House Renovation 0 Repair of Failed Septic Sy Item
{iE Checklist (to be completed by office staff-person receiving variance request application)
ij Please submit copies in 4 separate completed sets.
Four(4)copies"of the completed variance request form
'✓ Four(4)copies of engineered plan submitted(e.g.septic system plans)
Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
Signed 1 iter stating that the property owner authorized you to represent him/her for this request
1E Applicant,understands that the abutters must be notified by certified mail at least ten days prior to meeting ate at applicant's expense
(for Titl V and/or local sewage regulation variances only)
Pl Full met ti submitted(for grease trap variance requests only)
if
C:\Documents and Settings\decollik\Local Settings\Tempop Internet Files\OLK \VARIREQ.DOC
—3
r � `� Sic
Town of Barnstable
NAM
�
Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,RS.
FAX: 508-790-6304 Sumner Kaufman,MSPH.-r
Wayne Miller,M.D.
March 7, 2005
Mr. Carmen Shay, R.S.
Box 627
East Falmouth, MA 02536
' % , I`^ e .
.v `�,:r
Dear Mr. Shay,
You are granted conditional variances on behalf of your client, William Porter, to
construct a replacement soil absorption system at 39 Woodvale Lane, Marstons
Mills.
The variances granted are as follows:
't
Section 360-1: The soil absorption system will be 75 feet away from the
f
' bordering vegetated wetland (south of property), in lieu of the 100 feet
setback separation distance required.
Section 360-1: The soil absorption system will be 89 feet away from the
bordering vegetated wetland (north of property), in lieu of the 100 feet
setback separation distance required.
Section 360-1: The pump chamber will be 45.5 feet away from the bordering
vegetated wetland (south of property), in lieu of the 100 feet setback
separation distance required.
310 CMR ,15.255 (4): To utilize a sieve analysis in lieu of conducting percolation
tests.
These variances are granted with the following conditions:
(1) Sieve analysis results shall be submitted to the Public Health Division
Office before the applicant obtains a disposal works construction permit.
The sieve analysis results should be included on the engineering plan.
ShayPorter
(2) No more than two (2) bedrooms maximum are authorized at this
property. Dens, study rooms, offices, finished attics, sleeping lofts, and
similar-type rooms are considered "bedrooms" according to the MA
Department of Environmental Protection.
(3) The applicant shall record a properly worded deed restriction, signed by
the owner of the property, at the Barnstable County Registry of Deeds
restricting the property to two (2) bedrooms maximum. A copy of the
recorded deed restriction shall be submitted to the Health Agent prior to
obtaining a disposal works construction permit.
(4) The septic system shall be installed in strict accordance with the revised
engineered plans dated March 1. 2005. Note that the septic system
size/capacity is over-designed.
(5) The designing sanitarian shall supervise the construction of the onsite
sewage disposal system and shall certify in writing to the Board of Health
that the system was installed in substantial compliance with the revised
plans dated March 1, 2005.
These variances are granted because the physical constraints at the site
severely restrict the location of the soil absorption system due to the close
proximity wetlands on two sides of the lot. The proposed soil absorption system
appears to meet the maximum feasible compliance standards contained within
the State Environmental Code, Title 5.
Sin rely you ,
W yne iller, M.D.
Chairm n
ShayPorter
CARMEN E. SHAY
(508)-539-7966
ENVIRONMENTAL SERVICES,INC. P.O.Box 627,East Falmouth,MA 02536
February 1, 2005
RE: NOTICE FOR BOARD OF HEALTH HEARING FOR TITLE V SYSTEM:
Residential Property
39 Woodvale Lane, Centerville, MA
Dear Abutter:
In accordance with MGL 310 CMR 15.00, CARMENE. SHAY- ENVIRONMENTAL SERVICES, INC.(CES)
request a local variance for the proposed Title V septic system for the residential property located at 39
Woodvale Lane, Centerville, MA. The following details the type of variance requested, technical
justification of the variance and evidence that the granting of the variance will not pose a risk the
environment as defined in 310 CMR 15.410 (1) (b). A Meeting will be held on March 1, 2005 in the
evening (7:00 pm) at the Barnstable Town Hall (200 Main Street, Hyannis) relative to the
following.
The following details the type of variance requested, technical justification of the variance and evidence
that the granting of the variance will not pose a risk the environment as defined in 310 CMR 15.410 (1)
(b).
Type of Variance:
1. A variance is requested to install a Pump Chamber 45.5 feet from a wetland..
2. A variance is requested to reduce the setback from the SAS to a Wetland from 100 feet to 75.6 feet .
3. A variance is requested to use a Sieve analysis in lieu of a perc test due to high groundwater.
If you have any questions, please do not hesitate to call the undersigned at (508)-539-7966.
Sincerely,
CARMENE.SHAY
ENVIRONMENTAL SERVICES,INC.
C��LQ �
Carmen E. Shay, R.S., C.S.E.
President
i
CARMEN E. SHAY (508)-548-0796
ENVIRONMENTAL SERVICES,INC. P.O.Box 627,East Falmouth,MA 02536
February 1,2005
Town of Barnstable Board of Health
200 Main Street
Hyannis, MA 02601
RE: REQUEST FOR VARIANCE HEARING FOR TITLE V SYSTEM:
Residential Property
39 Woodvale Avenue, Centerville, MA
Dear Sir or Madam:
In accordance with MGL 310 CMR 15.00, CARMEN E. SHAY- ENVIRONMENTAL SERVICES,INC.(CES)
request a local variance for the proposed Title V septic system for the residential property located at 39
Woodvale Avenue, Centerville, MA. The following details the type of variance requested, technical
justification of the variance and evidence that the granting of the variance will not pose a risk the
environment as defined in 310 CMR 15.410 (1) (b).
The following details the type of variance requested,
sted, technical justification of the variance and evidence
that the granting of the variance will not pose a risk the environment as defined in 310 CMR 15.410 (1)
(b).
Type of Variance:
1. A variance is requested to install a Pump Chamber 45.5 feet from a wetland..
2. A variance is requested to reduce the setback from the SAS to a Wetland from 100 feet to 75.6 feet .
3. A variance is requested to use a Sieve analysis in lieu of a perc test due to high groundwater.
If you have any questions, please do not hesitate to call the undersigned at (508)-548-0796.
Sincerely,
CARMEN E.SHAY
ENVIRONMENTAL SERVICES,INC.
ht
Carmen E. Shay, R.S., C.S.E.
President `
i
##39 WOODVALE LANE CENTERVILLE MA
Floor Plan
NOT TO SCALE
Bathroom
8' x 7'
Kitchen / Dining Bedroom
GARAGE
Living Room
Bedroom
TOWN OF BARNSTABLE
LOCATION 29 I uV QO Q � SEWAGE#
VILLAGE Ctff1�- V'Q\\\ ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NOe—Tp
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)_ j sP (size) 3D GS l K/
NO. OF BEDROOMS - 3 -
OWNER
PERMIT DATE: `c�B� 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 lea mg facility) Feet
FURNISHED BY Vo'D
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�7 a TOWN OF BARPiSTABLE
C7 LOCATION 9 4j00 P k1AQ— d4__Q_ SEWAGE# js
VTLLAGE GAP"yQ\\___ASSFSSO/R''S`M-AP�&iPARCEL I G,O" F�7
INSTALLERS NAME&PHONE NO..11L fCJ Yam `_7
SEPTIC TANK CAPACITY V*-ti lam A em —*
LEACHING FACILITY:(type) �� (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: 4-5-�O,� COMPLIANCE DATE: 6
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 my wetlands exist
within 300 feet of lea mg facility) Feel
FURNISHEDBY V4.b
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2p J TOWN OF BARNSTABLE
LOCATION _ ` �"codUct le- Z" SEWAGE #
VILLAGE �2�17��fl.��e ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
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SEPTIC TANK CAPACITY DDD �I
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LEACHING FACILITY: (type) �G . (size)
1 NO.OF BEDROOMS .3 //.
:BUILDER OR OWNER 6 C w 11 O K e e
PERMITDATE: aCjU - COMPLIANCE DATE:_ r
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 VIVA-
on site or within 200 feet of leaching facility) V/t/• ' I-- Feet
Edge,of Wetland and Leaching Facility(If any wetlands exist
within 300 feet 'f leaching facility) Feet
Furnished
of
r^ Joe; � .r
31R'
6-0 - as
` DEED RESTRICTION
Whereas, Jennifer Ogg, of 39 Woodvale Lane, Centerville, Massachusetts, is the owner of
39 Woodvale Lane, Centerville, Massachusetts,under deed recorded at the Barnstable County
Registry of Deeds at Book• Page 227 on December 3,,2004.
193c��
Whereas, Jennifer Ogg, as the owner of said lot has agreed with the Town of Barnstable
Board of Health to a restriction as to the number of bedrooms which can be included in any home
built on said lot as a pre-condition to obtaining a disposal works construction permit in
compliance with 310 CMR 15,000 State Environmental Code, Title V, Minimum Requirements
for the Subsurface Disposal of Sanitary Sewage;
Whereas, the Town of Barnstable Board of Health, as a pre-condition to granting a
disposal works construction permit fora septic system in compliance with 310 CMR 15.2000
State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of
Sanitary Sewage, and authorizing the issuance of a building permit for the construction and
installation of the same, is requiring that the agreement for the restriction on the number of
bedrooms in any house constructed on the lot be put on record with the Barnstable County
Registry of Deeds by recording this document.
NOW, THEREFORE, Jennifer Ogg, does hereby place the following restriction on her
above referenced land in accordance with her agreement with the Town of Barnstable Board of
Health, which restriction shall run with the land and be binding upon all successors in title:
1) 39 Woodvale Lane, Centerville, Massachusetts may have constructed upon the lot a
house containing no more than three (3)bedrooms. Jennifer Ogg agrees that this shall be
a permanent deed restriction affecting the land located at 39 Woodvale Lane, Centerville,
Massachusetts,and being shown on the plan recorded in Plan Book 246, Page 145.
For title of Jennifer Ogg, see Book 19309,Page 227 at the Barnstable County Registry of Deeds.
Executed as a sealed instrument this,21/ day of August, 2005.
JenO6r Ogg
tA RMEN E. SHA Y (508) 548-0796
ENVIRONMENTAL SERVICES,INC. P.O. Box 627, East Falmouth,MA 02536
October 13, 2004
Mr. William Porter
39 Woodvale Avenue
Centerville, MA
RE: 39 Woodvale Avenue, Centerville, MA - 310 CMR 15.00 Title 5
Design Proposal
Dear Mr. Porter:
Pursuant to your request, the' following is a proposal to design an upgrade to the on-site
subsurface sewage disposal system located at the above referenced address. All work performed
shall be at a minimum in accordance with the requirements set forth in the Massachusetts
Environmental Code Title 5: Minimum Requirements for the Subsurface Disposal of Sanitary
Sewage, Regulation 310 CMR 15.000. ,
As mandated by Title 5, observation and recording of Deep Observation Hole Tests, Percolation
Tests and Soil Evaluation will be performed with the approving Board of Health. The soil
evaluation and engineering time for a percolation test cost will be included in the design cost
unless existing conditions result in time spent over three hours. Time over three hours will be
billed at an hourly rate of$65.00/hr. If this additional time is required this cost will be billed over
and above the actual system design cost and will be billed separately. The test holes will require
the use of a subcontracted backhoe for excavation. The cost of a backhoe is included in this
proposal.
The plans and specifications shall be prepared by a Registered Professional Engineer or
Registered Sanitarian as mandated in 310 CMR 15.220. Upon completion of the site-specific
subsurface disposal design plan, you will be furnished with three (3) copies of the plan.
Additional copies of the plan can be provided for additional cost.
Upon completion of system installation, you as the property owner will be responsible for having
a certified as-built plan prepared and submitted before the approving authority will issue a
certificate of compliance. We can on behalf of the property owner perform the as-built survey
and plan and obtain a certificate of compliance from the approving authority pursuant to the
requirements set forth in 310 CMR 15.021 (2) through (6). The cost of the as-built plan
preparation is included in this design cost contract.
- Prior to the issuance of the Certificate of Compliance, the local approving authority is also
required by the regulations to make a sufficient inspection of the system to determine that all
work has been completed in compliance with the applicable requirements set forth in the design
plan and Title V Code.
Soil Evaluation& Percolation Test included
Design& Plan Preparation
Backhoe for Perc Test
Preparation of RDA Paperwork
2 Night Meetings (1 Health & 1 Con Co
Less Deposit of
Town of Barnstable Fees (Additional - $100 anticipated total)
Note 1: If minimum setback distances from the proposed septic system to the property
lines are needed it may be necessary to set stakes on the lot corners. If important
property monumentation in the area is missing or destroyed, a property line survey
may be required to accomplish this. A full property line survey is not included in
this design contract. If necessary we could perform the property line survey under
a separate contract.
Note 2: If a passing percolation test is not obtained on the day of the soil examination due
to poor soil conditions, the time associated with obtaining the necessary variances
from the local and state approving authorities for the system design will be billed
over and above this contract. If this situation occurs we will notify you and obtain
your authorization before proceeding with any additional work.
Note 3: Our proposal is based on the design of a conventional on-site sewage disposal
system. If an innovative/alternative system is required due to existing site
conditions, the design fee will be adjusted according to our standard fee schedule
over and above the price shown on this contract. If this situation occurs we will
notify you and obtain your authorization before proceeding with any additional
work.
Note 4: Client is responsible for all State and Local filing fees
Note 5: If the determination of a Resource Area, filing of a Notice of Intent or Request for
Determination of Applicability form with the Local Conservation Commission
and the State D.E.P. are necessary your property must meet criteria of the
Massachusetts Wetlands Protection Act. Typical criteria include being within 100'
of a wetland or a resource area. Costs associated with complying with the
Wetlands Protection Act are charged over and above this contract.
Note 6: If attendance of ADDITIONAL Board of Health or Conservation Commission
meetings is required due to existing site conditions an additional fee of
$150.00/meeting will be charged for each meeting, if you or the Town of
I03/11/2014 21:36 ;SAX 001
VI/ V/LVIJ Ia.zu rA .. �V.,a/• v.
' Barnstablc reyucst tho presence of the design eztgineer/registered sanitarian. Q
:hoard of Health and/or C-anservatlon,QmMasIien MfIfine is anticipated but
not Qua�ranfzell,ac►d is Included to th a contract.
Z�Qte is .1 State and/or local variances must be oppliod for due to existing site conditions,
the time associated with these applications will be billed over and above this
contract_ The contract does include the cost of filing a property setback variance
due to the size of the property, Local anti State Eggs not included jn Vai rignee
,'ilk
I"you have any questions regarding this proposal,please do not hesitate to call me at(509)•549-
0796.
Sincere] .
f
Carmen E. Shay, R,S., C,S,E,
President
FOR: Responsible Party
7.ease sign for "Responsible Party"and return original,
Ti'possible please include a copy of the deed for your property and a copy of the mortgage plot
plan and any other plans of the property with this contract.(For lot Size,reference and dimension
data)
Prior to doing any work on the property, we reserve the right to post a notice of contract. The
pirties to this contract specifically agree that Carmen E. Shay has no obligation to release .
d°swings or other documents until the final bill for services has been paid.
A.copy of the executed contract will be forwarded to you for your records,
J�
TO N OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE s ASSESSOR'S MAP & LOT
INSTALLER'S NAME& PHONE NO.
SEPTIC TANK CAPACITY All 21d GJ'g�JS
LEACHING FACILITY: (type)--,-, 29�4(size)
NO.OF BEDROOMS
BUILDER OR OWNER k
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of.leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
Within 30;feet le'n a ' ity) Feet
Furnished
L
P �
3 t�Joc�.ual _--
-_..w TOWN OF BARNSTABLE
LOCATION 3 9 SEWAGE
VILLAGE ASSESSOR'S MAP & LOT l90 - J�7
INSTALLER'S NAME & PHONE NO.
'`SEPTIC TANK CAPACITY /9 e
L'LACHING FACILITYAtype) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
I'I DATE COMPLIANCE ISSUED:-
VARIANCE I NTED: Ye No
�,415 U /
N
PROPERTY ADDRESS; 39_Woodv_ale L•ja,@,______
02632
------------------------
On the above date, I Inspected the septic ,system at the above address,
This system conslsts of the following;
1 . 1 -1000 gallon septic tank.
2 . 1 -6 'X8 ' block cesspool.3. 1 -leaching ,terdench. 30 longn4 1 ce'Ary 2the%T*wing oondltlonv
on my 4--This is a title five septic system. ( 78 Code )
'15. The septic system is in proper working order
— at the present time.
6 . The laeching trench is presently dry.
7. The waste water is 48" below the invert pipe
of the cesspool.
SIGNATURE:, _..L�� %f�
Company: Joa!2h_P _ Macomber_& Son , Inc .
Address:- Box-66-
Centerville He__02632-0066
Phone:-___308
THIS CERTIFICATION 00es NOT CONSTITUTE A QUARANTY OR WARRANTY
J6SEPH P, MACOMBER & SON, INC-
T+nk>i•C�r<><poolri•L�ichllelds
Pumped i In:tili�d
Town Sewer Connootlons
P.O. Box 6y7S•JJJ8e�77, MA 02632.0066
yYtl T ,
COMMONWEALTH OF NIASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
,r
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
m Property Address: 39 Woodvale Lane
en ervi e,mass.
Owner's Name: Irene Hazelton Henry
Owner's Address:196 Main Street
Kin ston Mass. 02364
Date of Inspection: 3 5/01
Name of Inspector: (please print) Joseph P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc.
Mailing Address: Box 66 Centeryille,Mass.
02632
Telephone Number: 908-775-1338
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 Section15.340 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: ~d
The system inspector sha ubmit 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 I
I
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 39 Woodvale Lane
Centerville,Mass.
Owner:Irene Hazelton Henry
Date of Inspection: 3/5/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
AP 1 have not found any information which indicates that any of the failure criteria described in 310 CMR
f 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
6A) 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.
A)Q 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:
iU Observation of sewage backup or break out or high static water level in the istr'bution bo . ue to broken or
obstructed pipe(s)or due to a broken, settled or uneve tstributton bo 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 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 39 Woodvale Lane
Centerville,Mass.
Owner:Irene Hazelton Henry
Date of Inspection: 3/5/01
C. Further Evaluation is Required by the Board of Health:
4), () 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:
Vcl Cesspool or privy is within 50 feet of a surface water
4,0 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.
4/0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
/Vt) 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 supple well". Method used to determine distance I,/,,
"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:
The SAS is 67 ' off the wetlands_ The wet- anrnss the strpat
See PACIP 10 Of 11
3
Page 4 of I 1 0
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 39 Woodvale Lane
Centerville,Mass.
Owner:Irene Hazelton Henry
Date of Inspection: 3/5/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the following for all inspections:
Yes No
�ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspoo
A,JJ,G� Static liquid level in the di,;iribution box ove outlet invert due to an overloaded or clogged SAS or
cesspool
}-squid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow
;/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
f times pumped d .
�y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
ater supply.
y portion of a cesspool or privy is within a Zone I of a public well.
L�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 forma
,)V (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/
I- the system is within 400 feet of a surface drinking water supply
v e system is within 200 feet of a tributary to a surface drinking water supply
the to i located in a nitrogen sensitive area Interim Wellhead Protection Area— IWPA or a mapped
_ _ system s to t d n og (; ) pp
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
sienificant 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 l 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 39 Woodvale Lane
en ervi e,Mass.
Owner: Irene Haze ton Henry
Date of Inspection: 3 5 11
Check if the following have been done. You must indicate"yes"or"no"as to each of the followine:
Yes l�o
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
_VHas 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 /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,k4uding the SAS, located on site ?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the affles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
/snxisting information. For example,a plan at the Board of Health.
etermined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5
'Page 6 of 1 I y
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 39 Woodvale Lane Centerville,mass.
Owner: Irene Hazelton Henry
Date of Inspection: 3/5/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):,.5— Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms):
Number of current residents: I
Does residence have a garbage grinder(yes or no):2�0
Is laundry on a separate sewage system (yes or no):,jjL [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes no): �
Water meter readings, if available(last 2 years usage(gpd)): A6
Sump pump(yes or no): it,1 �r.. �. C-
Last date of occupancy: :°�r
COMMERCIAL/WDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): A)r¢ gpd
Basis of design flow(seats/persons/sgR,etc.): ,CA
Grease trap present(yes or no):A
Industrial waste holding tank present(yes or no):,&
Non-sanitary waste discharged to the Title 5 system (yes or no):424
Water meter readings, if available:
Last date of occupancy/use: .t/A
Y OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as pan of the inspection (yes or no): _
If yes, volume pumped: _gallons-- How was quantity pumped determined? mil¢
Reason for pumping:
TYPE OF SYSTEM
Septic tank,"—ibution Wx,soil absorption system
41,$ingle cesspool
zX Overflow cesspool
Privy
�L;,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)
,L16 Tight tank .a Attach a copy of the DEP approval
LU 6 Other(describe): AJ,4t
AAro. 'mate se of al ompon s, date instal a (if known) nd source of in rmation:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:39 Woodvale Lane
Centerville,Mass.
Owner: Irene Hazelton Henry
Date of Inspection: I/5/n 1
BUILDING SEWER(locate on site plan)
Depth below grade:M 1�
.Materials of construction: cast iron jr/d 40 PVC other(explain): a !Z
Distance from private water supply well or suction line: /d'1'`
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear ticlht.No evidence of leakage.System is vnted throuh the
1Q � housevent.
SEPTIC TANK: (locate on site plan)
Depth below grade:
Material of construction: ncrete�metal,pfiberglass,,4 polyethylene
e4other(explain)
If tank is metal list age: � Is age confirmed by a Certificate of Compliance(yes or no):,�(attach a copy of
certificate) �� ,� �,_ ��}
Dimensions: 7 k G y Ie ' v c2"y wf�
Sludge depth ,
Distance from top2LfjWdge to bottom of outlet tee or baffle:
Scum thickness:ZR �/ —
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee W baffle.
How were dimensions determined: '�4`�`1112�.r —
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage, etc.):
Pump the septic tank annLal1y Garhacip (jic=ngal is iraaant
Inlet & outlet tees are in pl ac e:mhP tank i s Gi-r„cturally sound
and shows no evidence of leakage.Liquid level at the outlet invert
is fifty one, inches.
GREASE TRAP:Id)(locate on site plan)
Depth below grade:
Material of construction ( concrete lU�metalfiberglassA/iQpolyethylene &other
(explain): )19
Dimensions: ,U
Scum thickness: 104
Distance from top of scum to top of outlet tee or baffle: _ �i_
Distance from bottom of scum to bottom of outlet tee or baffle: It _
Date of last pumping: //d
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 is not present
7
I
F'✓ ' Page 8 of 1 I D
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 39 Woodvale Lane Centerville,Mass.
Owner:Irene Haxelton Henry
Date of Inspection: i.s/n 1
TIGHT or HOLDING TANK:)2p (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 41h
Material of construction: concrete,pA metal .dA fiberglassii,,1 polyethylene d�/ other(explain):
M
Dimensions:
Capacity: gallons
Design FIoH: _gallons
Alarm present(yes or no): o)h
Alarm level: e),4. Alarm in working order(yes or no):
Date of last pumping: y/f
Comments(condition of alarm and float switches,etc.):
Tight or holding tanks arp not prpsant
DISTRIBUTION BOX:A,)0 (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: _,d,29
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 hox is not =racpnt
PUMP CHAMBER:(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): 24
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump chgmber is not present -
8
L
s� yPace 9 of 1 1 a
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM,INFORMATION (continued)
Property Address: 39 Woodvale Lane
Cen ervi e,Mass.
Owner Irene Hazelton Henry
Date of Inspection: 3 5 01 /
SOIL ABSORPTION SYSTEM (SAS)!/ (locate on site plan,excavation not required)
If SAS not located pxplain why:
��
Type
D leaching pits,number:Q
�9leaching chambers,number:
leaching galleries,number: ,
�
eaching trenches,number, length:
," eaching fields,number, dimension . 0
overflow cesspool, number:
innovative/altemative system Type/name of technology:
'Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Loamy sand to medium fine sand No signs of hydraulic failure
'i. or pnnaing Soils are ry V getatinn iS normal.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: f
Depth—top of liquid tort invert:
Depth of solids layer: 1,114-f-e.
Depth of scum layer: d
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):Ak
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Soils same as above.No signs of hydraulic failure nr pondong_
Vegatat-i nn i c nnrmal
PRIVYat,� (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.):
Privy is not present.
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:39 Woodvale Lane
Cen erville,Mass.
' Owner: Irene Hazelton Henry
Date of Inspection: 3 5 01
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.
QV -
� T
\ YO/
10
Page I I of I l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ProperT Address: 39 Woodvale Lane
Centerville,Mass.
Owner: Irene Hazel Henry
Date of Inspection: 3 5/01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water ;W feet
Please indicate (check)all methods used to determine the high ground water elevation:
____Obtained from system desi plans on record - If checked,date of design plan reviewed:
bserve�siie a utttng prope bservation hole within 150 feet of SAS)
eckeoca Boar o eaIth explain:
Checked with local excavators, installers- (attach documentation)
-b Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used water countours Map
Gahrety & Miller model
sr -12/16/94
r I
x -
• _ 11 I
` .'nr+^n'rr�•+n- rnr mr'nmrnrner+rr.r.mri•.tr+srRr+r►*frrtnm*wfal�tlrrv+RT+ .TTTTT-fir:�-.
"OWN OF Barnstable BOARD OF HEALTH
SUBSURFACE 9FWAGF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CEnTIFICATIO N
+.T••••. .-T.IIT.^-rn.nr*n•nrn TTnT*tT'rr1'.'-t•t-t.m'�Rnrr-TRRIaosrlR+alRnIF�IST7 remnT.frRrl►-Tmr.+r.-.rrrr-•- --.
-TYPE OR PRINT CLEARLI'-
PROPERTY INSPECTED
STREET ADDRESS 39 Woodvale Lane Centerville,Mass.
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Irene Hazelton Henry
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Irf'34-.-
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or city St4t♦ LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1578
.T
A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system nt
®recoinmendations
his address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one ;
System PASSED
2
The inspection «hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe environment as defined in 310 CMR 16 . 303 . Any faiIkire
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have con acted has found that the system fails to
Protect the j)ublic health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
0
Inspector Signature Date
ne copy of this ce t.ification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEAL'I'II.
* If the inspection FAILED, the owner or"oporator shall u
pgrado ' tho system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd . doc
l—
i
,
SEPTIC TANK SHALL BE FACTORY COt,e>Tt^,JC1Eu 0,
r DURABLE WATERTIGHT MATERIAL AS PER V' C ?'", ^�'
PERCOLATION TEST
TE T TLE CODE 2_ .
Y CENTER ACCESS COVER OF SEPTIC TANK TO BE,
: ,
0 0 GALLON 1SEPTIC I e` f Percolation Test: -DECEMBER 6 20D4 EXIST. 1 0 �L01 H 0 TANK RAISED a 1
+ PLAN OF' SEPTC SYSTEM
Date ORASED WITH THE APPROPRIATE RISER TO Wt,:l• � ,
Test Performed By: CARMEN E. SHAY C.S.E. 6" of THE EXISTING GRADE AS PER TITLE V.
Results Witnessed By. DAViD STANTON (BARNSTABLE B.O.H.)
NOT TO SCALE
+ + Percolation Rate: <2 min./inch SIEVE ANALYSIS TO FOLLOW THE ACCESS COVERS FOR THE SEPTIC TANK,
f I DISTRIBUTION BOX AND LEACHING COMPONENT
I 1 SET DEEPER THAN 1 FOOT BELOW FINISHED
I 1 GRADE SHALL BE RAISED TO WPTHIN 12" OF
I FINISHED GRADE.
i I INSTALL TUF-TITS GAS BAFFLES OR EQUALS
iLIJI ON ALL OUTLET TEE ENDS
LOT #9 i No. 1
Test Hole :-20'0",ACCESS MANHatEs i
LOT 00
i DRAINAGE POND a 24-aaros r
DEPTH SOILS ELEV.
I 0 98.00 F». ..I � .... •oteorenw
1\J/
n FILL •- ` INLET
'mi t ram. not to ae.t ount
I 1
0 'fIU�JP�4wcr
;
C (� 0"-48" 94.00
SANDY LOAM I a j r L1ry M a"rch a
L, 10
WETLANDS - V=92 -� (•� --'`-T ':•�--:-- �•
EDGE O ELE � f J� I 48"-60" Ap 93.00 STEEL•REINFORCED PRECAST CONCRETE a-a i
V _ -
' i------ - ___- --_- - ---------- ----- _ ' 9 Lo PLAN' VIEW CROSS-SECTION _ TON
J SANDY AM I E�:�Kj
_ _ 60"-72" BW 2.00
---------- �'�\ �r- �-'' Med-Coarse Sand
1 I \ 2.5 Y 7/2
I ,
t \ \ ✓ , 72 120 C 1 8.00 ALL OUTLET PIPES FROM THE :.
VARIANCES REQUESTED:!
OSET LEVEL BOAT LEAST82 FT. CONCRETE GONER
1. REQUEST AVARIANCE TO INSTALL AN PUMP CHAMBER 3 5. a, T
.•...� ..A.•� 2
45.5' FROM A WETLAND. --'" KNOCKOUTS -
J 2. REQUEST AVARIANCE TO INSTALL AN SAS 75.6' FROM A WETLAND. - - -ts.5- ounET I (- rJ"! i2- iNt T
i 3. REQUEST VARIANCE TO USE A SEIVE ANALYSIS
Note: Remove soil down to el. 92.00 & replace with _
p r, IN LIEU -0F A PERC TEST. �,: .,;.. �. ...: � �,•rt `�> "�z ,
(40 FOOT RIGHT F WAY) clean coarse sand w/perc. rate' less than or i -75.5---- 4" - SCH. 40 Tel -1 7
or equal to 2 imin./in. before' & after placement PLAN SECTION CROSS-SECTION
50 FROM `WETLANDS (5 FOOT STRIPOUT ALL AROUND AS SHOWN) Perc i
SIEVE ANALYSIS TO FOLLOW 3 HOLE 'H-10 DISTRIBUTION BOX
S 79d 58' 45" yi' } I Perc Rote= Less Than 2 MPI NOT TO SCALE
" I 165,00 I t Observed ESHWT® 72"or Elev 92.00=ELEVATION OF WETLANDS TO POND 2-20' REMOVEABLE ^__1
I , \
MANHOLE COVERS WITHIN
6" OF FINISHED GRADE. e-e
' h RESTORE TO FINISHED GRADE ELEV. • ,4 L s ^1 i::, r
LOT #3 ; ASPHALT a
17,400 +/- S.F. i DRIVEWAY
PROJECT BENCH MARK ,� I / i LIFT OUT CHAIN NtEt r_� ` _� a THE ACCESS COVERS FOR ;I,- SEPTIC TANK,
TOP OF FOUNDATION ' / 99P --_ -----99 I INLET INVERT / ; DISTROUTON Box AND LEAGN;111. COLA IDt;FNT
``� / ��.. i - 7 V SET DEEPER. THAN 6" SELOv FIN +._D
ELEV. = 100.00 (Assumed) i i / ��' Design Calculations F�..9+� OUTLET WER ELEV.- 95.45 GRADE SHALL BE RAISED TO w'HtN 6- or
3j" H E ABO r CHECK VALVE
15' j Number of Bedrooms: 3 Equivalent to 330 Gal./Day gg $~ �j`
(FRE PR cCTlON� �' •'r;. r,#'v""'}:�"�,.',;••''^ _, FIAP.SF1£D GRAD,"_.
1 I 1 2" SWING CHECK VALVE-P.V.C. STEEL REINFORCED PRECAST CONCRETE
N i i _ Garbage Grinder: No 60. PLAN VIEW
+ + EXISTING /I tj-- 9$ Leaching Capacity Required:330 Gal./Day Minimum ( Title V ) 57' 2; y-24''�„°"BLE co A'" r
r
i i 2 BEDROOM l 1 CO Septic Tank - 2 x 330 Gal./Day = 660 USE EXIST. 1,000 GAL. Septic Tank.
i I HOUSE f/ I / O SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch
J rah.dearerxw .+.
/ Bottom Area: 0.74 al s ft. x 450 s ft. = 333 gallons te- glET e'T_ : e,�W#t to mW
I I S / / l 8 g / q• 4• 9
99 I I Sidewall Area: NOT USED - - - -1----
SLAB FOUNDATION l I /� --------- _� 1 ,V l ,
I I--_e I / � Providing: = 333 gallons R Put„ CHAMBER ELEV.- 9,.4 � •t �,�,,. i---tr,�„>�- ,
LOT #4 98- _1 1 f ( o ,2•a, 3/4• - „/2• Stan,
97 ? i \`O #3s I / I LOT #z 4 i
YR
' 24 / PUMP DETAIL L ,. �•
96 -1 . T_ �_a. - "t
U + / Not to Scale :-,c
I B U OA lV C' Y C�1 L CCJL A Tl 0iV S
`i�7 I �� �,` ' �� L / CROSS-S�CTi N END-5ECT!ON
94 _ _Q' �\��� - t -'�/ i �T H LE #1 Weight of Sepfic Tank: 8,240 lbs. PUMP NOTES & SPEC/F/CA TIONS 1000 GALLON H-10 SEPTIC TANK USED AS PUVE CH V ii_R
r `�\ \ o -- ELEV 98.00 I Nor To SCALE
�'OS o ,% Weight of Soil Above Tank 4 766 lbs.
_ !
I 93- --1� i \ \ �. .� 1. PUMP SHALL BE INSTALLED IN STRICT COMPLIANCE NOTE: PUMP CHAMBER TO BE FACTORY WATERPROFFED PRIOR TO SHIPPING.
1000 GALLON Total Weight Down: 72,406 lbs. WITH MANUFACTURER'S SPECIRCATIO,NS
\ J 2. ALARM SHALL CONSIST OF AUDIBLE SIGNAL &
1 �i5t. 1 DOD GALLON PUMP CHAMBER
SEPTIC TANK _
l Cp j \ H-10---�•--- -- H-10 --- r Weight of Water Displaced: 2500 lbs. AND POWERED RED WARNING LBYH SEPARATE T TO BE fNC1��FROM IN UlLD1NG PUMP SPECIFICATION CALCULATIONS
1 "I. L>_ 1 \\ \` \ I- CIRCUITS TO PUMP.
I 1 \ \ 3. DOSING SCHEDULE:
® SHED
l
i \ _ 330 GALLONS 4 DOSES 82.5 GALLONS DOSE
STA TIC HEAD L CU 7i N __ ��.__. •...�
/ / N CA
.N riasr rCe c� d r Septic- Tank
I
- - - - cs 8a e Fo Se o an
\
----
l r ____ s 2 Ere of D Bax In
Z3 \
N 45.5 1 - �
7 9 .45 El.vatron of Bottom of Pump Chamber
cn \ 9 p
� � I I � ---__ __ FLOAT LOCH TION CALCULA TiDNS
----- _.�_.., 44.00 Weight of Pum Chamber. 8,500 lbs.
�� - 't- ---- g 97.92 - 91,45' - 6.47' Static Head
121.0 „ r_�� Weight of Soil Above Tank 4, 766 lbs. 82.5 Gallons i 7.46 GAL./Cu Ft - 11.03 Cu Ft
s 78d 4J5 30 II �9� Area of Bottom of Chamber - 8' x 5' - 40 Sq. Ft. DYNA&f1C HEAD
` -_` -_- Total Weight Down: 12 666 lbs.
N 79d 48' 50" E ------------- -
Height of Water for One Dose (H) 1 L03 Cu. Ft. / 40 Sq. FL
H - 0.28 Ft. = J.36"
9 Friction Head For 3"5CH 40 PVC Pipe
-- --- Weight of Water Displaced 2500 lbs. 0'10 GPM - 0.005 Ft./100 Ft.
--- ___
------ ------ �� ��� Pump On = 10" �50 GPM - 0.0t Ft./100 ft. Use Gould Model 3887(WS0511BF) Pump
E OF WErLAN 93 112 HP 2*Solids Hondlinrg
EDGE I_ Pump Off - 6' 0100 GPM - 0.40 Ft./100 R. 230 Volt Phase I
DS ELEV_ * No Ballast Required For Pump Chamber Alarm 20.0" Total Dynamic Head - 6.87' 0 100 CPU OR EQUIVALENT
92.00
` NOTE:
LOT # 166 EXISTING SAS TO BE PUMPED DRY & THE PROPERTY LINES ARE APPROXIMATE AND
PUMP PERFORMANCE DATA
LOT ## 144 FACILITATE NEW SAS INSTALLATION.REMOVED TO FACILiTA ARE COMPILED FROM A SURVEYED PLAN ENTITLED GENERAL NOTES
NOTE: THE STRIPPED OUT SOIL CONTAINING LEACHATE "CERTIFIED PLOT PLAN AT #41 1RA000IS BLVD., YARMOUTH MA
DATED-MARCH 3, 2003 BY BSC GROUP of W. YARMOUTH, MA. 1. Contractor is responsible for Digsafe notification
FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED 40
! AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN and protection of .all .underground utilities and pipes.
OF AS PER BOARD OF HEALTH SPECIFICATIONS. IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 2. The septic tank and distribution box shall be set
THE SEPTIC SYSTEM INSTALLATION. level on 6" of 3/4"-1 1/2" stone.
LEGEND 3. Backfill should be clean sand or gravel with no
MAP
stones over 3" in size.
i- LOCUS M A r 40 4. This system is subject to inspection during installation j
PROFILE 0 SEPTIC SYSTEM by CARMEN E. SHAY - Environmental
5. The contractor shall install this system in accordance
88X0 with Title V of the Massachusetts state code, the approved Ian
DENOTES PROPOSED o pp p
r e and Local Regulations.
SPOT GRADE _
6. If, during installation the contractor encounters any ;
" 20 soil conditions or site conditions that are different
C : DENOTES EXISTING E
104X46 0 from those shown on the soil to or in our design I
`l SPOT GRADE g 9
installation must halt & immediate notification be
s ,� 'f \� 1t aas"bat "� ,.,�► , PL o made to CARMEN E. SHAY - Environmental
*NOTE: INSTALL TUF-T1TE GAS BAFFLES OR EOUALS ON ALL OUTLET TEE ENDS. PROPERTY LINE
_ �` , ' - `'; as ilri+e+r tq,. ll+ ,,•" § � 1-- i0 7. No vehicle or heavy machinery shall drive over the
Finished grade over system 2% slope away fl, septic system unless noted as H-20 septic components.
Finished grade over system= 99.00 1. �'' \ e. t" Z\ PROPOSED CONTOUR I
' � 8. Install Tuf-Tit, gas baffles or equals on all outlet tee ends.
VENT PIPE (® Least 24 Inches tall) • t "
DBOX Schedule 40 PVC w/Charcoal odor Filter t vt1 tm xr - - - 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
--t0' min. from Provide Risers 97 97 EXISTING CONTOUR "
• EXIST. House house to septic tank Provide Risers if necessary to bring INLET Pump Chamber cover *n��4 Xs, 10. All solid piping, tees & fittings shall be 4 diameter
to bring.Septic tank covers to grade and outlet cover to within t _
within 6 of finished grade " TOP OF SAS ELEV 98.15 �- "
s of finished grade �•" '" ,' � '' ' """"`" Schedule 40 NSF PVC pipes with water tight joints.
+.��.�� . . � DEEP TEST HOLE & p P 9
/ t 0 20 40 60 80 100 120 140 11. Municipal Water is Available.
'` - ' s ? PERCOLATION TEST LOCATION p
:• : S- 1 8" per foot S-.005 _
'.Perforated P.V.C. 2•-t/8'-t/2"Washed Ston . t
Level fort' .. 0) Amd'3q*it'+IP. ay812"tNllt:T6Ai r °;. ,'y Y.;•4'. +'
s , -• Invert Elev.= 97.50
STOCKADE FENCE
Pe, foot177S. 9/8` per too FORCE MAIN ,":1 3/4'44' Washed St«e Bottom of Leach FacilityElev.= 97.00 ~~ Capacity - US G.P.M.
EXIST. `n L,
PIPE FROM �, N 10' 40' Ot IJ '`t' 'S•,'6';I;Ysa7j...r: `,::°e7' .,i,:"'yh. ~�'ti'",`+.\).`
0 EXISTING
FOUNDATION to C7 A ., .i!I, 11kic .4E '4'y..,•4�r :L��r'�
I
° 1000 GALLON 5'p II I) , 5 PROVIDED Bottom of Test Hole 1 Elev.. 88.00
n 4' Sch 40 PVC (0 r 1000 GALLON 9" Sch. 40 PV _ > � Adjusted ESHWT ELEVATION = 92.00 P
> m SEPTIC TANK F' SEPTIC TAN _v 5 STRiPOUT ALL-AROUND
CONCRETE m 11 t 1-10 a, U a i I-10 > -
\ � PROPOSED
tri c ' �Obs. Groundwater - Test Hole 1 Elev.= 92.00 (ELEV. OF WETLANDS TO POND = 92.00 FOR ESHWT) RE V ( , � ( � N S e
SLAB FOUNDATION ?; y II o II C1 - C 11 i
PREPARED FOR .
5 a II
STONE a1 Q 6" OF 3/4"-11/2" STONE a1
� v, � 6" OF 3/4"-11/Y STONE a, I
SUBSURFACE SEWAGE DISPOSAL SYSTEM
c PUMP >
CHAMBER ! C Note: Remove soft down to mod - aaarer sand loy.r k r.plaa.with N 0. DATE: DEFINITION
o f
SYSTEM STEIV/ PROFILE c (Clew. 92,00 Estlmot.d)k repl000 with dean coomI eand a/pore.
rate less than or equal to 2 min./In. before tr utter placement
Note: AN leach Milos to be copped at end* /PVC nape. 3 1. 0 5 per B 0 H e I e c o n f. �'� 3 9 W 0 0 D VA L E �A N E
Not to Scale / P
Note: Certification of FN Material Required.
Before and After Placement by Sew Analyses MR . W I L L I A M PORTER C E N T E R Y (L L E i MA
39 WOODVALE LANE
LEACH FIELD -CROSS-SECTION
y ,�� PREPARED BY:
F 1,4, < `
NOTE: TANK AND PUMP CHAMBER TO BE FACTORY WATERPROFFED PRIOR TO SHIPPING.
CENTERVILLE MA 02648 HEY L�'. H
3'-6" on center 4'-0" on center' 4'-0" on center 3'-6" on center T ; �: .E nt
(617) - 504- 399 6
_ L'NVIRONME'NTAL S'L'R VICES, INC.
v S I IAA � I
:.
a»� 1
- � No P.O. BOX 627 I
.... .......
as a one
12'Min.
3/4"-1 Washed Stone s Min. ;P, 01 1,a EAST FALMOUTH, MA 02536
/ 2 ar SANITAR\P��na
15,
TEL FAX : 508-539-7966 i
SCALE: 1 ,,_20' DRAWN BY: CES DATE: DEC. 7 2004
Sch. 40 4" perforated P.V.C. pipe
PROJECT SD-648 FILENAME: SD648PP.DWG SHEET 1 OF 1