HomeMy WebLinkAbout0092 YACHT CLUB ROAD - Health 2 -Yacht Club Road
Centerville
A =210 036
S M E A D
No. H163OR
UPC 10259
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplitation for lrispogaal *Pstem Construction Permit
Application for a Permit to Construct( ) Repair"(4�upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Addre or Lot No f.2 Y 4a -avb 9 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel �2/0 3u Gram✓
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
113/ouenl .�n)C.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building _I"2'y/(��►�/G� No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) %O gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank j_rX&i(,yt Type of S.A.S. 2 W fQ /(��1dAS Ey/f�/ GJ�Sffjil/'�
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) _:Zy 5f_,d cL yew d—he,<j a t.&J /U 5co
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 Certificate of
Compliance has been issued by this Board of ealth.
igned Date
Application Approved by Date `j c,--
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
TOWN OF BV
ARNSTABLE
�LOCATION_� SEWAGE#1@09 l -(3
VILLAGE fl,We ASSESSOR'S MAP&PARCEL Q
INSTALLER'S NAME&PHONE NO. QA I n)L)i c
SEPTIC TANK CAPACITY.
LEACHING FACILITY:(type) G .(size) IQ g j(
NO.OF BEDROOMS 3 C�FSIf✓►�
OWNER (�„J
PERMIT DATE: �'� 0,0 a i COMPLIANCE DATE::)-/7,2O oR
Separation Distance Between the: 1
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 40a1'IV Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 260 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching fa�cility)� Feet
FURNISHED BY _ , It r �C�e i71�; To�
Nam`
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l
fk)ecic_ y 3o
1 `7'a5 12'q�'
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No. / ® Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:''
Yes "
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation 6pstem Construction",Permit
Application for a Permit to Construct( ) Repair(✓) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components w ,
f Z.
Lya ion Addre�s or Lot No f-0 y 4(h s-Cy„b Owner's Name,Address,and Tel:No.
'4 I P
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
VA 131OUTA) r,,,C sc�-yzo ��'�/ �f1c�✓ill /1/Jf�S�r°�
Type of Building:
Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder( )
Other Type of Building )"rlydt /G! No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 1%0 gpd Design flow provided ?" gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ic y>l/r, Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) hc)c 11 ,� /y/of SW
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 Certificate of
Compliance has been issued by this Board of Health.
igned Date ! �14 9'a'ov
�
Application Approved by �- Date _3� ...f
Application Disapproved by Date
for the following reasons
r
Permit No. K-,r(,- t """ } oc - Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
CPrtifiratP Of CDmpt,i act
., THIS IS TO CERTIFY,that the On-site Se age Disposal system Constructe ) Repaired(Ille Upgraded( )
Abandoned( )by �G``l.� 1/� � j Gi'N///YI� .Y ✓ /f /1/ L
at 4 2 /�ll�,�N�/ri!// has been constructed in accordance /
with the provisions of Title 5 and the for Disposal System Construction Permit N40/ dated c /,
Installer yt / /rt.tf,.I r- me. Designer ILd /.sum°
#bedrooms Approved design flow.,*�(� gpd
The issuance of tV/17
ermit shall]rn�,ot be construed as a guarantee that the system willlfunation' as designed
Date r /-"-I Inspector
_ No ;?4 Q tC I Fee �f 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
MisposaY *pBte"on8traction �Prmit
Permission is hereby-granted to Construct(. )- "' Repair(r')_... Upgrade( ,;Abandon
System located at 7 Y4ll� l'fi1�
+
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Constructionnust a completed within three years of the date of this permit.
Date �/ t � Approved by
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Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. °f l�
Important: A. General Information v
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
'erg" City/Town State Zip Code
(508)428-4028
Telephone Number License Number
B. Certification
certifythat I have personally inspected the sewage disposal system at this address and that the
P Y p 9 p Y
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 onsite
sewage disposal systems. I am a DEP approved system inspector pursuant to Section f1;5.340 of
Title 5(310 CMR 15.000).The system:
r~.''' t
® Passes. ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
c.st
cn M
02/16/07
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
92 yacht club•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section 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:
The septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
92 yacht club•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
92 yacht club•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each'.
ach of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the 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.
92 yacht club-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
f
Commonwealth 'of Massachusetts
W Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont )
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ 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.
92 yacht club-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® 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)]
92 yacht club-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 03 Number of bedrooms (actual): 03
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): . 330
Number of current residents: 01
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No t
I
Water meter readings, if available last 2 ears usage d 2005:72,000
g ( y g (gpd)): 2006:45,000
Sump pump? ❑ Yes ® No
Last date of occupancy: 02/16/07
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
92 yacht club-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
,M 92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: J.P.Macomber&son
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: Pumped septic tank 07/12/06 for maintenance.
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
92 yacht club-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M s 92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is
required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
1
Depth below grade. feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a.Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
-------------------------------------------------------------------------------------------------------------------------
Dimensions: 8'6"X4'1 0"X57-
Sludge depth:.
0
Distance from top of sludge.to bottom of outlet tee or baffle
37"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
8" -
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured
92 yacht club•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is Centerville Ma. 02632 02/16/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.Tank appears structurally
sound.No evidence of leakage.
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.):
I
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):
92 yacht club•.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑_ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No distribution box present.
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
92 yacht club•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
01
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.No signs of hydraulic failure.Vegetation appears normal.Water to invert pipe in leaching pit
was 60"to pipe at time of inspection.
92 yacht club-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� M 92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
92 yacht club•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
92 Yacht Club Road
Property Address
Joan Young
Owner Owner's Name
information is Centerville Ma. 02632 02/16/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.
3.?
92 yacht club-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
. Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 92 Yacht Club Road
PPoperty Address
Joan Young
Owner Owner's Name
information is required for Centerville Ma. 02632 02/16/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used:Gaherty& Miller Model 12/16/94 ground water elevations.Used:Technical bulletin 92-000-01
plate#2 annual ranges of ground water elevations.Used:Observation well data June 1992
92 yacht club-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
TOWN OF BARNSTABLE
LOCATION Afj4-r C dv3 iZ® SEWAGE # �J Yc®�
VILLAGE CeZe r% Vl ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. N\A C046 hep\,
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER CZv9SQ N YdUA)A
DATE PERMIT ISSUED: Cl 17.Y
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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N�. �✓��,,. F�s...Jc.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�<<--!.r..... OF............... . .. ......... '.................................
App iration for UiBpasal Wurkfi Tnnitrnrtion jIumit
Application is hereby made for a Permit to Construct ( ) or Repair � ) an Individual Sewage Disposal
System at
Location ddre s or Lo NQ, n r t
�o s�.ca .�..�.......�.11 .o 1. .cs r..1 = -`�Qn -------------•...3.n1. ca• `'b �•-(O�i Cl � .1/..... ... ..r.......
O ner Address
Installer Address
� Type of Building Size Lot___________________________S q. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building __________________________•- No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ..................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width..................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------.:........... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil.......................................................................................................--..............................................................
x
U --•--•-•----•--•---•-•------...•--•----•-----••-•--....---•---••-•----••-..........••-••-----••-•••-----•-••••••••--•••••-•••-••-----•--••-•-•------•-••-•------••••-••.......................••-_......
W
x -•---•-----------------------------•-------•-----••-----------------•------••---•-••-•-•••--•-•--•-•---••••-•-•------•-----••••-•-•---••-•--••---•-•••---•-•-•-••-•-•-•---•-•--••-_.
U Nature of Rep 'rs or Alteration—Answer when applicable---_-�---_ i -.-_ . ..;pt1�
••. - . ----�L411, -----------•--•---------------------•--.---------.-------------------------------------•------------•--•-••--•-----•---------------••------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI:; 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued byytt boXr Iof health
Signed........... _rcc�n. F._._l .s�.L1.�cxr I
.............. .................................
Application Approved By........ �- .,A.......; ��. .
Date
Date
Application Disapproved for the following reasons--------------------------------•---••-------•---------------...-------------•-------------...-•-•---•-•••..---•-
----•-----------•-•......•••••-•--•----•---••--•....•---•--------••-•--••••---•----•-...•-•------•---••--I-••-••-•-•.......-•---•---•--•----•--•--••••--•••-•---•--•--••-•--••---•---•-•-•---•---•-•-----
Date
PermitNo............................••-......--------•-••------. Issued.......................................................
Date
LOi: A7ll N� SEWAGE PERMIT NO.
L5 4 ,< /01- D 3 �
V I L L A G Tt-
11-1
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INSTA LLER'S NAME i ADDRESS
IUIL0EIt OR OWNER
Y o
DATE PERMIT ISSUED ���
DATE COMPLIANCE ISSUED
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THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
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No d"� .z/`/3„ Fizz_��. .TJ.....•••-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- 2 •�} ............. ...OF............ s + r I...................................
Appliration for Disposal Works Tonstrurtion rrrmi :
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at: y
i 11 Location-,.Address or Lot No. if ff }
1 ..l ... r t L`(3 C_1.!' 1 U�1 i' C' ... C LJ 7 Gw
O n e r�' Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures .._......--•..................... -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter-----_.......... Depth................
x Disposal Trench—No..................... Width....0............... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter....._......._...... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...................._..
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•---•-•--•----------------------------------------------------------------------•---......_......••..........................................................
0 Description of Soil.................•............------•-------------------•-•------•-----------...--------------------------------•-----------....---•--------...---..._..._..------.--•--
x
U ..................................................................................................•.....................................................................................................
W •-••-•----------------- -----------------------•-•---......--------------•------••------------------------------------------ ........................................................U Nature of Repairs or Alterations—Answer when applicable______c_??:.. - ..._ ..........i._._ 5 ...:ti -...;;................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of IT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
1 t 1
•. � Signed............. t.:... �........................:'-----........__
Date
Application Approved By------- ---•- .. ...-•••••-••...... ................
Date
Application Disapproved for the following reasons______________________________________
............•..................•--------------•------- •--•........•.
..............................................................._•--......................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ?. ..............OF...........-:: ...........f%J.:.............................................
Tntifiratr of Tomplionrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at........ •----•---- �: '�T /. ..t - ("' ' /�=�'�---------•-••----•----•----------•-•-•-•-•---•----------••-•--------•-•-.
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No%= .l_. dated
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF CTORY. y-�;�`�`'-
�Iti 6 (r'
DATE----•------•-----•.........................v.......-- - •-- ----------•---. Inspector....._..------- --.. _...-------------•---------------•----.........------.._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Nb� ?•-- ...........
` ............................ ........................�.�........----• FEE....
Disposal Works Cwontr ion Vvrrmit
Permissionis hereby granted................................................................................................. ............................................
to Construct ( ) or Repair ( L_)-in Individual Sewage Disposal System
atNo................ --•-----• = mi l............................. e ,
----------=-----•--•---•--------••------..........--•----•-•-•-•....................
Street
as shown on the application for Disposal Works Construction Permit No.....................Dated..........................................
'Y / i i
y Board''of`Health
DATE...............
.f.._.. ✓.._.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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