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Home My WebLink About0020 DACEY DRIVE - Health 20 Dacey Drive Hyannis A=252-051 t Commonwealth of Massachusetts POP 0,51-.03-2, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 Dace Dr 1`0 Property Address ,David Hartin Owner Owner's Name information is required for every Oln-re_ry I I I e Ps Ma— 02632 7/14/15 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in aPi way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tat) I 64P key to move your inspector: cursor-do not Michael DiBuono use the return - ------------- key. Name of Inspector DiBuono Sewer.and Drain as Company Name 8 Johns path Company Address ,S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 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: Z Passes El Conditionally Passes F-1 Fails E] Needs Further Evaluation by the Local Approving Authority 7/14/15 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 DER 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. t5,ns-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Fag 1 of 17 ' Commonwealth of Massachusetts W� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dacey Dr Property Address David Hartin Owner Owner's Name ------------- - - ...--- ----— --— ----------—- —----- --- - - information is required for every Centerville` Ma 02632`- 7114/15 _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: - I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of a single leach.pit. Level.inside pit was 24 " below invert pipe and-no staining above that,was visible. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Foam .o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dacey Dr Property Address David Hartin _ Owner Owner's Name information is required for every Centerville __ _— -__ — Ma_ 02632 7/14/15" _ page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System—Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water levei 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•.3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address David Hartin Owner Owner's Name information i's required for every Centerville Ma 02632 7/14/15 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 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. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. El 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 ano|ysie, performed at a DEP certified laboratory, forfeca� � 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 ho this form, — 3. Other � � _'---_______-____--__-- � D) System Failure Criteria Applicable toAll s: | � You must indicate "Yea" or"No" to each of the following for all inspections: � Yen No El �� Backup of sewage into fsni|hvor system component due hu overloaded or �� clogged SAS orcesspool Discharge or ponding of effluent to the surface of the ground or surface waters due toan overloaded or clogged SAS orcesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS orcesspool �� Liquid depth in CeSspOO| is less than 0^ below invo�oravailable volume is less �� than }6 day flow m.=-am Title s Official Inspection Form.Subsurface Sewage Disposal System'Page^m`, ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Da ce Dr _Y Property Address David Hartin Owner — -- - --- --- --- ------------------------ ------ ------Owner's Name - - information is required for every Centerville _ _ Ma 02632 7/.14/15 page. CitylTown 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- 10,000gpd. ❑ ® 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. t5.ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 20 Dacey Dr Property Address — -- ---- ------- - — — ---- David Hartin Owner Owner's Name— ---- -- ------------ ------ ------------- - --- --- ---- - information is required for every Centerville Ma `02632 7/14/15 page, City/Town State Zip Code -------------_ _----._..--------- Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes.. No. ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the-system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? Z. ❑ 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dacey Property Address David Hartin Owner Owner's Name information is required for every Centerville _ Ma _02632 _ 7114/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of a single leach pit._Level inside pit was 24 " below invert-pipe and no staining above that was visible._— -- Number of current residents: — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears us-age d 166 gpd — 9 ( y (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: date Commercial/Industrial Flow Conditions: Type of Establishment: - ----- ---- - .. ---- ------- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): - ---- -- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - - ------- -- -- t5ms•3/13 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dacey Dr Property Address David Hartin Owner Owner's Name information is required for every Centerville _ Ma 02632 T114/1-5 _ page. CityfT'own 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: ------ ------ - ---- ----------------.-_- Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons -- How was quantity pumped determined? ------------ Rea son 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): t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dacey Dr —_ Property Address -- David Hartin Owner Owner's Name ------ ----- -------- --- --- — information is required for every Centerville Ma 02632 7/14/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2�ears Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18" — feet Material of construction.- 0 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.): System is vented throught the roof_ Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El other (explain) 1000 gallon ..--------- —--------- -- If tank is metal, list age: _--- _-- ---- -------- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon Sludge depth: 3, l5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Fora Im 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o a,.• 20 Dacey Dr Property Address David Hartin Owner ------ ----------------- -------_._.__..._ ------..---...------------------- Owner's Name — --- information is required for every Centerville _ Ma 02632 7/T471'5 _ page. City/ own 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 24"— — Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 42 -- ------ ------------- Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick —_ How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are iUlace, no evidence of leaking__ Grease Trap (locate on site plan): Depth below grade: _NA _ ---__--- - --_- 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 15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dacey Dr Property Address — -- David Hartin_ Owner Owner's Name -- --— ---—------- ------ -- — information is required for every Centerville _ - Ma 02632 7/14/f5- _ 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.): Tees are in place-and levels are normal. 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 El 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Ix Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dac Dr Property Address David Hartin Owner Owner's Name information is required for every Centerville_ -_--- Ma 02632 7/14/15 _ 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 At normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution Box is level and at normal level with no signs-of carry over or decay_ 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t51ns-3/13 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 20 Dacey Dr Property Address — David Hartin Owner ----------------__------------------------- _-------- Owner's Name — information is required for every Centerville Ma 02632 7/14/15 ---- ----------- ------- --- ----- ----- --- - page. City/Town State Zip Code Date of Inspection--- D. System Information (cont.) Type: 1 ® leaching pits number-., -- — ---- - ❑ leaching chambers number: — --- ❑ leaching galleries number: ❑ leaching trenches number, length: -- ------ ❑ leaching fields number, dimensions.- El 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.): No signs of carry over and no signs of hydraulic failure. 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-3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts l W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 20 Dacev Dr Property Address ------ --- David Hartin Owner Owner's Name information is required for every Centerville _ _ Ma _ 02632 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.): No signs of ponding or hydraulic failure. 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.): t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts �U Title 5 Official Inspection Foram Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dacey Dr Property Address David Hartin Owner Owner's Name -— ---- --°-- - -- --- --------------------- --- -- ----- - - - information is required for every Centerville _ Ma_ 02�632 7/14/15 w sp page. City/Ton State Zip Code Date of Inection _ ®. 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 (Sins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 17 Assessing As-Built Cards Page I of ) "—r0M1 '0F BAhNSTABL.E _ LOCATION.0 E Al ��1 I I G A� SEWAGE 0 9 s C) 1 I VILLAGE R'S MAP&LOT -+ -- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 D U C-fi LEACHING FACILITY:(type) p(Y _ (size) S K 7 )6 d D G n L NO.OF BEDROOMS BUILDER OR OWNER, Q F}-Y5 / PERMfl GS'DATE: 3 q. COMPLIANCE DATE: l3— 5 Separation Distance Bawl=the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet" Private Water Supply Well--nd 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 leachingfacili ) Feet Furnishedby- R, L Q 0 R U9 C `�c• C 3 D `11 h5 (o littp://\N\�l\�'.toN�!ii.bai'IlStable.nla.us/Assessing/HN4display.asp`iiial)pat-=2>?0510;?&seq=l 7/8/2-015 Commonwealth of Massachusetts Title Inspection 5 Official Inspects®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dacey Dr Property Address --- — — ------ David Hartin Owner Owner's Name -- --- - information is required for every Centerville ______ _ Ma 02632 771`4Tf5 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+ ft - - - — 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: 3/7/1995 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: NGE at 13' According to test hole data on site plan dated March 7 1995 1n Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Dacey Dr _ Property Address ------------- ---------- -- — -- -- David Hartin Owner Owner's Name - .....---- - - -- — -- - _—.. - -- —- --------------- ------ information is required for every Centerville _ _ Ma 6263Z' 7/14/15 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-taAll-Systems)"completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �� TOWNOF BARNSTABL / LOCATION G A' G v 1 l y��r S SEWAGE # 9 r ®S VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE:NO. D C 2' 'PSEPTIC TANK CAPACITY ' I'b 0' 4'B„L — Y G y0 GAL, ►`LEACHING FACILITY: (type) 11'. 4f (size) NO.OF BEDROOMS BUII.DER OR OWNER f PERMTTDATE: 3 q S+� COMPLIANCE,�DATE:�`"f��' Separation Distaa:e Be► -gm the: t�,,k , ,. " ,,. :. z t Feet Maximum Adjusted Groundwater Ta61e and Bonom of Leaching Facility Private Water Supp)ytWel!and Leaching`Faciliiy (If any wells exist t 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 l F ' �. '.n. ' r � a. , r,. { { � � f �� . �' ,� r�' a �' l . � � n � � M � . � � ,t , ' �'t �� y' ' '��yls t Fyn '� � `.' ,~t, "® t ter+ � +y e y w � + :� ��. . � . � � � � � � �� ;.� .. No....1 ....._..0 FEs...........1�. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Alip iratiou for DijVu3al lV ar1w Tomitrurtiuu runfit Application is hereby made for a Permit to Construct (j,/jor Repair ( ) an Individual Sewage Disposal System�at C 3 3f 33 H -_aez, ------------------------••-•---•---••--..._..--------- ..-•----......-- -• -----------------------....------...--•-•--•--•-•--------•--. tion-:\d s or Lot No. a �....< ------------------------ Own Address a �. . ..............•....•. .--- - --------- --.--------------------.---•-------........ Instalter Address f Type of Building Size Lot----- ................Sq. feet t , Dwelling—No. of Bedrooms---_.-_______________________________...Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Bui1dingW00 f—.tl --_A-. No. of persons---------------------------. Showers ( ) — Cafeteria ( ) a' Other fixtures ......................--------- :. d W Design Flow...................R.n.................gallons per p I per day. Total daily flow........33a..........................gallons. WSeptic Tank—Liquid capacity-1-000.galIons Length---------------- Width_-.--.-.----_- Diameter_------------- Depth.----_-_____---- x Disposal Trench—No- -------------------- Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter---..---.-_-------. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing nk ) 1-4 Percolation Test Results Performed by / �� `� ------------------ Date ...3 ..._._... Test Pit No. L.__ ;--_-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........................ P4 ---------------------- -/ --- - -- 0 Description of Soil------ - ---------------------------------------------------------------------------------------------------------------------------- V ......------•--------------•-----•---•---------------------.....----------------------------------------------------------••---...---------------•-------------------••--------------•----------•-------- W UNature of Repairs or Alterations—Answer when applicable................................................................................................ 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 Co p e has een issued the board of health. C Signed .. ...... .. ._------------ ---- ----------------------------------- Application /.... ... Approved B ---------------------------------------------- 3..- . .�..— PP Y - tS.... ...Z .._...._.-------..... Date �.. Application Disapproved for the following rearons: ......................... ......... ............... ............ -- ......_. ......... .......... . .............. ... ...._.. ..._............_............---------------------------------------------------------------- ........ ........ ...... �J Date Permit No. . . ....�.(, ..-....&_.6�.L .......... Issued ------------- .:�. .�... / Dare No......L.!2........��6� F�s............� .r�.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphratiou for Di-ripinial Wnrk,6 Towitrnrtinn Prrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at* . ..... -----------------------------------•-----•----••---------- — �...... n-:\dd s Lot No. '- L 1 ............................................................. f 21 W wnera,,, � Address Installer Address Type of Building Size Lot------ .....Sq. feet .� Dwelling— No. of Bedrooms._--------____________________-___-------._Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of BuildingW0W�`�Cf^u-. No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ______________________________ _ _ -------------•--•---------------------------.----.------------•-----•------- ... W Design Flow....................L� ................gallons per on per day. Total daily flow--------336--------------------------gallons. W Septic Tank—Liquid capacity.wU U-gallons Length________________ Width---------------- Diameter.--------------- Depth................ x . Disposal Trench— No- -------------------- Width.................... Total Length.................... Total leaching area--------------------sq. ft. 3 SeepageiPit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z' Other Distribution box ( ) Dosing nk �".¢¢�) y Percolation Test Results Performed by... ------t._�.�1.0 Date-_-_-----:3--..QS---•--•--•.._.. Test Pit No. 1__-.a:.)._;..__minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ G%, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water....................... �- -- r -,--- -------------------------------------------------------------•-_...--......................................................... Descriptionof Soil. I^a�A- /a-Pi---��+ �---------------------------------------------------------- ------------------------------ --------------------------- U ------------------•------------------------------------------------------------------------------------------------•---------------....------------....-----------------------•--•---•---••-•--••...--- W ----•--••--•----------------••----•-....-•--------••---•-•-----------------------------•--•---•--••------------•------------------------------------••-•---•---------------••--•--•--•---•--•-•----•---- UNature of Repairs or Alterations—Answer when applicable._._-..-.--_................................................................................... 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 Cotn°plian. has een issued by e board of health. Signed - ..... ...... c....-...1-- th ------------------ -- - --�//-;....��.... � 1 Ihce Application.Approved BY ---- --------- /I .-....... .-. ? .- 5:....... ..--- .- Dare Application Disapproved for the following reafonr- -----------------------...-..-------------------...........------....._----------------------------- ...............................................------------------........-..------------....-.._.... ------------------------------------------------.-----------_-..--..-..--..------ ---------------------------------------- �- C„ Permit No. �...�r.' f a..�� `� - Dace Issued ...............` . ��---".1.- -...... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gertifirate of Complialare THIS IS TO CERTIFY That the Individual Sewa e Disposal ystem constr}'cted ( �) or Repaired ( ) by :—= ..... _.. - ! ----------------- -- _ --............... _3 In)c II- at .. 3. ...._........ ...... . --------- �f ..'w+�t -----------------------------------------------..-------------..--------------.------ has been installed in accordance the provisions of TrlTf :E 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. --------C --..vc,'_. f _ dated .._.... -..-_.--__..........._.-----.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. o'J DATE--- '"' „ ._-........f. - Inspecto � •' :... -1!'�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE l <' � FEE ................ TaPerl` �ark� un�#r�r#Uan �.ermit to Constructon is 1� orrebepair granted Individuals S .wage Disposal System-----••_-----•-••-------------•-.-------••---•-•.-•----•••-...••-•_•- at No. ( _ 00 - --- I�� -------------------•--------------...----•-----------.........---•--._........... . ..... _.. r` _.... j Street as shown on the application for Disposal Works Construction Permit o.=1_- '...... Dated.......................................... Board of Health ---•-.-.--•----•------•--••.•-• DATE................L,>...�J %._ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS (� 51.:, i. C'!lln' r I .r V�.� I +.H4' •ter. ,<....- rV� J� SINC,c-� FAMIL-C 3 'DAIIL•( �-ov-tW � X5; S I C ' 33v x So/• 44 S A 4 - 'PIT. �/ 31 Ul�PcfWOO 51DEW4LL__.A2C-A:'- 1O3 sf--, Fkap 1 . :. , BOTTOM A ;= 78 5F TDT-AL U i16FJ 4D l • Qv ay TOTAL DAILY 'F�-0Yl = 330 6f'D 1, cry �o�^ '� �� \,. ,-� o Pc2Gi0C.AT10N . QATE :_ �'J I� 'Z.M1+J ILE% �0' z� - - .�1% OF s SULLIVAN EPA �BJ(! PTIER [C. p-� ��C'SST 6�rq {6��' '. I �• � �,1�_�_.. AL Fi,-43 TF =34 ---w lol�wt1 p v e /Al✓ vlST �Nv GAL, Lp wl i f 7 ¢ Z w : A►i.'SrQucruZC) sir Aitk S•G. SToNt:,. MOW T14AN 4! vrep B � Q4ALL 8E �4-20 .� ou 1AGE Su�UiviSioN MAP 2SL/51 253 /9 SAu� Ci-I FI® (�L d1 PLd N�VE1.UEGD, 'P2vFl Lam- � 1 go .SGDL�. LGCA'TIDh! '_ CEJJTCftVIc1F /uy,quuiS , =70 DATJ='J MArL."7 (qq� P�o�ros�:� PLAN DER_ I C�'I FY :T� AT T 4E L �c.ca SFIcw�J HFZeoN G0mTlL S wlrA T11� 5vPati s 'Op TRjlr rMWN O P-A"'�rAZ L& PL -BL sos Pc,. -1 E, d tvv I �r L-ocdTIE�D WI-rol d "T�F- Tlzcv .alt,1 ,r 1. WD CoL)eT Pc.M 3WZ I A 1t15TI?v�,4E�T' p 'filo�.J4J_ AOD Sueveyo,z5 SUfZt,;'E J ' T•.AND TN£ qMe . 4I-�vut W o�- l3E c�v L E06i N CEV u�,ci� T'o5'Ti��LISri -FtEtzTy laNzS STE►zvIu.G Mau , II APPLICANT; 7�3AySIt;E