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Commonwealth of Massachusetts
Title 5 official-Inspection Form 2
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
i4
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 4-11-13
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.
e
A. General Information
1. Inspector;-
Shawn Mcelroy A�-
Name of Inspector
Upper Cape Septic Services -
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification t
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: '
N Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4-11-13 1
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. AForm:t5ins•11/10 Title 5 Official I p 'on Subsurface Sew ge D iIsposal System•Page 1 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,•''V 264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Hyannis MA 02601 4-11-13
required for every H y '
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: A
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
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.
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.
>r; ❑ Y ❑ N ❑ ND (Explain below):
. t
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not.for Voluntary Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 4-11-13 '
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System,Conditionally Passes (cont.):.
❑ 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):
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.
• ter . . .
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
t5ins-11/10 Title 5 Official Inspec5on Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Vol untary"Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 4-11-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) ,
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: _El The 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.El The 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.
3. .Other: ,
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for.all inspections:
` Yes No
11 Backup of sewage into facility or system component due to overloaded or
t ® clogged SAS or cesspool
a ® 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 Y2 day flow I
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Vk Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 4-11-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
® Required pumping more than 4 times in the last year NOT due to dogged 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 fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd-
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts j
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not forVoluntary Assessments
M 264 Bearses Way
Property Address
Bank Owned (Contact David Holt c@ Today.Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 4-11-13
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
❑ E 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? '
.0 ❑ Were as built plans of the system obtained and examined? (If they were not
r available note as N/A)
. ® ❑ Was the facility or dwelling inspected for signs of sewage back up?
t'® ❑' Was the site inspected for signs of break out?
® 0 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)]
D. System.Information
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
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts ,
Title 5 Official Inspection' .-Form r
a Subsurface Sewage Disposal System'Form -Not for Voluntary.Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is H annis ,.+ MA 02601 4-11-13
required for every y
page. City/Town x State Zip Code Date of Inspection
a
D. System Information {. t.- ' • _
Description:
Number of current residents: 0
Does residence have a garbage grinder?' ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required]. ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? _ ❑ Yes ® No
• Water meter readings, if available (last 2 years usage (gpd)): -
Detail
I r
Sump pump? µ ❑ Yes ® No
Last date of occupancy: 2-2013Date
Commercial/Industrial Flow Conditions:
' Type of Establishment:
Design flow(based on 310 CMR:15.203): Gallons per day(gpd)
rr • ; ,� 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:
t5ins•11/10 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official; Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
required for every Hyannis MA 02601 4-11-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records: ,
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) 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):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is H annis MA 02601 4-11-13
required for every y '
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):.
Depth below grade: 36"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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 30"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: , . 1500 gal
Sludge depth:
12"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official -inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real'Estate 1-800-966-2448)
Owner Owner's Name r
information is required for every Hyannis MA 02601 4-11-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) v.
Distance from top of sludge to bottom of outlet tee or baffle 2011
I
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
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
I
Commonwealth of Massachusetts'
Title 5 Official. Inspection -Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. !.
I
264 Bearses Way
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Hyannis c "' ' MA 02601 4-11-13
required for every y •
page. Cityrrown ,. ,. State Zip Code Date of Inspection
D. System Information (cont.) 9
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.): '
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
I
- ❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain):
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
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form f {
Subsurface Sewage Disposal System'Form.-Not for Voluntary Assessments
ti 264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 4-11-13
�
page. City/Town: State Zip Code Date of Inspection
D. System Information (cont.)
' 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.):
Good condition with water at working level and no sign of back-up.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
i
Commonwealth of Massachusetts
L: Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today.Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 4-11-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers - number: 2-500's
❑ 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.):
Leach chambers in good condition and empty at inspection with stain line at 6"off bottom of chamber.
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
t5ins-1111110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
o Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1=800-966-2448)
Owner Owner's Name
information is
required for every Hyannis MA 02601 4-11-13
page. City/Town State Zip Code Date of Inspection '
D. System Information (cont.)
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 i
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
• 1rr
r .
t5ins-11/10 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @_,Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis r MA 02601 4-11-13
page. City/Town ,. State Zip Code Date of inspection
D. System Information (cont.) -
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
3
16*
' I CW - e�
�'- • 3 5 7
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form-Not-for Voluntary Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 4-11-131
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 high ground water: 12
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:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
264 Bearses Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 4-11-13
page. City/Town State Zip Code Date of Inspection-
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
, 20 Crocker St
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is Centerville MA 02632 4-11-13
required for 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. Please see completeness checklist at-the end of the form.
A. General Information
1. ,Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evalu ion by the Local Approving Authority,
4-11-13
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.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection` Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
M 20 Crocker St
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 4-11-13
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:
System is in good working order with no sign of failure.
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.
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): ,
t5ins•11/10 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
c
Commonwealth of Massachusetts
Title 5 Official Inspection -Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 20 Crocker St
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is Centerville MA 02632 4-11-13
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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):
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
t5ins•11/10 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
A 20 Crocker St
Property Address
Bank Owned (Contact'David Holt @ Today Real Estate 1800-966-2448) -
Owner Owner's Name
information is C
required for every enterville MA 02632 4-11-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 isurface 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.
❑ 17he 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.
3,. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or®
f' 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 '/z day flow
t5ins-11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
A
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 20 Crocker St
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 4-11-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 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-
10,00.0gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
I
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
20 Crocker St
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 4-11-13
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
El ® 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 backup?
® ❑ " Was the site inspected for signs of break out?
® '❑ Were.all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® El 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 CM 15.302(5)]
D. System Information.
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
i
Commonwealth of Massachusetts , r
Title 5 Official Inspection Form
b
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Crocker St
Property Address r,
Bank Owned (Contact David Holt @ Today Real.Estate 1800-966--2448)
Owner Owner's Name ,
information is Centerville '' MA 02632 4-11=13 r
required for every -
page. City/Town State Zip Code Date ofAnspection
D. System Information
Description:
Number of current residents: 0
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? El Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
t
Sump pump?, i, ❑ Yes ® No
Last date of occupancy: , 2-2013
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
r i" ,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:
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts =�
Title 5 Official l nspection -Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
20 Crocker St
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is Centerville MA 02632 4-11-13
required for every `
page. City/Town. State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
i
General Information
• Pumping Records:
Source of information: N/A
' Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system '
❑ Single cesspool '
❑ Overflow cesspool '
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) 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):
i
i
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17
I •
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
20 Crocker St
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is ,
required for every Centerville MA 02632 4-11-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) - I i �
Approximate age of all components, date installed (if known) and source of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: " 30"feet
Material of construction:
❑•cast iron ® 40 PVC ❑ other(explain):
E
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan): .
Depth below grade: 24"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1 f Fes'
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:
12"
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
i
Commonwealth of Massachusetts -
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Crocker St
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is required for every Centerville : MA 02632 4-11-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) +
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20" .
1 rr
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15" .
How were dimensions determined? Tape
Comments (on pumping.recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and. no signs of leakage.
Grease Trap (locate on site plan):
Depth below grade: " feet
Material of construction: t
❑ 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
t5ins-1 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
J
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
20 Crocker St
Property Address
Bank Owned (Contact David Holt @ Today Real,Estate 1800-966-2448),
Owner Owner's Name
information is required for every Centerville MA 02632 4-11-13
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.):
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
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date J
Comments (condition of alarm and float switches, etc.):
,
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts .: �.:•:' r . . .t
Title 5 Official. Inspection Form
Subsurface.Sewage Disposal System Form Not for Voluntary Assessments
20 Crocker St
Property Address
Bank Owned (Contact David Hon @ Today Real Estate 1800-966-2448)
Owner Owner's Name "
information is required for every Centerville MA 02632 4-11-13 ' Y
page. City/Town f State Zip Code Date of Inspection
D. System Information (cont.) . .a. ► " r
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.):
Good condition with water at working level and no sign of back-up.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
r
If SAS not located, explain why:
t5ins•11/10 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official, Inspection' .. Form
Subsurface Sewage Disposal System Form, Not:for Voluntary Assessments t
20 Crocker St
Property Address
Bank Owned (Contact David.Hoft @ Today Real Estate 1800-966-2448)�
Owner Owner's Name
information is required for every Centerville „ !y. MA 02632 4-11-13 .
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4-Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields •...number, dimensions:
❑ - overflow cesspool number:.
' ❑ * - innovative/altemative system r
t
f
t Type/name of technology: -
t _ Comments (note.condition of soil, signs of hydraulic failure;level of ponding, damp soil, condition of
vegetation, etc.):
Infiltrator field in good condition and empty at inspection with no sign of back-up into d-box or
surrounding stone.
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
t5ins 111110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts r '�
Title 5 Official Inspection- Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'^ 20 Crocker St
• Property Address
Bank Owned (Contact David.Holt @ Today Real Estate 1800-966-2448)' .
Owner Owner's Name
information is
required for every Centerville. ' t MA 02632 4-11-13
page. City/Town - State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
1, J
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.):
r •J. ,
I •
I
t5ins•11/10 + ,, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Crocker St = '
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is Centerville - '' MA 02632 4-11-13
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) '
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
n &ck
O _ .
o
6 -p qo,
a -4% a 3,9
` 0,
sN�t
for t
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
20 Crocker St 4
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is
required for every
Centerville ' '+ MA 02632 4-11-13
page. Cityrrown _ State Zip Code Date of Inspection
D. System Information (cont.) -
Site Exam: ,
❑ Check Slope "
❑ Surface water
- ❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'
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:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Crocker St
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1800-966-2448)
Owner Owner's Name
information is required for every Centerville MA 02632 4-11-13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates COST $30.00 for 4 years. A Busin
(WHICH YOU MUST DO gy '
M.G.L. - it does not give you permission to operate). You must firsfi obtain the necessary
at 200 Main St., Hyannis. Take the completed form to the Town Clerk' ess Certificate ONLY REGISTERS YOUR NAME in the Town
the Business Certificate that is required by law. s Office, 1" FI., 367 Main St., HyannisMA 0260 natures on this form
: ... Crown Hall) andCY
.. <+r9",•�. :_. : ", � net
Fill in
Please:
APPLICANT'S DATE:
-I
BUSINESS UR NAME:
YOUR HOME
ADDRESS:
NAME OF NEW BUSINESS TELEPHONE # Home Tele hone Number: .
1S THIS A HOME OCCUPATION? 'e ' �r
Have you been given a �—YES NO TYPE OF BUSINESS Q
g pproval frrom4te building divis"on? YES
ADDRESS OF BUSINESS NO Cc
MAP/PARCEL NUMBER O�G
When starting a new business there are several things you must do in order to b
Barnstable. This form is intended to assist you in obtaining the information you e in compliance with the rules and regulations of th_e Town of
of
Yarmouth Rd. & Main Street) to make sure you have the appropriate t may need. You MUST GO TO 20t Main b i (corner is
ppropriate permits arid licenses required to legally operate your business in this
I. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
COMMENTS: **
Authorized Signatu re '
2. BOARD OF HEALTH
This individual has een f the permit requirements that pertain to this s type of business.
Authorized Signature** MUST COMPLY WITH ALL
COMMENTS: "ATARDOUS MATERIALS REGULATIONS
-3. CONSUMER AFFAIRS
This individual has Lbeen,info informed of SING AUTHORITY)
licensing re uire q ments that pertain to this type of business.
COMMENTS: Authorized Signature**
a
f '
k
14
R Dater
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: C64o6in C�Pna-,iAty 5•2. rO .� CP-
BUSINESS LOCATION: ses 10'-1,'--0 1 1- Af—_QX01 INVENTORY
MAILING ADDRESS: r• n o CS TOTAL AMOUNT:
TELEPHONE NUMBER: -7� �� � ��
CONTACTPERSON: aU l CaLt6,0
EMERGENCY CONTACT TELEPHONE NUMBER:� 4 -��� MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION/RECOMMEND IONS: Fire District:
Waste Transportation: Last shipment of hazardous.waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Ibisirifectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
k Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
h
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
jA
(s Degreasers for engines and metal Printing ink
r�
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
r} Battery acid (electrolyte)/Batteries Lye or caustic soda
i
' Rustproofers Misc. Combustible
} Car wash'detergents Leather dyes
{ Car waxes and polishes Fertilizers
! Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners - (inc. carbon tetrachloride)
1'
NEW � "USED"_ -� Any other products with "poison" labels
`.-._ _�_ _
Paint & varnish removers, deglossers _ _ (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other,acids)
Floor& furniture strippers Other products not listed which you feel "
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
4/Wihdshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
yr. -s.•'s m a :1+'2`.„V,��+.r-w M-a..w-..r _
�R S a,�"�' ,� �- •e � Y 3 v�.� �, �,q� a q^�+� .:ly t a �� _r � �i�-' a. ,a��'�', y �• L .
.y
g
f TOWN{iOFRNSTABLE -'BAR-W `i`
n e.
Ordina ce o"`r�`R guFlaton.
y WARNING TICE
Name of Offender/Manager °� 0t d'ob .
�.. .
Address of Offender_` . ► - i : 4t: MV/MB Reg #.
Village/State/Z 'ip '°d N �A r� > MA ,(_�����31�- - SSA
Busisness Name A am/pm) on
Business Address3. ' r
„ 4Signat'u=e of : nfo=cing fficer.
r . Village/State/Zip` ���'�,� r� k
Location o_f Offensea� �_ k�. 17
Enforcing Dept/Division
'FactsA 3 E' i'� IN %0A 6 � - i �3 .-_ ► : �:,.
i
f,- This�`will serve onl as a warning;. At this t�.me no legal 'action has been taken,.
It 14s the goal of Town agencies to achieve : voluntary compliance! of Town
Ordinances, "Rules; and- Regulations,. Education efforts and wa=n.ng nof'ices are
attempts to:..gain voluntary compliance`._ Subsequent- viol'ations will ,=esul,t In
E appropriate legal: action by the Town r , Yf
s
s .WHITE OFFENDER CANARY] ORDJREG PROG� 'PINK ENFORCING""OFFICER GOLD _ENFORCING DEFT �, ,
�ro�wrr off.�A�vsT�BL�
�ire 5. l.�l a SEWAGE:.W
VILLAGS �7`a n n s ASSESSOR'S MAP&LqT______.
-INS TI LL.ER":5 NOW 8c PHONE NO
I.SEMCTANK CAPACITY. !S d V
LEACI3TNG ff�ACIg.ITY' (��)
NO OF BSDROODAS
BBJI].1(�F,.I�OR OW1V�R
PrERFIdITOAT'E ,:...... Ct�NQ'�IR►lC 1R1�T : ....a
Sepsuataoe��isB�eCe B�tvreer�t��e
Maximum t Tactile to lltrl3nttotn of Leuc:h�n�F,l�ility
I'�rv�q� 'Jatc r Supply;UJ4�I assc�Uap fig p1celety G any �e19s cx(sti
� 7repi
ae�sacs orvlthan?AQ feet;df teaching frtcil►ty)
Fcl�;e.i���Ietland end'Leaciupg P�ci6lty(IF uny w�tl d5 exert
s+ntlaue 3[t0 fc c2 a ii
.Icttalug fucelry) P
pure>J�hcd b s��w�
r'
EHE
(74
d V
0 0
�\6
TOWN OF BARNSTABLE
LOCATION 'A 7 r-c rseS SEWAGE #
VILLAGE C,%, ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 41 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted GroundwaterTable 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 300 feet of leaching facility) Feet
Furnished by
�� � � � � �
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.x
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t,
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1 '
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V
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' '----�-"-•.I �. ,__ ` ..1.�+;� . Yr _� .•.-.�ti.n-.----ti - ... T, i:---.---�,�.- - -"-a - •. -• . 'w'"'7•T"''�s•r-•w-pr--:'--.^--"`+.i--•^•-
No. _ I FEE
Board of Health,
APPLICATION FOP ➢ ISPOSAL SYSU 1[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(�Upgrade( ) Abandon( ) -�jComplete System ❑Individual Components
Location (o ,`` Owner's Name
Map/Parcel# Address
Lot# 07 Telephone#
Installer's Nam Designer's Name
Address i� Address. 0. t
V
Telephone# t 6 C,5Telephone#
Type of Building l�eJ�'t 1Q�� Lot Size (Q sq.ft.
Dwelling-No.of Bedrooms t�Q �� Garbage grinder (4/A
Other-Type of Building -,1M—W- K No.of persons Showers(tiCafeteria (
Other Fixtures l)c" , kr@ SIN c IN4 Z CILL
Design Flow(min.required) 3?)C) gpd Calculated design flow - Design flow provided 21 •S gpd
Plan: Date bq Number of sheets
gg 1 Revision Date
Title G�
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator n Date of Evaluation �y
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire ton t to lace peratio til a CertificaW
Signe DateCe h been issued by the Board of Health.
Inspections
k
No. / ;i _. .. FEE
COMMONWEALT14 OF MASSACIIUS�ZITS
Board of Health, C c n 1ACM\19 MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) -XComplete System ❑Individual Components
Location 2(,. T;QCKSQ,-
Owner's Name 4y
Map/Parcel# 3 , ' dz Address
Lot# r� Z F 3 3 Telephone#
Installer's Name f-A sgx •% Designer's Name
Address E->nA� Yfl f }�, A Address �. tm
Telephone# 1 t Telephone#'
v
t� Type of Building 'FQ \C�eC1/`t t \ Lot Size sq.ft.
Dwelling-No.of Bedrooms Loco ( 1, _ Garbage grinder
Other-Type of Building (�`J O_C1Q No.of persons. Q Showers (W,,Cafeteria
_s_ j% Other Fixtures l C2,IY.V �C�.�-1 jC�'C C V qr, . t� �_C'al ,�..�
Design Flow(min.required) _ �� gpd Calculated design flow Design flow provided:„-,!A. S gpd
Plan: Date 1�04 Number of sheetsSS �+ Revision Date
Title ✓�, ^`C�� �Q1� C �- (l'1 �pC�rtlC.'�
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Rvalu- Stla. Date of Evaluation y
a� DESCRIPTION OF REPAIRS OR ALTERATIONS �``o �
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire s to not to place the�sys 11 C��in opera6otil a Certificate of C mpliance h been-issued by the Board of Health.
Sign d //+' / 1 Date
Inspections
w
-z: ,
ir
No. '� FEE
COMMONWEAA � OF MASSAC DTI
/}
Board of Health;
CERTIFICATE OF COMPLIANCE
Description of Work: El Individual Component(s) /Complete System
The undersigned hereby .ertify t at the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded Abandoned ( )
by: nY �
at "�S I / r J �.
has been installed in accordance with,the provisions of 310 CMR 15.00 (Tit/,5) and the approved design plans/as-built plans relating to
application No. dated -i A roved Design Fl9w (gpd)
Installer t✓ 1 ;it ��,'�;�,/ q A , i,
YL
Designer: Inspector f ' 4 Y}i" lll, !�� .��N ate:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.oi-CO 4 — YO I FEE C�
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
M '
Permissio,-n} is hereby granted to;
Construct( ) /Repair ) Upgrade( Abandon( ) an individual sewage disposal system
!!
at :'�/1� In,/ 1 " I/l si a . in as described in the application for
t _
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the ld-ate of thi<r—xrmit. All local conditions must be met.
���4 1
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health- �rT
i
TOWN OF BARNSTABLE
.-LOCATION _ �� �Gc rse-S SEWAGE *-2M '�OI
VILLAGE y'1'VVI ASSESSOR'S MAP & LOT 6 r ��
INSTALLER'S NAME&PHONE NO=.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ✓ size) TJ- V 7(
NO.OF BEDROOMS , ) .
BUILDER OR OWNER d"'
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 Feet
within 300 feet of leaching facility)
Furnished by
i
8
Al� . �(� L6 3;
No.....I.. -__YY FRs..........1.C.?°---c-...
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
8arnataW� Kian Department BOARD OF HEALTH
3_ TOWN OF BARNSTABLE
rwr.
ApplirttOff for Di-aipoottl Work.. Tonitrnrtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System a ', )
- .......... r
�, .••---v
k . ...........
L t' n•Add css oLqt N
Owner Addre
W
Installer Address
UType of Building Size Lot............................Sq. feet
,., Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Pk Other—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 capacity.._.__......gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit---------_.......... Depth to ground water.........................
40 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R; :.......................................•-----------------•---•--•--•-•-----••---•-•-••'•--------------...............................................
:
0 Description of Soil..........................................................................................................................................................................
114
V ._..---•-----------------•-•----_.__.-•-•-••----•-••-•--•--...___._._._'------'-'-•--•----•---•-•-_-_------•---------•---•-----------•---•--_...-•••-----••--•-•'-----------•--•-'-•---•----•••--•---
W
x --- ----•--•-•--.. ............................. -------- --•-•- • .
U Nature of Repairs or Alterations—Answer when applicable...........,pJ-�t�......../S�_P__P__.. �.:.._._._........
-•--•---•-•....................'--•-__.__.-•-•----•----'-•-----• _...._..____._._.............._.__-_...-----•---------_.._._..---_-._.__..•---•.....---------------------_..__...-••--..._.._.......__.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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.
Signed ........................................................................................................... .................................:......
Dace
Application Approved By�............ .... ... .. .-` ....:'. -....g.3 '....
Application Disapproved for the following reasons: ........................................................................................................................................
..........................................
............
................................................................................................................................I......................... ......................................--
pp Dace
PermitNo. ..........l.....L.....".....�77.............................. Issued .............................( .......................................
Dace �
-------------------- -----------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(MITI-ertifi ate of (1:1-vinjiliart e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ................................................................................................................................................................................................................................................
I nscsl Irr ......
at ......................� y......... . ........ - ........ ................. ...............................................................I.................
has been installed in accordance with the provisionkjf TI"fLE 5 The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ... `.��.Y....��.A..f............... dated ...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
~DATE........................................................................................................ Inspector ..............................................,...................................................
�---- --------------_----- ----- -- ----------- -- --------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE f
_ M.e
No... FEE..... ......
4 3�io�osttl ork� �un�tr�r�tion �rrmit
Permission is hereby granted....................:••••-•-••---•-------------------•..............
.-------------•-------------.............
----------- ......
••-•......
to Construct ( ) or Repair ( �n Individual Sewage Di osal System
at No............ ` a.,. -e.,.......V� -
.
Street
as shown on the application for Disposal Works Construction Permit No7y___��t�j` Dated...........................................
...-----••........-•••--•--.....---••-------••--'----•-•••....•••-----------'--'--------------------•---
Board of Health
DATE.................................................................................
FORM 36508 HOBBS R WARREN,INC..PUBLISHERS
No....1..y:.._y.•f - FIz$.......... .. 2....
THE COMMONWEALTH OF MASSACHUSETTS
- BOARD OF HEALTH
_J yTOWN OF BARNSTABLE
6 i� I
I Appliration for Diopoottl Work,i Tonotrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System ate+
. - ----- ------------ -_--•-••- .-.-
j L ti n•Add css j o t No.
............. 11 �._(�?!4�.. Q�S.. . �'� D�i/a► ........... �iOZAef
Owner Addre
W
Installer Address
UType of Building Size Lot............................Sq. feet
e-a Dwelling— No. of Bedrooms-------------------------------------
--------Expansion,Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q, Other fixtures -----------------------------------------------------------------
d ------------------- -------------------------------------------------------
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.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing.•tank ( )
04 Percolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. l................minutes per inch Depth of Test Pit-------------------- Depth to ground water........--..............
LZ4 Test Pit No. 2................minutes per inch Depth of Test Pit....--.--........... Depth to ground water.....--......--.....---.
O Description of Soil----------------------- -C - ,_"'Ii="':-_ = _') - ,"` ----• ----
V
' I
----------------------------------------------------------------------------------•----.._._......------------------------------... ---•-----•-•------•-----. -- ...........
U Nature of Repairs or Alterations=Answer when applicable.------....�J-__ Z..._...../a0 O.- ..�C,r-:.. ........
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the,provisions of TITLE 5 of the State Environmental 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.
Signed ................ .............................. ....................................................... .. ..........................:......
Dare
e.
Application Approved By ............< ..... ...... �, .. .............................................................................. 4 Application Disapproved for the following reasons: ..................................................................................................................:..............
................................................................ . ....................................................... ........................ ........................................
yyPermit No. ....... ..`......Z.//,f.......................... Issued ........................................................D�e......
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifirate of QlII>I plianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...................................................................................................................................................................................................'..................................................
Installer
at ......:::............. y.........1'� ......... C ............. .......................................................... --
has been installed in accordance with the provisiof TITLE 5 The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .... .��-....y.' ................. dated ...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................................................................................................... Inspector ..............................................:...................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
9cctt TOWN OF BARNSTABLE
No...l•.!..'.y. FEE.....L.Sl. .......
Biopooal 30orkii Tonotrurtion "prrmit
Permissionis hereby granted.............................................................:........----•--------------------------_----------•-----------•----._,:...._....
to Construct ( ) or Repair ( n Individual Sewage Disposal.System
:-
UStreet
PP P
., as shown on the application for Disposal Works Construction Permit No. ._�.:_._ Dated..........................................
....�.
Board of Health
DATE................................................................................
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
Town of Barnstable V
°F'ME rp`"° Regulatory Services
Thomas F. Geiler, Director
BAMSTABM
"�; � Public Health Division
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 1 (5
Designer: �� ��� Installer:
Address: 1`7� Cam - Address: �'�� •.
rc02�
On 8 ® '7�15> �was issued a permit to install a
(date) (installer)
septic system at alle,/ bbased on a design drawn by
(address)
1:5k4AY &U1TMtr --,Am Sdated f' �O
(designer)
/V 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.
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.
ZH:Of MA
I st 'er ature o� sgcy.
( ) CA
u SHAY cn
Ago/
No.' 1189
'(Designer's Signature) (Affix De e�, ere)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVIS N. 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
°r
�,-. min. from 'NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. VENT PIPE ((o Least 24 Inches tall) SECTION A '•-A _10 Schedule 40 PVC w/Charcod Odor Fdter BOX SHALL BE
Existing Foundation se to septic tank PROFILE VIEW OF LEACHING SYSTEM SET 10N FOR tz- gOVOt a' 4'4y
TOP OF FOUNDATION EUV. 100.00 (Assumed) ° tank can°'° --t be
edgtki 6 In. of finished grods - '� 3-6'OUTLET " .. i. a/ ij r a c bi$I
O otfe ow Septic Tank 98 00 Grade over D-Box- 88 00 oust SAS- k7 EVE Y8.2S lips- Messes �♦•A'I f/l Rd1N Or.rrh.i Y6n. i/!' //Jl°'�edni A..bw. KNOCKOUTS i T a �ft ag t°7 +rC W 5t
s . 12• tNILT I X e na jffj� '°' s+f
S 0 02 3 HOLE H-20 r o �.
DIST. BOX 3' Naxkrsen cover Top of SA$-Elev.:9500 : r a�e?vr� ro
OUTLET
.JW
14' NEW S-0.01 or Greater S- 0.010" per toot ♦ J :`. -�". u"06 k° f '. 8rm rA
NEv PIPE 1,500 GAL / D•v� o 4• - SCH. 40 i M r ry
E"""' o 0 - o PLAN 1SECTION CROSS-SECTION
x „ 7s' 1.75' nt, Ab"L4
f'RQI EXIST.rOUNnAt>nt x SEPTIC TANK � a 4 0 0 0 0 0
w uT f Wert at
A H-10 w. °� o o 2 Units Q 85 - 17 + �a•f a5 r. Qhrygt+s & r
coHcaE1E rt>rL ° . 1 04 4, 4' ` E 6 e Its yaw i
$ a p 3. ' ♦_5;--- 3.5' wt►� " '' ,. + t
SYSTEM PROFILE 6compact./a'a'a„ �; o m 12' tcfQ2e Ler>eth 3 HOLE H--20 DISTRIBUTION BOX
Not to Scale - c Effective Width NOT TO SCALE 30att 1
e rsr,e�e+dly a s M4 Karrf:o -^^"
c c ° SOIL ABSORPTION SYSTEM (SAS)
_ o ,
6 In.of 3/4"-1 1/2' 0 500 - jC H-20 LEACHING UNITS / WIGGINS PRECAST GENERAL NOTES
compacted stone m
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE Bottom of Test Hole 1 Elev.- 87.00 Not to Scale 1. Contractor is responsible for Digsafe notification
and protection of all underground utilities and pipes.
�Obs. Groundwater - Test Hole 1 Elev.- NONE OBSERVED 2. The septic tank and distri ution box shall be set
level on 6" of 3/4"-1 1/2 stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size.
4. This system is subject to inspection during installation
by Carmen E. Shay - Environmental Services, •Inc..
5. The contractor shall install this system In accordance
PERCOLATION TEST with Title V of the Massachusetts state code, the approved plan
lJ I V and Local Regulations.
6. If, during installation the contractor encounters any
Date of Percolation Test: AUGUST 4, 2004 LOTS 3> & 32 soil conditions or site conditions that are different
Test Performed By. CARMEN E- SHAY, R.S., C.S.E. from those shown on the soil log or in our design
Results Witnessed By. WAIVER (per Barnstable B.O.H.) installation must halt & immediate notification be
SHAY ENVIRONMENTAL SERVICES, INC. made to Carmen E. Shay - Environmental Services, Inc.
Percolation Rate: Less Than 2 MPI 0 36" Assumed
7. No vehicle or heavy .machinery shall drive over the
10.5' 46•30. septic system unless noted as H-20 septic components.
___ 8. Install Tuf-Fite gas boffles or equals on all outlet tee ends.•
i 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
Test Hole 00, 1�� 5� *: a` . .i - ��� 10. All solid piping, tees & fittings shall be 4" diameter
Schedule 40 NSF PVC es with water'tight joints.
� %.`-:. ': • - -VENT� pipes 9
DEPTH SOILS ELEV. �' ':.'_ / .11. Municipal Water is Connected to ALL OF The Residence and Abutting
o se-oo
;•' C� i' TEST-HOLE #1
- `-IfLEV.= 98.00
Sandy Iroperties Within 150 Feet.
�' e' ► s�. � t:�. -. ;
Loom
PROJECT BENCH MARK THE PROPERTY LINES ARE APPROXIMATE AND
10 Y 3/2 i' GRAVEL TOP OF FOUNDATION COMPILED FROM THE SURVEY PLAN GENERATED BY
A 96.25 DRIVEWAY ,'� CAPE & ISLANDS SURVEYORS OF MASHPEE, MA
I �, DECK ELEV. = 100.00 (Assumed) ENTITLED " PLAN OF LAND IN BARNSTABLE, MA,
Londyoom �' 2 MA", DATED MAY 8, 1979, PLAN # 17201-K
10 YR 5/6 ��' & THE DEED DESCRIPTION ( C133931)
8.- M" Be 95.00 / IT ;SHOULD BE USED FOR NO PURPOSE OTHER THAN
Med• �� e O�G� THE SEPTIC SYSTEM INSTALLATION.
� on
2
a - eT EXISTINGXISTING CESSPOOL TO BE PUMPED OUT AND
3s"-t32" C, 87.00 ,�� 'ct� 2 BEDROOM REMOVED TO FACILITATE NEW SEPTIC SYSTEM INSTALLATION
HOUSE NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
FROM THE EXISTING CESSPOOL TO BE DISPOSED
OF AS PER BOARD OF HEALTH SPECIFICATIONS.
NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
{ 9 �\
p 0 -_-__ h ASSESSORS MAP 310, PARCEL 029
0- Q�
1500 GALLON ��O O LEGEND
SEPTIC TANK
Perc #1 0.
Depth to Perc: 36" to 54" NSF SPERO THEOHARIDIS 104X1 DENOTES PROPOSED
Perc Rate= Less Tho 2 MPI Failed SPOT GRADE
Groundwater Not Observed LOTS 291 3d & 33 Cesspool
No Observed ESHWT DENOTES EXISTING
ADJUSTED H2O Elev. = None 6,955 Square Feet +/ X 104.46 SPOT GRADE
PL PROPERTY LINE
\ � 96P PROPOSED CONTOUR
d' - - - - - -97 EXISTING CONTOUR
3-2+' aAM. ACCESS MANHOLES ® DEEP TEST HOLE. &.
10 e• PERCOLATION TEST LOCATION
FOOT STOCKADE FENCE
L= .0
n
INLET / / / OUT EThi THE ACCESS COVERS FOR THE SEPTIC TANK, LOT
LAN
DISTRIBUTION BOX AND LEACHING COMPONENT
F .�,,.�z SHALL RAISED TO WITHIN 6" OF 0 F PROPOSED SEPTIC SYSTEM UPGRADE
:-.• ' x •"-_ry•,�._7--��:: .^ FINISHED GRADE.
STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITS GAS BAFFLES OR EaUALS E M
PLAN VIEW ON ALL OUTLET TEE ENDS
PREPARED FOR
/-3_24• REMOVABLE COVERSMR_ PA U L C A H 0 0 N
AT
< 3 min. cleerance
mhr r min Wet to outlet , 1Y 1/'►} 2 6 4 B EA R S E S WAY
10•mh.� u, OUTLET -{�-- -
s -r ILII S _r HYAN N I S, MA
-- 4'-T min.
Liquid depth Design Calculations
12
ti� tM PREPARED BY:
Number of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Gal./Day Min, per Title V)LIN t 7.� •�•z '--..•-:�, _.:'°z.- -: i Garbage Grinder: No ��1 it li l ► ll ti l 10*'-a" Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) E. uA Y
CROSS SECTION END-SECTION Septic Tank : - 2 x 330 Gal./Day = 660 USE NEW. 1,500 GAL. Septic Tank. 0 20 40 5 VIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch
Bottom Area: 0.74 gal/sq. ft. x 300sq. ft. = 222.00 gallons P.O. BOX 627
TYPICAL 1500 GALLON SEPTIC TANK Sidewall Area: 0.74 gal./sq. ft. x 148 sq. ft. = 109.50 gallons EAST FALMOUTH, MA 02536
NOT TO SCALE Providing: = 331.50 gallons
(H-10 LOADING Use: (2) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH, SCALE: 1 "=20' TEL/FAX : 508-548-0796
TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND SCALE: 1"=20' DRAWN BY: CES DATE: AUGUST t' , 2004
4' of WASHED STONE ON THE ENDS. PROJECT#SD810 FILENAME: SD61OPP.DWG SHEET 1 OF 1