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Commonwealth of Massachusetts
. ,rp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c.
69 Nobadeer Road s
Property Address ' j
Janet Weatherbe
Owner Owner's Name
information is 's
required for every
Cen ilie MA 02632 12-29-20
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered n any
way. Please see completeness checklist at the end of the form.
_,I"OF fA4A 7 i,
fmporta t:When A. Inspector.Information .' Si 151 9�y�;
fo
on the computer, ; �: JAMES N.
use only the tab James D.Sears =�:
key to move your Name of Inspector
cursor-do not Robert B.Our Co.INC. C a
use the return. �c
Company Name lac'
key. 363 Whites Path s iNSPE`�p.�`
Company Address'
South Yarmouth MA 02664
City,Town State Zip Code
508-477-8877. S 16623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance-with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance"of on-site,sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority.
4. ❑ Fails -
12-30-20
pector'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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional.office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system willperform
in the future under the same or different,conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.............<„ 69 Nobadeer Road
Property Address
Janet Weatherbe
Owner Owner's Name `
information is required for every Centerville MA 02632 12-29-20
,
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary;Complete 1, 2, 3, or 5 and all of 4 and 6. -
1) System Passes:
® I have.not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal. Tank D Box and pit.
f
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system,upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*-or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank;is less than 20 years old is.available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 '
cam, Commonwealth of Massachusetts
Title 5 Official* Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Janet Weatherbe
Owner Owner's Name
information is required_ for every Centerville MA 02632 12-29-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cone:)
2) System Conditionally Passes (cont.): _
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or dueto a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
El broken pipe(s) are replaced ❑ Y ❑` N1 ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced. .. ❑ Y ❑ N ❑ ND (Explain below):'
❑ _ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by'the Board of Health: s
❑ Conditions exist which require further evaluation by the,.Board of Health in order to determine if
the system-is failing to protect public health, safety or the environment.
a. System will pass unless'Board of,Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which.will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface,Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Ins ection Form
IIb Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Nobadeer Road
u� - -
Property Address
Janet Weatherbe
Owner Owner's Name
information is re Centerville MA 02632 12-29-20
wired for every
4
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50.feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety.and environment:
❑ The system has'a septic tank and soil absorption system (SAS) and the SAS is.within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The,system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
[]'The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply-well..
❑ The system has aseptic tank and SAS and the'SAS is less than 100 feet but 50 feet or
more from'a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified,laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate.nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered..A copy of the analysis must
be attached to this form.
c. Other:
1
4) System Failure Criteria.Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Janet Weatherbe
Owner Owner's Name
information is Centerville MA 02632 12-29-20
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary.(cont)
4).• System,Failure Criteria Applicable to All Systems: (cont:)
Yes No
El ®' rStatic liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool'
❑. ® Liquid depth in eanpmal is less than 6" below invert or available volume is less .
than%day flow octT—
❑ ® 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply::
Any portion of a cesspool or privy'is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ N 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.]
µ-The system is a cesspool serving a facility with a design-flow of 2000 gpd- .
❑ ® 10,000 gpd.
❑ ® The system fails. I.have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section'C.4.
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
Ell El Area,, IWPA) or,,a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 .Official Inspection Form .
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Janet Weatherbe
Owner Owner's Name
information is required for every Centerville MA 02632 12-29-20
page. City/Town State Zip Code Date of Inspection
C. Inspection. Summary. (cont.)
If you.have answered"yes" to.any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system-.considered a significant threat under Section C.5:or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes or,"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board.of Health
❑ ®.. Were any of the system components pumped out in the previous two weeks?
❑ Has the system received normal flows in the previous two week period?
Have large volumes of water been.introduced to the system recently:or.as part of
El ®
this'inspection?
® Were as built plans of the system obtained and examined? (If they were not
El
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?
® ❑ a. 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 deter nined•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)] r
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection .Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Janet Weatherbe.
Owner Owner's Name \
information is required for every Centerville MA 02632 12-29-20
page. City/Town State Zip Code Date of Inspection
D..System Information
1. Residential,Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
1000 Gal. Tank D Box and pit.
2
Numberof current residents:
Does residence have a garbage grinder? ❑ Yes; 0 No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
2018 - NA
Water meter readings, if available (last 2 years usage (gpd)): 2019-51,6100 Gal
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
15 5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
u
69 Nobadeer Road
Property Address
Janet Weatherbe
.'Owner Owner's Name
information is Centerville MA 02632 12-29-20
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System.Information (cont.)
.2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑. No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ -No
41
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: 2016-
Was system pumped as part of the inspection? ❑ Yes ® No
l
If yes, volume pumped: gallons
How was quantity pumped determined? _
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
69 Nobadeer Road
V
Property Address
Janet Weatherbe
Owner Owner's Name
information is"
required for every Centerville MA 02632 12-29-20
`.
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont)
4. Type of System:
® Septic tank, distribution box, soil absorption system
El Single cesspool
s ❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ y Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained,from system owner) and a copy of latest
inspection of the I/A system by system'.operator under contract
❑ Tight tank. Attach a copy<of, the DEP approval.
❑ Other(describe):
Approximate age of-all components, date installed(if known) and source of information:
1983 Permit # 611.
Were sewage odors detected when arriving at the site? ❑ Yes ®' No
5. Building Sewer(locate on site plan):
28„
Depth below grade: 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.):
Pipeing is 4" PVC SCH -40
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y � 69 Nobadeer Road
u-
Property Address
Janet:Weatherbe
:Owner Owner's Name
information is Centerville MA 02632 12-29-20 z
required for every
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
22
Depth below grade: feet
Material of construction:
® concrete: ❑ metal ❑'fiberglass El 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: 1000 Gal. Precast H -40
2"
Sludge depth:
28„
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
12
Distance from top of scum to top of outlet tee or baffle
17
Distance from bottom of scum to bottom of outlet tee or baffle
AsbuHow were dimensions determined? Sludge Judge
Judge
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 at working IeveL�Tank and covers at 22" below grade. Outlet baffle w/inlet tee. No sign of
leakage or overloading.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
e Title 5 Official Inspection Form
li, Subsurface Sewage Disposal System Form-Not for Vol untary:Assessments
69 Nobadeer 'Road 3
Property Address
Janet Weatherbe
Owner Owner's Name
information is
required for every Centerville MA 02632 12-29-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.,)
7. Grease Trap(locate on site plan): Y
Depth below grade: feet
Material of construction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness`'
Distance fromtop of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last ,um in :
p P 9 -
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:' -
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons'
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
iIb Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'69 Nobadeer Road
Property Address
Janet Weatherbe
Owner Owner's Name
,information is Centerville MA 02632 12-29-20
required for every
page., City/Town •State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments.(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required)..Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on,site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D_Box is 16"x16"-3' below grade w/one line out. Box is clean and solid w/no sign of over loading,or
solid carry over.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
�v Title 5 Official ' Inspection form
�1� Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments
69 Nobadeer Road
V
Property Address
Janet_Weatherbe
Owner Owner's Name
information is required for every Centerville ' MA 02632 12-29-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
l5insp.doc--rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Janet Weatherbe
Owner Owner's Name
information is Centerville MA 02632 12-29-20
required for every
page. Cityrrown' State Zip Code Date of Inspection
D.System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a precast pit w/2' stone. Pit at 4' below grade w/cover at 18". 1'water in pit. No High
stain line.No sign of over loading or solid carry over.
r
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 18
Commonwealth of Massachusetts
�v Title 5 Official ln!;pection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.�� 69 Nobadeer Road
u
Property Address
Janet Weatherbe
Owner Owner's Name
information i e
required for every Centerville MA 02632 12-29-20
,
page.. City/Town State. Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):.
Materials of construction:
Dimensions
Depth of solids
Comments(note.condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Jun 06 2001 1131 AM HP Fax page 1
Commonwealth of Massachusetts
_ Title 5 official inspection Form
tSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Nobadeer Road _
Property Address
Janet Weatherbe
ner Owner's Name
rmation Is Centerville MA 02632 12-29-20
�Ired for every ----.--.-- —
e Cityfrown state Zip Code Date of Inspecdon
D. System Information (cont.)
14, Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, Including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1; Subsurface Sewage,Disposal System Form-Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Janet Weatherbe
Owner Owner's Name
information is required for every Centerville MA 02632 12-29-20
page. CitylTown State,` Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
Check cellar
Shallow wells
No 12'+
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record'_
If checked,date of design.plan reviewed: 8-5-83
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:
T.H. on Design plan 8-5-83 12'+ no G.W., Bottom of pit at 10`-below,grade. Bottom of.pit at 2' above
T.H. Depth..
s
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c Commonwealth of Massachusetts
,lip Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
69 Nobadeer Road
Property Address
Janet Weatherbe
Owner Owner's Name
information is required for every Centerville' MA _ 02632 12-29-20
pager QW`rown State Zip Code, Date of Inspection
E. Report Completeness Checklist
Pp p
Com lete all applicable sections of
this for
m inclusive
® A. Inspector Information: Complete all fields in this section.
B:Certification: Signed & Dated and 1, 2, 3, or 4 checked -
C.-inspection Summary:
1, 2; 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist),completed
®. D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of.Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage•Disposal System•.Page 18 of 18
Fee 7�
- .•-�
THE COMMONWEALTH OF MASSACHUSETTS Entered incompute
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation for Mispo8al 6pstem Construction permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System 2Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.u3-18-$9? ' l $
�a I UO r ,MoAze-&� i
Assessor's Map/Parcel � 1�}") '2e-rl�•2-� U 1(N'Q
Installer's Name,Address,and Tel.No. �rj(>���/—g � Design is d Name,Address, Tel.No.
no CIA- Aeseca� �-Xinsh`rsj 4-0,nk
Type of Building: //
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) a �S
Date last inspected:
Agreement:
The undersigned agrees to ensure the constructioaaintenanc afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Env' ee the system in operation until a Certi113117
Compliance has been issued by this B d ealth.Sign d __...Date 7
Application Approved by Date ;
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
No. �`—P� •'" ' � Fee ✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TQOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplication for Mis oral Opstem,Construction Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.(-a 7 I bbaJ ce r•fik-J- Owner's Name,Address,and Tel.No. /&-SS93 - /'_4-_Q5
Assessor's Map/Parcel ASO )�}
e r� ��v 11 1116U_1 X_ 1),2 L� �j or 5a r J or.
Installer's Name,Address,and Tel.No. 6-o �)�/-9 `3 Designer's Name,Address,and Tel.No.
,36r-+0 M C''c,rS+ri_)C� �1� c JIJf4 Ae.5eca..Q e hiro X,4s '�r11
L-/5-1.-rt a ki "l-," sAsU l
Type of Building: /r
Dwelling No.of Bedrooms/ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. 1
Description of Soil
jl
i
Nature of Repairs or Alterations(Answer when applicable) 1;�5p� K i s Q c P-404-e� AA k -
k �
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and mn can e)of the afore described on-site sewage disposal system in
accordance with the'provisions of Title 5 of the Environ 1 Code and n/ot to place the system in operation until a Certificate o
Compliance has been issued by this B�qd flealth.
Sign d Date
-Application Approved-by.- = Date _
a
Application Disapproved by Date f
for the following reasons
Permit No. l 1 ac_3( Date Issued
----------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
TIES IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Rep5ed(,)e) Upgraded
/ 6r ( )
Abandoned( )by � Ics�D 5 J-7 (f J/`(e_)n _� �-
at
-�e i0 12 has been constructed in accordance /
with the provisions of Title 5 and the for Disposal System Construction Permit Noc 17 ate. dated -2 13I J -7
Installer Abr 4-y/a(.Lt. { )r,5 f r } ;n r y Designer WA
#bedrooms Approved design flow gpd
The issuance of this permit sha111Jnot be construed as a guarantee that the system 11 funcfio)n as designed.
Date d 5 Inspector
---------------------------------------------------------------------------------------------------------------------------------------
No. j Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
i
Disposal 6pstem Construction Permit
Permission is hereby granted to o/nstructt ) /fRe air((�'} Upgrade( ) Abandon( )
System located at 6 / ALAI-7 e_1_417
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
�I
Provided:Construction must be c mplete within three years of the date of this p nnit.
Date �/ 3 � Approved by
Jul 07 2017 1326 HP Fax „ i page 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is Centerville MA 02632 6-29-17
required for every
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 1i}0 feet.Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
R
ET
cf�
33 0
Af A 3
�_ . -ilk
-y' �3 ,
tsinr.doc-rev.0/16 71iie 5 Offidd Inspection Foiar Subsurface Sewage Disposal System•Page IS of 17
f
o-
o�� Tti e Town of Barnstable Barnstable
Regulatory Services Department QUWWWcac j
BARN$'C'ABLE,
6 9. ,.� Public Health Division m
A
if°N4A� 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 /� Richard V.Scali,Director
FAX: 508-790-6304 /'T ( � �/ /Zt.f �� —Z Thomas A.McKean,CHO
Co e
m I .fie a
CERTIFIED MAIL#7015 1730 0001 4987 61612
July 31, 2017
DEVERY, MARIE,E
9 SANDALWOOD DR
CLIFTON PARK NY 12065-2700
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 69 Nobadeer Road, Hyannis,MA was inspected on
06/29/2017 by James D. Sears, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
0 Septic tank must be resealed.
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
AA—1
lomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditionally Passes Letters\69 Nobadeer Road Hyannis.doc
Town of Barnstable
0 ,�� Regulatory Services Department
Public Health Division
200 Main Street,Hyannis MA-02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A McKean,CHO
Feb 6, 2007
4 Rev. 5/11/16
DEADLINES TO'REPAIR FAILED.SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15,000) _
An`k"marked in the ❑is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑Discharge or ponding of effluent to the surface of the ground w .
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe:
❑Backup of sewage into the house due to an,overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution:box above outlet invert due to an overloaded or
clogged SAS or cesspool'
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑Any portion of the cesspool within a Zone.1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
q Single Cesspool'
y"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
o Leaching pit or cesspool with high liquid level,<12"below inlet (per Town Code
§360-9.1)
❑Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
QASEPTIMDEADLINES•TO REPAIR FAILED SYSTEMS.doc
r
,Jul 07 2017 1323 HP Fax page 1
Commonwealth of Massachusetts
Title 5 Official inspection Form
hml
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "'
i tiq
69 Nobadeer Road
;e
Property Address +JX,
X.
Marie Devery
Owner Canners Names
Information is "
required for every GerterAe MA 02632 6-29-17 cy'
page. CityfTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:when A General Information
filling
outout forms A.orms ��gtunrtrrpr
use only the tab 1. Inspector-,on the computer, �# SN OF aggss!.,��.
keyto move your
cursor-do not
James D.Sears �:' JAMES N
use the return — rn
key. Name of Inspector —'_t3 SEARS -+
Capewide Enterprises *'
_Q Company Name •, FRTyFti��p`T
153 Commercial Street ��i,F
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
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 6(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7-6-17
spector'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 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.
t5lna.doe•rev.W16 Title 5 Of9c121 Inspection Form:Subsurface Sewage Disposal System-Pege 1 of 1T
(7 S
L v
1
,Jul 07 .2017 13:23 HP Fax page 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is required for every Centerville MA 02632 6-29-17
page. City/row n 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:
❑ 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 c6teria not evaluated are
indicated below,
Comments:
Conn Pass-Tank Leaking. The system is a 1000 Gal. Tank D Box and pit.
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):
Tank leaking-Need to reseal tank.
1511ns.doc•rev.6116 Title 5.01fiaal Inspeclion Form:Subsurface Sewage Disposal System-Page 2 of 17
,Jul 07 .2017 1323 HP Fax page 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is Centerville MA 02632 6-29-17
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (coat.):
❑ 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 ❑ NO (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe($). The
system will pass inspection if(with approval of the Board of Health);
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (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
t5ftdoc-rev.5116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
,Jul 07 2017 13:23 HP Fax page 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is
required for every Centerville MA 02632 6-29-17
page. Cityfrown 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 a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
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
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in SupplM is less than 6" below invert or available volume is less
than Y day flow Pi?"
15ins.doc•rev.6116 Title 5 Official InepecUcn Form Subsurface Sewage Disposal System•Page 4 of 17
,Jul 07 2017 13:23 HP Fax page 5
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is required for every Centerville MA 02632 6-29-17
page. Cityfrown 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.
t5lns.doc-rev.6110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5of 17
,Jul 07 ,2017 1323 HP Fax page 6
_C\ Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is required for every Centerville MA 02632 6-29-17
page. Cityfrown 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 pant of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) 1310 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 16.203 (for example: 110 gpd x#of bedrooms): 330
15ins.doo•'ev.6116 Titles d In F •P f 17
Official spection Form;Subsurface Sewage Disposal System age 6 0
,Jul 07 ,2017 1324 HP Fax page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is Centerville MA 02632 6-29-17
required for every
page. Cityfrown State Zip Code. Date of Inspection
D. System Information
Description:
The system is a 1000 Gal Tank D Box and pit.
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
I� information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 2015-2,200Ga1's2016-3,000Gal's
Detail;
Sump pump? ❑ Yes ® No
NA
Last date of occupancy, Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatsJpersonslsq.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:
15ins.doc•rev.616 TKIe 5 Officie Inspection Form:Subsurface sewage Disposed System•Page 7 of 17
,Jul 07 2017 1324 HP Fax page 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
lug"
69 Nobadeer Road
Property Address
Marie Devery
Owner Owners Name
information is
required for every Centerville AAA 02632 6-29-17
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: NA
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)
❑ InnovativelAltemative 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 IIA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5imaoo-rev.616 Title 5 Official Inspection Form:Suhsurfaoe Sewage Disposal system-Pape 0 of 17
Jul 07 2017 1324 HP Fax page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is required for every Centerville MA 02632 6-29-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Approximate age of all components, date installed(if known)and source of information:
1983 Permit # 83-611.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 28
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.):
Peeing is 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: 17"rest
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: 1000 Gal. Precast H-10
Sludge depth:
3"
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
,Jul 07 ,2017 1324 HP Fax page 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
F
r 69 Nobadeer Road
Property Address
_Marie Devery
Owner Owners Name
information is required for every Centerville MA 02632 6-29-17
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 NA
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank leaking-level at 2' below cover.Tank and covers at 17" below grade. Inlet tee, outlet baffle.
Need to reseal tank.
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
15ina.cloc-rev.&16 Title 5 Official Inspection Form:Subsurface Sewape Disposal System-Page 10 of 17
Jul 07 2017 1325 HP Fax page 11
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
NOW
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information Is
required for every Centerville MA 02632 6-29-17
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
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5lns.doc•rev.6116 Title 5 Official Inspection Form:Stbsurface Sewage Disposal System•Page 11 of 17
Jul 07, 2017 1325 HP Fax page 12
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is required for every Centerville MA 02632 6-29-17
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.):
D Box is 16"xi T-33 below grade wlone line out, Box is clean and solid. No sign of over loading or
solid carry over.
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:
l5ins.doc•rev.6l16 Tille 5 Oft el Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Jul 07 2017 1325 HP Fax page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 69 Nobadeer Road
Property Address
Marie Dever
Owner Owner's Name
information is Centerville MA 02632 6-29-17
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cost.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ inn ovativelaiternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a precast pit w12'stone. Pit at 4' below grade w/cover at 18 Pit is dry w/clean like new
walls.
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.Aoc•rev.6/16 TAIe 5 official Inspection Forth:Subsurface Sewage Disposal system•Page 13 of 17
Jul 07, 2017 1326 HP Fax page 14
Commonwealth of Massachusetts
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Dever
Owner Owner's Name
information is Centerville MA 02632 6-29-17
required forevery
page. CitylTown 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
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.coc-rev.6116 7iNe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
.Jul 07. 2017 1326 HP Fax page .15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owners Name
information is Centerville MA 02632 6-29-17
required for every
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
F�
RvR 13
'I�cK
-� 33r
'6 VL
p-3= y�
13-3
t5ins.doc•rev.6J16 Title 5 Official Inspection Fotm:Subsurface Sewage Disposal System•Page 15 of 17 u
,Jul 07. 2017 13:26 HP Fax page 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is required for every Centerville MA 02632 6-29-17
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N�
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: 8-5-83
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:
T'H. on Design plan B-5-83 12'+ no G.W.. Bottom of pit around 10'below grade. Bottom of pit
around 2'aboveT.H. Depth.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins.doc-rev.W16 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 16 of 17
.,Jul 07. 2017 13:26 HP Fax page 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Nobadeer Road
Property Address
Marie Devery
Owner Owner's Name
information is required for every Centerville MA 02632 6-29-17
page. Cityrrown State Zip Code Date or 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.doc-rev.6/16 Title 5 Official Inspection Form!Subsurface Sewage Disposal System-Page 17 of 17
69
LOCATION SEWAGE PERMIT NO.
IXT 16 No i3fMKL
PILLAGE
INSTALLER'S NAME A ADDRESS
BUILDER OR OWNER `
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
a
70,
Y J�
� W
v�
W
Ivu.:d..,�..��1...... F�$...yQ.............
THE COMMONWEALTH '6F MASSACHUSETTS
BOAR® OF HEALTH
. .. oF.......
.................................
Applira#iaau for Disposal Warks Cn mitrurtion rprafit
Application is hereby made for a Permit to Construct ( -�or Repair ( } an Individual Sewage Disposal
System at:
........ ...... .
tt`Location•Aid-dress 1 , or Lotto. �y�
......................_._..._.til..Sr 7.......1..... A........................ �.� L�l� iG�X.:.....�C 4.� .t�.�C�...:f.[.�✓tom�e�%Irl
Owner Addres
a :............... 1 e2✓, .r.... lam.-- ........./- !1l2%ram........i!!!J��.S=..........................
,taller Address
g Size Lot_...-.. .* /......Sq. feet
U Type of Building �.®__
Dwelling—No. of Bedrooms.............. ........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures
W Design Flow__________________.5.4�...............gallons per person per day. Total daily flow---------------- ..............gallons.
WSeptic Tank—Liquid capacity_/ gallons Length__'t W... Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
� Diameter Depth below inlet_....'........ Total leaching area25'/-:.�.�sq. ft.Seepage Pit No........_�---____-- ,f - p
Z Other Distribution box (eT IDosing-tank ( ),,``
Percolation Test Results Performed by..A✓!.- .t �� �- Z-
1 1_ � ��Date._....J ¢ 8, ............
P19..�Y Test Pit No. 1.....eC Z...minutes per inch Depth of Test Pit------- _..___ Depth to ground water---- d _�.....
fro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P41 ..........-•-•••••-•••......•-------•-•----•-••j---------•---• -----------------•--....-_......................
O Description of Soil _ TAP ..................
Cj -•--•-----•---------------•---------------••-•-•-•------'. �� �Z� �A/1.5� _. �s-s!Yfrt/ _leY—
W
x •---•••-••-•-•-------•-•------•••-------•----••-•-----•-------------••--••••-•-•----------•-------•----•-•-•----••••••--•---------------••-----••••--•••---•------•-•-•-•-••••......•-•••-----•---......
U Nature 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 iITI 5 of the State Sanitary Code— The dersigned further agrees not to place the system in
operation until a Certificate of Compliance has be i ed by e of health.
igne ------------••-------•------.---•-
. e
Application Approved By ---•• - ..... .-...-•--...... ................•......---_..
........................... Date
Application Disapproved or he following reasons-----------------------------•---=----------------------------------•-----------------••••---•-••--.....---------
--------------------------••---•----•-•--•••.;-•-•----••-•••--------••--••------•......--....••-----••-•-...••-••.....••-••--•-••----------------------••......--•-••••-•-•-----••••-•------•-----.._.._.
Date
PermitNo......................................................... Issued.......................................................
1
No. ............./.. .. c
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
m-. .. .........OF...... P/ .................................
. pplirFation for Elhipas ai Works Tontitrurtion rumit
Application is hereby made for a Permit to Construct (✓f or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address
n Lot o.
......................_. /..rG./-5t....•..--•............. 7!�f' r?C .. or....
// Owner // ddre
a --••....................... lK -•-•. ? .a-T/'•--. •-- -• y � G..S =
(� taller
Address
UType of Building Size Lot...ZD..g /.....Sq. feet
Dwelling—No. of Bedrooms.............. .........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............... No. of persons............................ Showers
a YP g ------------- ( ) — Cafeteria ( )
Other fixtures ........................................................... .._._....
w Design Flow.................. _..__._........gallons per person per ay. Total daily flow................ ...............gallons.
WSeptic Tank—Liquid capacity_Igallons Length_✓` ,_.. Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-._.--------_-------sq. ft.
Seepage Pit No........./_---------- Diameter....../---'...... Depth below inlet.....5......... Total leaching area;Z5_S-'?..,..sq. ft.
Z Other Distribution box (vol Dosing tank ( ) �)
aPercolation Test Results Performed by..(,3�-u� _ f�'IC�U �4��a Date......5/¢ s?7............
P/fSS' Test Pit No. 1.:_-4.Z...minutes per inch Depth of Test Pit......./2._..... Depth to ground water-__No
44 Test Pit No. 2....:..........minutes per inch Depth of Test Pit.................... Depth to ground water----------------........
Ra ------------------------------------------- ............... ...
.--------•------;---------------------------------------------- ........
O Description of Soil............................ -- Z----- ..Su,� of i.., _-_, _._ 1�? � ..................
0 Nature 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 T.IT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
igned"'----------------------------------------------------------•----.....----.._.....-- ......... ...... ---...----
Date
Application Approved By_ --...--•-----------------------•----•---•------•----.....------•----•- ._ri/'
l
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------------•-- ---•--...._.._...
----------------•--------.....-----•--•-----•------------•-------•-----------------...---------•------------•-•--------------•---•-•------------------------...........................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF................................................I...................................
�rrtifiratle of (1untpli�anrr
THIS I �f RTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
••-
/& ay
has been installed in accordance with the provisions of TI T. j/°�f The State Sanitare•cribed in the
application for Disposal Works Construction Permit No.. ''"v� ________________ dated_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU A GUARANTEE THAT THE
SYSTEM WI UNCTION SATISFACTORY.
DATE...f/.A1.---•--•-•------•---•-••-..........•-•-••-•-----•---•--- Inspector-------- ----- •-------------------••-•-•----------------------...-••-•-•-•--•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.....................................................................................
No.--•..................... FEE........................
i �raaa as Qlaanotrnrfian Vir ntit
Permission is reby grant G �. : .1:,, ..... ........................:�?----- ------ ....................................................
o to Construct r Repa' ( ''an IndivK, age isposal S.
at No.. . .
Street O�K
as shown on the application for Disposal Works Construction Permit No................ . ted._ _._._........_.
f fop -------- --- --------------••-----------••-------------•-•--••--..----
..0 /! / ? and of Health
DATE -------- ; --•---------- ................
i
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
12/28/2020 ShowAsbuilt(1700x2800)
LOCATION b9 �I1�a �. SEWAGE PERMIT NO.
LbT 16 No I/
VILLAGE �d
INSTALLER'S //✓✓NAME fA�7ADDRESS
K• h'iCK�S
GUILDER OR OWNER
x
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
Gam-
q et / o
3
https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=250147&sq=1 1/2
S/TE PL A N T YPICAL PROFIL E
SCALE — l " = .' ' F L. E- L NOT TO SCALE
/8"S TD. L T WG T C.I. MH CO VER
y 4 C.I. PIPE _-_ 4"BlT FIBER PIPE TIGHT ✓DINTS
---�, FLOW LINEW44
OUTLET LEVEL
__ TO FIRST JO-L INT
DWEL LING , o /�; - --/4 C-1. TEEC/. TEESTANDARD PRECAST — --
�5 CONCRE TE I:°L GALL ON
-,------ L —A SEPTIC TANK DISTRIBUTION BOX
8 TO BE INS TA L ED ON
LEVEL , STABLF BASE
SEPTIC TANK
TO BE INSTALLED ON
LEVEL , STABLE BASE
Al/ S o
I� 4
2"- 1/8" TO //2 " WA SHED PEA 5TONF_
ouT 150
, pIA. �2 �
L L E� � ALL AROUND FREE OF IRONS FINES LEACHING P/T
TO y , ��PT� # DAAV_r--ILL J AND DUST IN PLACE _ BASE TO BE LEVEL
BRICK 8 MORTAR COURES
M.&T e0g , L- _ Q' AS REOUIRED TO BRING 314" TO I -l/2' WASHED CRUSHED
�T D P$4 EG`4 a�T STONE ALL AROUND FREE OF
COVER r0 GRADE 24„C.I. MH COVER
c.0 uG I c5c 6, AND FRAME AL , ---- —�\ \ IRONS, FINES AND DUST /N PLACE
T4„ - 4 -INLET 8 FLOW LINE- - - LEACH/NG Pl T SEC TION-
_ _ _ _ _ _ _ __
PIPE
� � I. CONCRETE TO BE 4000 PSI 28 DAYS
K t7w L
� EL �� I -T„ 2. REINFORCED vV!TH 6'' x 6" N0 6 GA W.W.M.
H —jo 3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREATER
14 i� ,Q � - I DEPTH REQUIREMENTS
�41 OPENING WITH 4-1/8" 4 NUMBER OF PITS REQUIRED D u E
OUTER DIAMETER 6 NOTE EXCAVATE TO ELEVATION �I.o OR LOWER AS
Ql /-314' INSIDE DIAMETER
L.-O'T 10 3"
REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH
G Z0,44 ► `'f m PIT REPLACE EXCAVATED MATERIAL WITH CLEAN
GRAVEL TO DESIGNED GRADE
4' O" -- - �--�---- -
MIN.
i EFFECTIVE DIAMETER
-_ (NOT TO EXCEED 3 TIMES EFf ECT/VE DEPTH)
WA TER TABLE - - I v Go
-----
;�; C !-1 F_ E XJ o U kJ 7 G; tz F_ U)
C.F-k; Lw E5titT
SO/L 4 ND tlEFC. 0AT,4 GENERAL NOTES
PERC. RATE MIN /IN . NO HEAVY EQUIPMENT TO RUN OVER SYSTEM
1 TEST BY SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD
1 : _ _ _ � v _
1 PRECAST REINFORCED CONCRETE UNITS
til [2 tj A L2 tj-�_ ( t1. G� /�� rj WITNESSED BY ' ' �' _- a', 4 ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
50 l,U A I-f TEST PIT GR EL.: DATE :
TO REVISED TITLE 5 OF THE STATE EN\IRONMENTAL CODE ,
/ _
--- MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF
TEST P!T NO. 1 P/9!+" TEST PIT NO 2 SANITARY SEWAGE EFFECTIVE I JULY 1977.
- -- ___ --� ANY CHANGES TO THIS PLAN MUST BE APPROVED Bi THE
BOARD OF HEALTH.
r-i.kjE_e-).__. AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE
BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
L, tiJ D Gt 2AV eLL PITCH ALL SEWER LINES 1 /4'' ; FT. UNLESS INDICATED
OTHERWISE.
U
DESIGN DAT4
BEDROOMS _ -- DISPOSAL N U rJ c-
EST. TOTAL DAILY EFF. _'' _GALS.
L EGEND - SEPTIC TANK I o'O E GAL
SIDEWAi_L AREA _ �"2 GAL./SQ FT.
BOTTOM AREA _-_ I ' � GAL./SQ. FT.
LEACHIN;� REQUIRED
Ox00 EXISTING GRADE 1o�• y SO FT SEWAGE DISPOSAL SYSTEM
-
ZONE ___~___ ____- �..p. 00 FINISHED GRADE ACTUAL '_EACHING AREA �St 'C�< SOFT FOR
T
DOMESTIC WATER SOURCE- 7 v I'--' tiJ \til a t� o . 00� INVERT ELEVATION i f2. L.)
L
i'.��� t J o 13
l G. 4 0 5 cj 2 - --- PROPERTY LINE ,�r �Kh D r. �°$' G f2 4,.1 T r2 V I t2 L. t; t
A � A-/ `�T A
PLAN REFERENCE : !" �*�--
. - -- ---- MEAN HI WATER ^! \HIGH A ER ; i �. �, q .et N. SCALE' AS INDICATED DATE :
BENCH MARK DATUM: __ L.) `:) 60 T o Wy _ � � � � MARSH WM M WQRW/CK & ASSOCIAT
ES
t L.f>v D ,'. l N ` k A A -Z A � L-, '� , BOX 801 - NORTH FALMOUTH
f:
IV/SSACHUSE T T 02556
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