HomeMy WebLinkAbout0074 NOBADEER ROAD - Health 74 Nobadeer Road
rA.=250-130 Hyannis
y
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TOWN OF BARNSTABLE
LOCATION 7 A/6601.0,,,\( SEWAGE# aIO 13 "q-1 0
VILLAGE �r 1 S ASSESSOR'S MAP&_PARCEL o�S 6
INSTALLER' I A� E&PHONENO. CO.
SEPTIC TANK CAPACITY a b w 7-7 g 77
LEACHING FACILITY:(type) L- L
NO.OF BEDROOMS JA_
OWNER ODD KARO uS
PERMIT DATE: l )L aO J'3 COMPLIANCE DATE: /-', " Y- 3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY eg6W(Dli 6X)_CW Jl5� (,Ce_
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: .,•C , TOWN OF BARNSTABLE Pool
LOCATION_ A/Q%D&A P� SEWAGE #
dILLAGE ASSESSOR'S MAP & LOT /.3
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY 1006
LEACHING FACILITY:(type) 6® L,L-44 f 1-A4-flGfl(size) ")Ca "
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER JDL.IL— A0-56
DATE PERMIT ISSUED: 3 g
DATE COMPLIANCE ISSUED: w 1 7..
VARIANCE-GRANTED: Yes No. - +
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No. `•` -� �.�� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Migogaf *pgtem Cow6truction 30ermit
Application for a Permit to Construct( )Repair(IL/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.7q ) DQA®k:6A PO: Owner's Name,Address and Tel.No.j�4_
Assessor's Map/Parcel 0 / 6J �/1�1 U _ocl0
Installer's Name,Address,and Tel.No.<Q WN RWfT& Designer's Name,Address and Tel.No.
9.0TR,64-W Qk MA05lw6/nt LLS
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 33o gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank _, ® Type of S.A.S. &14,64q4 K
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of T' e 5 of1,A9Enviro mental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue this of '1 h.
Signed Date ) GCJ
Application Approved by £ ,_- Date
Application Disapproved for the following reasons
Permit No. Date Issued 3—zrl-P
No.
.. is. Fee e V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
/ Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
1
01ppfication'for Mi5pogal *pgtem (Construction permit
Application for a Permit to Construct( )Repair(Upgrade,( )Abandon( ) El Complete System El Individual Components
t .rf Location Address or Lot No. QA(r}� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel Z �� G �/� r ! •�
Installer's Name,Address,and Tel.No. 4�1p(/ Designer's Name,Address and Tel.No.
P.0 TR& i6P U2 MA45FOA5/1 LLe,
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank tap Type of S A SJ
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of T e 5 of Enviropmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue his d of h.
Signed Date
Application Approved by f Date
Application Disapproved for the following reasons
Permit No. 9 —l7 Date Issued 3- Z C'-�9
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance {
THIS IS TO CERTIFY, that the O site, wage Disposal System Constructed ( )Repaired X)Upgraded ( )
Abandoned( )by
at a c_.e-_ 7 1 hasbeen constructed in accordance.
with the provisions of Title 5 and the for Disposal System Construction Permit No. ,7" (v/ dated z Q -91'
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date �_h ....21 V Inspector \ —,
u
01
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS.
igogaY *p.5tem Con!gtruction Vermit
Permission is hereby granteed/to Construct( )Repair( ))UT grade+( )Aba don( )
System located at "7' ���h a C��- r'�`/ /�
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this t
Date: Approved by
W ,
OJ9A7
NO
TICE: This.FOr1 11 1.i Is To Be U 11 sed F 1.or the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I , hereby certify that the application for disposal works }
construction permit signed by me dated
concerning the
meets all of the
property located at
following criteria:
e There are no wetlands located within 100 feet of the proposed leaching facility f
i
e There are no private wells within 150 feet of the proposed septic system
e There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
e If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will DDI be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division O.I.S.map) __
B Observed Groundwater Table Elevation(according to Health Division well ma J�
SIGNED: DATE:
LICENSED SEPTIC SYST INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also If the licensed Installer posesses a eertlfled plot playa,
this plan should be submitted].
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L �)CATION SEWAGE PERMIT NO.
�-1nT 801
AVA
INSTALLER'S NAME & ADDRESS
0 U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED j�. y®X0,
GJ �`'
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FID
No...03... r..... Fps........ .................
THV COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEALTH
OF...-. .-. 1��N--....-.. .....................................
ApplirFa#ion for UWpooaal Workii muitrurtioaa tIrrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: r.
ation-A r s
.....-----..�-�—... �- 1:........:...........c..
Owner �� Address
-----------------------------------------------------------------------------------------
Installer Address
d Type of Building Size Lilt_...........................Sq. feet
V Dwelling—No. of Bedrooms_________________�•-. ..-----_._.._Expansion Attic ( ) garbage Grinder
a �
A4 Other—Type of Building ____________________________ No. of persons---------------------------- Show6 (� ) —'Cafeteria ( )
Otherfixtures ----- -----......................................................................................�'......................................
Design Flow.......................... _ _______ allons .per person per day. Total daily flow...-_._______. •0- gal
w �-- - � ��_ -------------- Ions.
WSeptic Tank—Liquid capacity j� llons Length____-.__' _.. Width................ Diameter---------------- Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area_----_._____._.__._.sq. ft.
Seepage Pit No---------- --------- Diameter_.,- `-li Depth below inlet........ Total leaching area.�l_ q. ft.
Z Other Distribution box ( ) Dosing tank
a Percolation Test Results Performed by......WI/ .Y L'( ..___ �` _ __________________ Date._. �________...
OF
Test Pit No. 1_42. minutes per inch Depth of Test Pit.....1_2._.-__. Depth to ground water----- .yam '
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------------------------------------------------------------------------------------------------------------------------------•---•--.........._----
0 Description of Soil....................................................................................................-------------.....................................................
x
w
V 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 TITLE 5 of the State Sanitary Code— The a der signed further agrees not to place the system in
operation until a Certificate of Compliance has bee s b t b of health.
Signed �.. --------------•-
- l ,C
Date
ApplicationApproved By..................................................................................................
Date
Application Disapproved for the following reasons---------------•___-.._.._--•____-_--._._._-___-___--__••----____•_-•_-_-___•________.___._____.___....._--____--
-------------------------•----•-------•------•-------•--•----...----•---•-------------••--...-----=--------••••--...•-•--•-•--•---------=---•----••---•-----•--------•••-•-----•-----•--•-•-------------
Date
PermitNo......................................................... Issued........................................................
Date
No................_....... ..............................
THE COMMONWEALTH OF MASSACHUSETTS
Y BOARD OF HEALTH
............ ................._OF...............................--------------------....
Appliration for DiipouFal Worse Tonitrnrtion ami#
Application is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal
System at
........, ..........r...l•......- t1.`....... ....... < P� ..................
� ..1 . /'�
__ocation-Ad ss, r Lot o.
- • r:_�.7...1.':........................ °. ?: `'r✓' �-- ��`/�
i Owner Address
Installer
r ---------------------------------------------Add----ress-------------------! .
�
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms__________________..___.______._.._.Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Otherfixtures. ---------------------------------------------------------------------------------------------------•••••----------•••---
Desi Design Flow ___._ ._.. allons per person per day. Total dail flow..___.______._
W g . P P �1?.. .. Y � gallons.
WSeptic Tank—Liquid capacity_[_49.� ]ions Length___2f___ Width................ Diameter-..........._--- Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................•sq. ft.
Seepage Pit No----------/--------- Diameter___/. "_f Depth below inlet___...5...._. Total leaching area7_5/_51� ft.
Z Other Distribution box ( ) Dosing tank )
Ii • � R
Percolation Test Results Performed by-_____ �✓ .. . 1! '':1`__ __._ �j.�I__________________ Date.... ....______.._.
aTest Pit No. 1__4�minutes per inch Depth of Test Pit...... .r __'___ Depth to ground water...... � f
Gi, Test Pit No. 2..........._....minutes per inch Depth of Test Pit.................... Depth to ground water........................
...............-.................................................................
•••......
......
----------------
_---------
•------------------------
.0 Description of Soil........................................................................................................................................................................
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 TITLL 5 of the State Sanitary Code—The u ersigned further agrees not to place the system in
` operation until a Certificate of Compliance has been s b t b of health.
Signed-------- -- .......................................... ,A'
Date
ApplicationApproved By.................................................................................................. ------------ ..................
•----• aa+1°' Date
Application Disapproved for the following reasons: =="=----------- ................
Date
PermitNo........................................................ Issued.................................................-......
Date
THE COMMONWEALTH OF MASSACHUSETTS =
BOARD OF HEALTH
...........:.....Vt�4 .OF........;r� ^, `' ::f '.. ...............................
Trrtif iratr of TompliFatta
THIS IS TO CERTI5Y, ,That thhe Ip�di�ual Sewage Disposal System constructed ,,)"or Repaired ( )
by = s .. ------------------- -- -......._..-----....._._..._...--•---------•--
` - Install •--.•....+
�, e Install
at......... ,*�K:-_......................................., e.�. ,J -fit?'.. '".` --------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___JV.3-:40_/______________ da.ted............. ,./4,`16;;,?,t_.._____._._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WIL�; V17
SATISFACTORY.
DATE...... ......... Inspector__
J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 07 HEALTH
f
�7 -�t�J ... ........... .........OF..-.-.--. 4: x_..__.!cf"�Cr.__......_..._...._..........._..
No.---•.......:............ FEE.._.........--•---_.....
Uiupu�Fal orhu tun rani
Permission is hereby granted_____________ .:•_..`:.__.___._ _______._ ............................
to Construc ( ) or Repair ( an Indivi.ual S wage Disposa' gystem
at No...- � ` � .��.e .. f -==--..� t :7 C' ,-------------•---.-.-..------------------------
- -
Street
as shown on the appli ion for Disposal Works Construction Permit N�o.._ ._c ___ Dated_ r
--- -j:C_=............
LBooard of Hea tY-ry�
DATE..... _.__ .. .............................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
i
No,DQQ "20 Fee /� V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for Misposar 6pstrm Construction 3permit
Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System [,'Individual Components
Location Address or Lot No.74 NOBRDEER RD, C&4rEPW l lie Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel Lit Pmiv� OF Ptnes AR Ceix"itie %j\N ®Zto 3 2.
Installer's Name,Address,and Tel.No.3'019"t)) -88.11 Designer's Name,Address,and Tel.No.
e;4�w��e. Cry{c.P�R�scS t.t_c,
i S3 Gcxr►rr�e �L Si- /►7AO?ec, #I* . 02AOL
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) AI w Lin e %rovrl /PJt90 (piq Ltv/Y %�1Jk 70
Ne`w b dox 4Nt -^4(E 1 Line %ro1Y, a 13ox To Le4cm hr
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of tLpalth.
-93
igne Date I "1"�®l
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 3 Date Issued `� _
No: _)0 13 Fee / y
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: w
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for Misposai 6pstem Construction permit
Application for a Permit to Construct( ) Repair()() Upgrade( ) Abandon( ) ❑Complete System ['Individual Components
Location Address or Lot No.74 N0661>Ee A RD. CC-NM.",J I IIC Owner's Name,Address,and Tel.No.
��tq��S1l N• MNLws
Assessor'sMap/Parcel- o2sn//39 41 F'vinr OF �iht_& h-R Cewkwjjtle tMp% 02(o31>
Installer's Name,Address,and Tel.No.Sob-If)) -S8'Jl Designer's Name,Address,and Tel.No.
C�J"c w�0� C�n�c�"e1�"scS l.•l.C,
53 cc�nme✓°crriL Si- MASIIPer_ mt. O�Z-64 N
TI pe 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) /%I tc w e t"a %•rorrt /,0(50` 4[t vnt %'9Nl M
_/eL—) l>- ecx 4/YtJ nlLEW Ctne /'role p 130X TO Lc4tl/ PIT•
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of e th.
igne Date -aZ
Application Approved by Date
Application Disapproved by Date
for the following reasons
k
Permit No. �,C) --G� 70 Date Issued
-------------------------------------
\ \ _ TIC E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( )
Abandoned( )by
at 7 4 N o p14 b ei:�R e"v rl✓ttj 111 t has been constructed in accordance l
with the provisions of Title 5 and the for Disposal System Construction Permit No. 1 3 Ll 7 a dated •a c`� ( r`} `�
Installer L C e- Designer WA i
#bedrooms Approved design flow 1y gpd'
The issuance of this permit sha l ndt a construed as a guarantee that the syste H ncti6Cn'�s designed.
Date / Inspecto --
-----------------------------------------------------------------------------------------------------------------------------------)-------
No. ��� 3 —�l � b Fee / � V '
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction 3permit
Permission is hereby granted to Construct( ) Repair(k) Upgrade( ) Abandon( )
System located at :q /40t3ADe.1=Q_ P,6. 07-6,32
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be compl ted within three years of the date of this permit.
Date a ) + Approv`d-by_
I�
Comm
onwealit of Mass a o setts
Title
Subsurface Sewage Dtsposai.�yster�a (Forte blot for Uoiuntary Asses srTrents
v 74 Nabadeer Rd .. _ .
_ Property A4d ress _.
Todd IViarcus ...:. ....�.
Owner : Owners Name
information is 6a 02632 : 12,14/2013
Centerville ....._.,
T
required:for every -
Pa9e City(rown p State, Zip Code Uate ofi irSspeetifln
Inspection results must ire s bmitted on this form..irt ect€ n<forli�s,may not be atti�r� i any
uv�y;I?teas see co idt nes chec fist at;the end of the fors.
Important hen..:- n Ctfa orm',cal, Ii
filfin out forms::
on'the computer;
use only the tab 1 InSpeGtaf:,
key to rriove your
(�/II
curso,c .rho not,. Sean t�. Janes —V ._ —
_
use the return :: =Name aflnspecfor
key
Capewide Entr�rlses — -__ _ _ _ _�
Company ldan€e
153`C.ammerclal St
reZrn Dash ee lea 026�t9 _
— .__— .�.. ..
—_
C�#ylTo�rn State Zip Code
8
548-477 8877 -- —
......
.:_
� 4522
Telephone;Nun bei License N&nber
_ ..
. ..
_ .._
_
_ .. __ _
........ . __ _ _
P.
I certify that I have personally Ri�spected the,sewoge disposal systerrz at this address.and that the
inforrr3atlian reported below i5 true, accurat .and caraplete;as of the fi rrre®f the inspection.The inspection
was par#ornied based on my training and:experience.in the pro pet function and rriainteriance of an site
seut!a a dis asal:s .stet s I a a.D app 0 s ste in pe for. ac�irsuant iYb ectican �5 3�Q f
. 9. p y
T tp�5(3 0 C R SD Qp.The system
Passes. ❑ i�riditionally Lasses ❑ Fails
❑ Needs Further Evaluation by the Local Apgraving Authority.
121412013
RnspectorsSignature Date _
The system inspector shaft subrr it a copy of tt s.ir�spectit n report to the Approving Authority{Board
_: of Health.rr DEP) ltliin 30 dr oflrleting this inpecion. 6f the system is a sriared'system or,
has,a:design flaw o#,1(}',000 god.or greater,.the inspector and the,system owner shall submit the
report to the apprrpriat regional of#ice of tiie DEP..Tie arigital shoutd be sent to the system owner
:copi s;sent to:the buyer, if appiicable, and'th approving atuhi?rity.
*Tha repoift nt escri es c€iitditi�ae at the tide df ins action and der the con iitions f apse
�t:that 4ii .This.ireseir�ra,stes t ® address hew-the systPm
: ii! poor in the#utur�: under
Ahe sam I Do r different don etio s'of lase:
i�bl
t5ms••3113 ... Tide 5 Official Inspection En ubsurfiace SewagsUispasal5ysdem•Paga`1.of 1? :
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 74 Nobadeer Rd Centerville is served by a Title V septic system consisting of
a 1000 gallon septic tank, new distribution box installed 12/4/2013, permit#2013-470, a 60'x4'x2'
leaching trench and a 1000 gallon leach pit. The system was found to be in proper working condition
at the time of inspection.
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):
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 74 Nobadeer Rd.
M
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
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 level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
74 Nobadeer Rd.
f Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. CitylTown 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 cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. Cityrrown 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.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ . Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
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 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 5
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
2013— 19,500 cu. Ft. &2012— 13,500 cu. Ft.
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 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:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Nobadeer Rd.
M
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. City/Town 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: 1000
gallons
How was quantity pumped determined?
Reason for pumping: to replace distribution box
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Z Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 '
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
original system installed 12/20/1983, leach trench added 1998, distribution box replaced 12/4/2013
S
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
Joint were ok, no leaks, vented through the roof
Septic Tank (locate on site plan):
Depth below grade: 10"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1000 gallons
Dimensions: -
Sludge depth: ---
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c,M 74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is Centerville Ma 02632 12/4/2013
required for every
page. CitylTown 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
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 was cleaned at inspection and should be done again every 2 years for proper maintenance.
outlet baffle intact, tank was not leaking and was structurally sound
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete . ❑ metal _ ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Nobadeer Rd.
M
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
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
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
0"
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.):
Distribution box was replaced for this inspection, permit#2013-470
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:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Nobadeer Rd.
Property Address
Todd Marcus'
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. Cityrrown . i State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1x1000 gals
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1 60'x4'x2'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was found to be dry at the time of inspection with no sign of past hydraulic overloading.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is Centerville Ma 02632 12/4/2013
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
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
C.omrxaonwe ft of Maescichusetts..
w
Subsurfpce Se aga:DJ;� at_yste cant t�otjfor\lcaksantary 4ssessrnents
a
743obader Rd.
_.: _ - __
Property Address
Todd Marcus,
_.
Owner &wne'r's"Maine
information is ( 02632 12�412013
y Centerville
required for.ever
gage.. Ctty!Town S#ate Zip Code rya#e of inspecfion'
a< r II .c )
Sketch C}f et age D,tsposal-Systerr� P Wide a uie of the sewa e;disposaI-systerti, including ties to
at leasfi#vuc�perrrianerit referenoe.lai�tlr' k.s i ar benchmarks.. o to all welds Within 00 6et:Locate
Where public water supply{enters the building. Check one of the baxes.be#o :
® :hand-sketch in the area;belowr
❑ drawing attached separately.
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15ins 3/13. Tide 6 Official Inspection Form:Subsurface Sevrage Dispossi System•Page]:5 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design pla t ns on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
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
;M 74 Nobadeer Rd.
Property Address
Todd Marcus
Owner Owner's Name
information is required for every Centerville Ma 02632 12/4/2013
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information— Estimated depth to high groundwater
E 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