HomeMy WebLinkAbout0463 MAIN STREET (CENT.) - Health �463 plain Street (Cent.)
Centerville
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TOWN OF BARNSTABLE
L,OCATION �l�3 n S� SEWAGE #
VILLAOE 4\ V ��� ASSESSOR'S MAP & LOT '�2(0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY --0 D O /
LEACHING FACILITY: (type)
NO.OF BEDROOMS_
BUILDER OR OWNER V �'✓ ICJ r
PERMITDATE: /-O COMPLIANCE DATE: O ,�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
� p C30
� ✓ 2ilia
0209- /a,Y
: Commonwealth of Massachusetts
TT
Tide 5 Official inspection Form ;
Subsurface Sewage Disposai System 'Form - riot f0-Voiu star} Assessments
3 Alci ►V? Y-j -
ropary Address y
Amer firmer s dame e
--��l�1/1 / �� ✓ /' l p S �? 02
rOwnrator:s
equired for every N _, o. gate of ,spectior
,page. Vity;I aWn o,
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:weer. A. Inspector [nf ation
filiing out forms
or,the computer,
use only the tab
Ivey to move your Name o'. rspectcr
GUr30r-QO not
use the return /��
, key. :CrrtQarV�i2^e +(1J(
l A
Company Lc-ess Od,
m —
Tip Cade
Z ,� � a 80 ��90J -� _iGense\umber
_eiectiu-�e.�
B. Certification
certify that: i am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); i have personally inspected the sewage disposal system at the property address
listed above;the informatics reported beiew is true. accurate and complete as of the time of my
Inspection, and the inspection was performed based on my salning and experience in the proper function
and maintenance "on-site sewage disposes systems.After ccnducting this inspection i have determined
that`u-,e
1. Passes
Z. DondEuon afiy ?asses
3. _ Needs Further Evaluation oy Local Approving.Aumory
'`.. Fail=
S �7 d,0
rspec crs g'eture Cate
The syst i; SpeCiCr Siia suD'i_a vl;v Of tn is :nsL)eC iCr: reu0 LC r e Approving Authority(Board
of Health or DEP,within 30 days of 00M. tinC this rspect c-.. if the system has a design flow of
6;OCC gad or greeter,tre r,spectcr a-�c the systern owner Shaii submit the report to the appropriate
regional office of the DEP.Theo ginal form snouid be sent to the system owner and copies sent to
the buyer; if applicabie, and ne approving aU hcrity.
Please note:This report only describes conditions at the time of inspection and under the
con
ditions 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.
-os:: ace Se..-age'sxsa Sys:ec.-?a5e
i
Commonwealth of Massachusetts
�s a Title 5 Official Inspection Form
�a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4--
Property Address Aci r) 0_S
Owner Owners Name
information is
required for every
page. City/Town State Zip Code Date of I specti
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) Zste asses:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
One or more system components as described in the `Conditional Pass'section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes', "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,' please explain.
The septic tank is metal and over 20 years old" or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
Y iJ N ❑ ND (Explain below):
t5insp.Qoc•rev.7f2612018 -me 5 0-f5aai inspection=om:Suosurace Sewage 7sposal System•Page 2 of 18
I
Commonwealth of Massachusetts
alp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
W'.0 V C 3 S4-
00
Property Address
Owner Owner's Nainforniation is
me lf,�
required for every e, zfI4
page. City[Town State Zip Code Date of Inspec on
C. Inspection Summary (cost.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumpsialarms 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):
17 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.doo-rev.7/26/2018 -itle 5 OfSdai;rspectcn Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
(3 A44 t SQL
Property Address
�-
Owner Owner's Name
information is e ` O 1 / a
required for every O` !o
page. City(Town State Zip Code Date of In pection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well'.
Method used to determine distance:
**This system passes if the well water analysis; performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections.
Yes No
Backup of sewage into facility or system component due to overloaded or
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
-iye 5 Of`dal hspxtlon=o�m,:Suosurtace Sewage Disposal System•?age d of 18
t5insp.doc-2v.7262018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
c Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�0 3 a yvi
Property Address
Owner Owner's Name /
information i e eN !6 A /'� h
� ad
required for every
page. City/Town State Zip Code Date of InspAction
C. Inspection Summary (cent.)
4) System Failure Criteria Applicable to Alt Systems: (cont.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
Icy or clogged SAS or cesspool
Liquid depth in cesspool is less than 5" 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 water supply
u well.
I Any portion of a cesspool or privy is within 50 feet of a private water supply well.
i►�' 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-
0,000 gpd.
r ,l��The system fails. 1 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 0.4.
Yes No
the system is within 400 feet of a surface drinking water supply
rLl the system is within 200 fee:of a tributary to a surface drinking water supply
—, the system is located in a nitrogen sensitive area (Interim Wellhead Protection
L Area—IWPA) or a mapped Zone It of a public water supply well
Tile 5::f`Ida inspeCiCn,For:Suosu`ace Sewage tis=sw System•page 5 of 18
iSiruP.tloC•rev.7262078
lips,� Commonwealth of Massachusetts
Title 5 Official Inspection Form
} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
vi'Qi
Owner Owner's Name
information is
required for every ..me-
N
page. City/Town State Zip Code Date of Ins ction
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
❑ P mg information was provided by the owner, occupant, or Board of Health
❑ W e any of the system components pumped out in the previous two weeks?
❑ e 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:
LZ�'XExisting 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)]
Tile 5 Q"dai hspe�.ion=or,^:Sub5Crlare Sewage Disposal System•?age 5 of 18
t5insp.doc•rev.7/2612018
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4r 2 J
Property Address
Owner Owner's Name
information is �H S (9Id 0
required for every
page. City[Town State Zip Code Date of Ins ection
D. System Information
,1. Residential Flow Conditions: � �-
Number of bedrooms (design): '`lumber of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description: /0 /(Ov :.. /'jb VT Se 41 C' TF"�' / J
ax
rs so Cry `lO✓) �av'�bDr �.�7�'Ka-_
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes ENO
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system. inspected? El Yes
Seasonal use? es ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑�Yes No
�v
Last date of occupancy: Date
?li:e 5 Vidal;nspecnon=crm.Sucsu`ace Sewage Dispcsal system•?age 7 of to
t5insp.doc•rev.7126=18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
OSubsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name i
information is � )
required for every
C
��I/1 ��17 0J�'
page. City/Town State Zip Code Date of In ection
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:
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.7/2620/8 -ine 5 o flaai nscecuo,^=ortn:suosurface sewage Disposal System•?age a of 18
Commonwealth of Massachusetts
LIP Title 5 Official Inspection Form
lz Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address /
Owner Owners Name ��
information is e & � 11V J/
La 6 3�
required for every lll.//� TTT'����
page. City/Town State Zip Code Date of Ins ecfion
D. System Information (cont.)
4. Ty;7teptic
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 1/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:
a o�3— �nl�
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
020
Depth below grade: feet
Material of struction:
,�41cast iron 4 0 PPVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
a 5 inspection=om.S tsurface Sewage D;sposa System•?age 9 of 18
t5insp.doc•rev.7/262018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 GZir/t s
Property Address A
Y`'0j
Owner Owner's Namr
information is " ��4 �y �j
required for every Q t (/� J 4
page. City(Town State Zip Code Date of In pection
D. System Information (cons.)
6. Septic Tank (locate on site plan):
Depth below grade: feet
Material c nstruction:
ncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy or certificate) ❑ Yes ❑ No
Dimensions: C l 'o
Sludge depth:
Distance from top of sludge to bottom of outlet"tee or baffle
Scum thickness r�
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet fee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N /✓I el o ��PiG� C•
o n Cowv�t .
Z.me.-aL 4 s
t5insp.doc•rev.712612018 'ive 5 offiaai inspecocn Fcirm..suosurace Sewage Disposes System•Page 10 or is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
TO
Property Address
Owner Owner's Name
information is / d h ✓Vj pli 44 Q,�--c `j /9 J
required for every
page. City/Town State Zip Code Date of/nspecti n
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
-i1fe 5 r`az'.inspacuon=om:S�esc=ace Sewage Disposal System Page 11 of 18
t5insp.doc•rev.7t26/2018
Commonwealth of Massachusetts
Title 5 Official inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Lf C; W1
Property Address
Owner Owner's Name
information is
required for every page. tY
Ci Rown (1 State Zip Code Date of In ection
D. System Information (cons.)
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):
L-Ve
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
dpx 2�6.-14AO
'rt1e 5^viical:nspecuon Fom.suns dace Sewage Disposal system•?age 12 of 18
5msp.doc•rev.?128f2018
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
IJ63 /p/41,V1
Property Address
Owner Owner's Name all— A/4 information is C ooZ 6 oZ d
required for every page. City/Town State Zip Code Date of InsVection
D. System Information (cons.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located; explain why:
Type.
.Soo 6.,l to
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativeiaitemative system
Typeiname of technoiogy:
'me 5 7fiaa.:ns pion=om:Suos�m`ce Sewage D'sposai system•Page 13 of 18
t5msp.yoc•.ev.7/2612018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
n�
Owner Owner's Name I/it
is cizol"'l-IG � o�6required for every �, fJ
page. CityFrown State Zip Code Date of spe ' n
D. System Information (cont.)
11. Soil Absorption System (SAS) (cost.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc_):
D 0 J, 4�
C, C—//-Cl W
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.):
-me 5�`cai nspenon Fom.Sucscriace Sewage Disposal Sys.em•?age 4 of 78
• t5insp.doc•rev.726/2018
Commonwealth of Massachusetts
Title. 5 Official Inspection Form
IM `��,' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owners Name 1-114 -e_-
information is Q�� /
required for every 1
page. City/Town State Zip Code Date of In ection
D. System Information (cons.)
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.):
Twe 5 Sae,.nsoecaon=o"_scosucace sewage Disposal System•?age 15 of 18
t5insp.doc•rev.77262018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 �� 7'
Property Address
Owner Owner's Name/' r_�`/e ) // CSj
information is /lam �e / V
required for every
page. City/Town State Zip Code Date of Ins ection
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 chmarks. Locate all wells within 100 feet. Locate where public water supply enters
the build' . Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc-rev.712612018 THIe 5 0`o2i nsp=con=c•n:suoscrtace sewage oisposal Svsten•Page 16 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3 S/_
r WM _. A
Property Address /A
ham.
Owner Owners Name
information is
required for every ►�PM y-y1 'e (��b �� S
page. City/Town State Zip Code Date of Ins coon
D. System Information (cost.)
15. Site Exam:
U Check Slope
ED Surface water
71 Check cellar
❑ Shallow wells
Estimated depth to high ground water: foet
Please indicate all methods used to determine the high ground water elevation:
71 Obtained from system design plans on record
If checked; date of design plan reviewed: Date
site (abutting property/observation hole within 150 feet of SAS)
,:]��bserved
Checked with A'i
oard ofHealth - explain:
H 1 /'tl-V �
Checked with local excavators; installers- (attach documentation)
Accessed USGS database - explain: O
You must describe h y stablished the high ground water elevation:
0-7 G441&,% 0�-5
CPAP .
f1 W LA.,�L
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t8insp.5oc•rev.712612018 _;;e 5.75cz:.rspe=cn=or:s❑osur,"ace sewage Disposal system•?age 17 of 18
c
Commonwealth of Massachusetts
-. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
LS
Property Address A/C? C4 (
Owner Owners Name
information is a�
required for every
4�4
page. CityfTown State Zip Code Date of Ins ection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
Certification: Signed & Dated and 1, 2, 3, or 4 checked
C. inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (F re m Criteria)and 6 (Checklist)completed
D. Syste Information:
For 8: Tight/Hoiding 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
,tie 5 `aa_:nsxc on=o, Suosurtace Sewage D'sposai System•?age t 8 0(t 8
LVnsp.loc.rev.712612018
No. U Fee�I /
TH18 COMMONWEALTH OF MAS4CHUSETTS Entered in computer:
Yes
PUBLIC.HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for �Digogaf *pgtem Cow5truction Permit
Application for a Permit to Construct( )Repair(64pgrade( )Abandon( ) D Complete System D Individual Components
Location Address or Lot No. J'/3 A/f ��� G i,�` Owner's Name,Address and T No.
Assessor's Map/Parcel vvl
zot_ fZa
Installer's Name,,Address,and Tel.No. Designer's Name,Address anpdT,el.No.✓
4 �1 (p_ t'N / /' -(,
�° `ZIZr—J,9j'7—
Type of Building:
Dwelling No.of Bedrooms Lot Size -sgtr Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 6 6 o gallons per day. Calculated daily flow Gam! gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank —?Zv Type of S.A.S. S= I� .ST)�a,?01
Description of Soil
Nature of Re airs or A t rations(Answer when appli ble) Clx.� � �� G —1�% ,J,d" Zd-rry n.
c'.A
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by P Bo Health.
Signed 1 Date _ r`C-)
Application Approved by ZS- Date S /—U 3
Application Disapproved for a following reasons
Permit No. a Oo 3— 2-r Date Issued S 'oil'U 3
No. 0 oar o oil; r 1 Fee J _
Y z Entered in computer: -THE CO-MMONWEALTH'OF MASS HUSETTS �.
f' — i Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pprtcatioit for Ztopo ar *pgtem Cottgtruction Vermtt
Application for a Permit to Construct( )Repair Grade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. f4 3 / a.�•-, Sc{ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel\ Z r!! C� _/ '
CAB- 1 ZG (�
,
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel No
1--j76 z-
Type of Building: /
Dwelling No.of Bedrooms 0! Lot Size 7 -s rftr Garbage Grinder( )
Other Type of Building &&d C,L No.of Persons Showers( ) Cafeteria( ) till
Other Fixtures
( Design Flow G tD gallons per day. Calculated daily flow h 7 7 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank _ -Zp Type of S.A.S. y 7-V SWga 1 ,tao
Description of Soil 30 ✓�� �+ ! H C) t S �A c� ice_
Nature of Repairs or Alterations(Answer when applic ble) j44.1- S a J--r
r Z 7 L A,,,,t k
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by tyis Boar.4 Health.
Signed Date _5'
Application Approved by 'lf Date S
Application Disapproved for tNie following reasons
Permit No. -XroI—3�2 Date Issued !;--dl- 3
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certiftcate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( L..-f6pgraded( )
Abandoned( )b
at IV./ I has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.2003-.)24/ dated c-2/-0?
Installer Designer ,
The issuance of this permit shall not be construed as a guarantee that the system i10ul 'o a/signed.
Date 2'7 1 D3 Inspector /
---------------------------------------
No. Fee ✓"
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS
Miopogar &pztem ongtructton joermtt
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon/( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
1 �
Date: / I /tl 3 Approved by
" f
5/25/01
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I,� ,/ truer fig-S,hereby certify that the engineered plan signed by me
dated -5 / ° concerning the property located at
q6 Sf . 6 e,4A4 v, meets all of-the
following-criteria:
kA-'This failed system is connected to a_residential dwelling only. There are no commercial or
busines&uses associated`with.the-dwelling.
Lv**' The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude.this fact or may conduct
preliminary tests at the site without a health agent present.
c..� There is no increase in flow and/or change in use proposed
61" There are no variances requested or needed.
%✓The bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation.[Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) b
B) G.W.Elevation +adjustment for high G.W. 3,6
DIFFERENCE BETWEEN A and B l 7
SIGNED DATE:
NOTICE
Based upon the above information,a repair permit will be issued for ,6 bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
q:health folder.pere&mp
OWN OF B ARNSTABLE
i LOCATION SEWAGE # 0. 2.2
VILLAGE �(` V �Il ASSESSOR'S MAP& LOT C� -J'2�o
INSTALLER'S NAME&PHONE NO. ?76
SEPTIC TANK CAPACITY 2-0®O
LEACHING FACILITY: (type) H d 40 We// (size) 1 > .-0
NO.OF BEDROOMS
BUILDER OR OWNER j-r 6t k'✓ IrC r
PERMTTDATE: COMPLIANCE DATE:1 _
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
RI
e 3O
� a ��C
------------
i '
ASSESSOR'S MAP NO. PARCEL
LOCATION SEWAGE PERKJT NO.
V,I'L LAG E
G t+CT (7L
IM� l 'S NAME a ADDRESS
BUILDER OR WNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED ���
�•.4a �xl,
-----------------
Aq Ema
iSSESSORS MAP NO:
PARCEL NO.:
No....... ._...... 3 1 `P--•— F.Es.....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
1...�. ,1. .........OF.....- !4Y_.....
Aliptiratiaatt for 14spaaii al Works Cnottdrurtwi n thrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................ .40 ........... ...................... ---------------- ........................................
Location.Address or Lot No.
Ow er Address
........... ---------------------------------------- .............. .....� -.. .......... ---------
Installer Address
d Type of Building Size Lot............................Sq. f
U Dwelling—No. of Bedrooms..________________________________Expansion Attic ( ) Garbage Grinder
P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteri ( )
a' Other fixtures ..................................
W Design Flow........��-�S....................gallons per person per day. Total daily flow........f :.:: .................gallons.
WSeptic Tank—Liquid capacity : allons Length---t�___ Width.--.T........ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width__. ------- Total Length............ Total leaching area-_-____---_--•----sq. ft.
Seepage Pit No....f` ----------- Diameter-_-_ Depth below inlet....... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---__---______-_---__.-.
Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................
-----------------------------------------------------------••--...--------------•-••--•-•--•-------•.........................................................
0 Description of Soil---................................................I....................................................................................................................
x
x ----•----------------------------------------•-----••---•--•---------•----------••---•--••••......•----•.... ...--...................
U Nature of Repairs or Alterations—Answer when applicable......`O_C'Z ........
-----�sc-C------�_----w. -------------k --------
Agreement: C,:5ueeS-
The undersigned agrees to install the aforedescribed Individual Sewage Disposal stem in accordance with
the provisions of i i�i L p J of the State Sanitary Code— The undersigned furtl e of to place the system in
operation until a Certificate of Compliance trrss b t boar lth.
Signed x -6
............................. ••-•••......--••----......_.....
Dane
Application Approved By.......... . . •-- •-•............. • .' .........
Date
Application Disapproved for the following asons:----••-----•--•-••-•.....•••-••••••••-•--••-••••----•--•----••-----••---••-•-•-•-•-----•---••--•--•---•......---
---•---••••--••-•-•••----•----••------•-...-••--....•----••-••-•-••---•---....••--•-------.....••......•.._......-•-•-•--•••••••-•-•--•••••••...•--•---•------------------------•--•----•-------••-•-•---
Permit No......................................................... Issued.------------••-• Date
-•----••--••-•----•----• at-------
--- — Date — — — — — --
�l
No...... ?...... .3 Jf I �- �P Fx$.... ..__.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........OF . ........................................
Applirtatiun for Disposal Works Tonotrttrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................ .L�..�A-..-----..... ....................... .............. ........................................
Location-Address or Lot No.
-------•--- .......... V la./ S�_rLy.)............... ----------__-------�-• --1�'" �,�.......................................................
O ner Address
Installer Address
UType of Building Size Lot............................Sq. feet
I—I Dwelling—No. of Bedrooms.._...................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ..---•-••-•••--•--••--•-•...---• .
W Design Flow....... _.? ........................gallons per person per day. Total daily flow........ __..................gallons.
WSeptic Tank—Liquid capacit 07_'it:kallons Length..k ___. Width.-T......... Diameter................ Depth................
x Disposal Trench—NTo. .................... Width_.__........_...... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No---t�.,............ Diameter....I_ ......... Depth below inlet_....t�(_.__....... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..........................................................---------••---- Date........................................
a Test Pit No. I................minutes per inch Depth of Test Pit------._...---------
Depth to ground water........................
Gil Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•-•-------•---••----••-•-•••..............•---••--------......._-------.............-••-•---•_...••.........................................................
0 Description of Soil.....................................................................................................................................................................
x
U -----------------------------------------•-•-----•-------------------------------------.....------------------------------------------------------------•----...-•--------------•-•-•-•-----------•-----
W
Nature of Repairs or Alterations—Answer when a licable._--_.. �T' ........ ' f —:� ____ ____
Agreement: t-� �, C)
The undersigned agrees to install the aforedescribed Individual Sewage Disposal ystem in accordance with
the provisions of!'tT R1�^
i�_ .: of the State Sanitary Code—The undersigned further�gx� not to place the system in
operation until a Certificate of Compliance h sbe -issued by boar fFh aIth.
Signed "---
Application Approved By........M __. _ : '" t2,•`�'_�j
Date
Application Disapproved for the following easons:---••---••-•---•---------•-•-•-----•-•--•-•--- ............................................................
.....................................................-•----....•••---•----------•-•-••-----------•••-••-•--•-•--------•------••-•--•-•-----•••--•--------•--••-•-••-••-•-----•---------•---------------
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....7. o kp�.�.:'! .........OF.... ..................................
Trrtifirab of ToutpliFanrr
THIS 0 Clii T F , That the Individual Sewage Disposal System constructed ( ) or Repaired
by..................... •--•----.. --------------------------------------------------------------------------------------------------------------------------------
Installer
has been installed in accordance with the provisions of T1 T 1 E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......... &---Cr'_ ........ dated-------r'J . ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G8JAUNTEE THAT YHE
SYSTEM WILL F NCTION SATISFACTORY. '
DATE............ y � -------•----------------------•---- Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CU.1 ' ! ............oF.._1.�=.:..c,_v�5a.:� .
�� 3 2 .0
NO.r .--•-•-•-?--•---- • FEE. .... ..._�........
Dispoad lVads Tono#rnr#ion anti#
Permission is hereby granted......... ---------`4.C=V'ter' .............................•••--------------.......-•------••--•----...._...............
to Construct ( ) or Repair (c man Individual Sewage Disposal System
atNo........ ?....... ..........._L..r_................. . ..............................................................
Street; r,
as shown on the application for Disposal Works Construction Pe m t No._ Dated____ .............
�) . •-•-••...............
DATE-----------
I.
L Q ( Board of
t
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS it
`s
t
SITE PLAN
Design Calculations N
SCAI...E: . "=20'
NE.arriber of Bedroorns: 6 Ro:,f r 28
BENCH MA`iKCORNER OF CONCRETE Gd€r6cye Grinder: YES (TO BE REMOVED, GRINDER I`atT ALLOWED `vlT} ; -..II�a D S(GN f ;y
APRON AT GARAGE E.FV.::::10�3.Ot3' (ASSUMED)
I-etaching Capacity Required: 660 Gaol./Day
a:t� " G C ' — tiff
Leas Ing Area Required: 6 .; Gal./�0.74 jai./�c{.F .,_8p2 Sq. t.
#445 MAIN STREET Proposed Leaching StnUcture: 1--50.51 X 13`W X 2'D Leaching Trench
_eaching Area
208089003 >revlded: g1c,, ; Sq. t,
v. ...
"
Proposed Leaching k"opncity: 6.14 gpd ;> 660 gp^. rera'u.
I 283.68' Main Strew
LOCUS
I
I
NO SCALE
I i
I ,
,
,
I
i
GENERAL NOTES
,
. ADDR=SS; 463 MAIN STREET, CENTERVII.LE
2. ASSESSORS NUMBER: 208 126
3. DIDOELOPER'S LOT:
4, TC;POGF7APF Iu INFORMA I€Ole `WAS CO,,``IPLIE D FORM AN
i s ON THE GROUND INSTRUMENT SURVEY.
1 ' 5. TOWN WATER IS PROVIDED TG` SITE & SURROUNDING PROPERTIES,
i LC / 6. REFERENCE PLAN: : t.AN 800K 75, PAGP 137
I 7. NO WETLANDS ARE € OCATED WITHIN 100 FEET OF SAS.
i N 8. NO POTABLE WELL S ARE LOCATED WITHIN 150 FEET OF SAS.
AREA = 0.92 ACRES CONSTRUCTION NOTES
N
LLJ ; DECK Contractor is responsible for Digsnfe notification
LL)
and protection of ail underground utilities and pipes.
j 2. 1'he septic tank and distribution box shin: be set
leve€ on 8" of 3/4" 1 1/2" stone.
3. Backfill Should be clean Bond Or gravel with no
F:.?,l: T NG stares cave= 3> it size.
z o C.)WELLING'
4.. This system is Sub er"t to inspection during installation
by Glen E. Harrington, R.S.
I o 5. 'l't1e contractor' shall install this systern in accordance
Q I Z B B . M M . with Title V of the Mossechusetts Environmental Code
I
and the Regulations of the Town of Barnstable.
1 6. Provide an Acme Precast H-20, 2000 gal. se tic tank, H—€0
106.23' bsmt slab elev; g 89
5—hole D—Box. & 5 H-20 500 gal. chambers or equal.
DECK 1ao.z�'€ 69'
7. No vehicle or heavy machinery sholl ;give over the
1 septic systern unless :rated as H 20 septic components,
gas ter€ r�. lrlstall gas baffle or equal art septic tank outlet tee end.
I GARAGE 9. All existing inverts and site conditions shall be verified by contra
I
€ 10. Existing leach pits to be purni.ped and removed.
105. 0' '€.AB L.=`OO.'Z. 11, Existing garbage grinder to be removed by licer:,�d plumber,
9rov \ \ .: I ,^' < < - - cor'wvr't `i.ter.
„ 1Cc n I d : t �' 'rer:t�; t t Cav r3S r:'"'a' t rid �dif,h, F.
I e� dr ` I
106.04 104. ewOY t '
99.66'
�o O O gravel driveway
---------------- ----------------------
I se c bock
peter post 3' dlo. tree 283.68'
0 98.84 X
+-zv"U sst.Acce�s ea aea><xc
1-50.5'L X 13'W X 2.0' D 'Oe °' °° s9 #469 MAIN STREET
leaching trench using
5 H-20 500 5 I 4, gal. chambers with •:' ��-'-
i of stone on sides r.•?: �' -•'. T` 'R- �`' `"'s
& ends.
O „ 34"
C3 124
5 H-20 500 gal. chambers STM'. ?!Fiyrcr<CFD PRECA"sT CONCRc-?:
END-•SECTION PLAN VIEW
H-20 500 GALLON CHAMBER
NOT TO SCALE LEGEND
USE ACME PRECAST OR EQUAL - OFMA PROPOSED SEPTIC SYSTEM UPGRADE
EAST€NG LEACHING PITS TO BE
---�/ PUMPED & ESACKF€LL;;D �Oa� EN N PREPARED FOR
'O R GT N MICHAEL LEARY
PROPOSED 2000 GAL , . 1070 AT
O O O H--ze SEPTIC TANK a• 9 a
s F��sTEP``a 463 MAIN STREET
EXISTING 20100 GAL �NfTAB\
.......1G' rein:, frorrl *NOTE: ALL PIPES ARE TO BE 4" DIA. SCHEDULE 40 P.V.C. a a H•-`0 SEP'r:C TANK"u" to scptisnK {TO 9E R�MOV�D} BARNSTABLE (CENTERVILLE), MA
NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE.
...........................................................................::....................................................................................................................................................................................................
rpfic tank coeerta v sat a nE gad ride over synt�:n=i% �Ir, rwa
:ing HODS@ rasthin �" of itn€,yhed grgr3e 9" p. y
5 HOLE DENOTES X:STING PREPARED BY:
c.Kt�.. ' POT G
x 104.46
^ra . . . E?IST• t3CiX Existfn Grade Elev.�100'f �% RAc�`.
���� � 9 GLEN E.. .S.
HARRINGTON, R
2' in. 95 EXISTING CONTOUR
Ilan : � �. . • max.
2 2000 GAL. N
�_ s-.ot washed atone Too Peastone Elev.=97.67' DEC' TESTHOLE.*
SEPTIC TANK STD A ROSE LANE
MARSTONS MILLS, MA 02648
u;, ur
/ r l 17' PLRCi?L. . Otv TE T
Invert
..WA:,f. ttt G O O C O -24•MIN.
�€ TEL: 508-428-3862
50.5' rent ev.= 1 T
LEACH TRENCH 12'f ........ . Approx. Ocraticn
y W ........ .W........_ 08-428-3862
s• n> �,.4"_t1,'z• sluts>. �- � � � u
> existing wc- er l€nO
FAX: 5
..................................................... ............................I..........
w VGW Elev. per Town dt Frimpter Maps=23.6't MSL
SYSTEM PROFILE ,.• .. 4' .............................
I _ _ _ _ MAY 12, 2003
r r.,• car *;fi'-tt,a 1� _.._.., ApprOx. 0C,-j ion SCALE: 1 "-20' DRAWN BY: GEH
ex:Sting gas service �DATUM: ASSUMED FILE: CRAWFORD SHEET 1 OF 1