HomeMy WebLinkAbout0180 EBENEZER ROAD - Health i 180 Ebenezer Road
Osterville F/R
A - 146 079
I�' a
Commonwealth of Massachusetts
_ . Title 5 Official Inspection Form �®
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessment
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 2013
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted bn this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: (�
key to move your
cursor-do not David B. Mason
use the return Name of Inspector
key.
David Mason
Company
Name
4 Glacier Path
Company Address
East Sandwich MA 02537
City/Town State Zip Code
508-367-1617 S1287
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 ntenanceof o e
CA
sewage disposal systems. I am a DEP approved system inspector pursuant�o ection 1'5.340
Title 5(310 CMR 15.000). The system: ,
® Passes ❑ Conditionally Passes ❑ fail' °
❑ Needs Further Evaluation by the Local Approving Authority ?
October 2, 2013
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the -
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
10
t5ins•11/10 Title 5 Official InspeMc.
Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This inspection information represents the condition of the system on October 2, 2013 at Noon and
only that date and time nor does the inspection guarentee the future operation of the system.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 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
�M 180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health).-
0 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
4 W Title 5 official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of 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•11/10 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
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 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•11/10 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
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 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
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2012; 92,000 gallons and 2011; 50,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per d
P Y(9P )
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Vol'untary Assessments
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is Osterville MA 02655 October 2 2013
required for every ,
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: Board of Health
Was system pumped as part of the inspection? ❑ Yes ®_ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osteryille MA 02655 October 2, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
June 30, 1977
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 25"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Observable components appear in working condition
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons typical
Sludge depth:
4"
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5- Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 180 Ebenezer Road
Property Address. .
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 2013
page. Citylrown 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
38"
Scum thickness
2°
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Scour Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Observable components appear adequte for the age of the tank. Effluent level with outlet invert
i
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 2013
page. Cityrrown 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 Level with 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 collapsed and replaced by Jim LeBoeuf Septic with new H2O Distribution Box
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 2013
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 gal
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
2 500 Gallon pre-cast chambers have never received effluent and are basically brand new because of
damaged distribution box diverting effluent elsewhere.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 2013
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.):
J
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is Osterville MA 02655 October 2 2013
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
l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
TOWN OF BARNSTABLE
LOCATION �`� �J�t���.� r'�'Q SEWAGE#
VILLAGE O T ASSESSOR'S MAP& PARCEL/�6— O 79
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(rype ���'T�/6 ��C'��A'i(size) '°'"' '' �3
NO.OF BEDROOMS J—a -4,e"
OWNER C,IL L A ov
PERMIT DATE: — 3—/,I COMPLIANCE DATE:
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is required for every Osterville MA 02655 October 2, 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: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Ground water contour map
® Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
gourndwater contour map and septic designs in the area
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Ebenezer Road
Property Address
Carmen Anglero and Wison Callan
Owner Owner's Name
information is
required for every Osterville MA 02655 October 2, 2013
page. CityTTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. g`,' � l Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes V
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Nplication for Disposal *pstrm Construction permit
Application for a Permit to Construct( ) Repair(1� Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No/c?o t �e�i�at`Z d-4ZT o Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel /y —' ��� � ���� C�����oZ 011 �7�y
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
;77j 0707
Type of Building:
Dwelling No.of Bedrooms -_7 Lot Size sq..8. Garbage Grinder( )
Other Type of Building 6 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) vided gpd
Plan Date ��Number
Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations Answer when applicable) GVd'D°1/44_� Z�� .FD��'�
P ( PP
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 alth.
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued ��
nn 2 �
No. d / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0[pplicatlon for Misposal 6pstem Construction Permit,
a
Application for a Permit to Construct( ) Repair(Repair(k Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No.
CPo ,Z EoT ,0 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel �� 6' of `''V ���j1Gl-_
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
7y1— oyoy
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building A*P'c0_1' No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) d Desi provided gpd
Plan Date Number of s Revision Date
Title
I
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
'I
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and mainienance 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 H alth.
Signed Date AV
Application Approved biy Date
Application Disapproved by Date
for the following reasons
1 2 l Permit No. �f<7 ?ee Date Issued /6— 3 — /-3
TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by `4//V
at o E �E�E Z eX O—P b has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.d0 3 e 3 8? dated
Installer Designer
#bedrooms Approved desi n flow �(i PTi.• "�� gpd
The issuance of this permit hall of be construed as a guarantee that the system ill ctioR asd/e'§i ed.
Date Inspector
r /✓ �``� ,
No. a d/ 3 — 3 k b Fee THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal Qipstem ConstCUttion permit
Permission is hereby granted to Construct( ) Repair(.44r Upgrade( ) Abandon( )
System located at C.>a �'G`l�Gr
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 b completed within three years of the date of this permit
1
Date o Approved by
TOWN OF BARNSTABLE
LOCATION --"00 -Z dW 40 SEWAGE#
VILLAGE ®�'� ASSESSOR'S MAP.&PARCEL-'50-6-- 0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type),41W ,7VX r ZS�4,cll size
NO.OF BEDROOMS 3 �F 'L�,r�'�6'®
OWNER c�IZ Z A
PERMIT DATE: �o e —� COMPLIANCE DATE:
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 ori'
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
�- L7.3
a
FAILED INSPECTION
COMMONWEALTH OF MASSACHUSETTS P CEL ' ®� 9, l
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I
DEPARTMENT OF ENVIRONMENTAL PROTE N
COP)
^ y
A
C t
vh
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLliNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 180 EBENEZER RD.OSTERVILLE,MA 02655
Owner's Name: MR.CARgQEENA
Owner's Address: 180 EBENEZER RD.OSTERVILLE,MA 02655' ������
Date of Inspection: 6/2/03JUL Q 12003
Name of Inspector: (please print) JOHN GRACI,INC. TOWN OF BARNSTABLE
Company Name: SEPTIC INSPECTIONS HEALTH DEPT.
P Y
Mailing Address: P.O.BOX 2119 TEATICKET,NIA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this addres-and at the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_ Passes
_ Conditionally Passes
_ Needs Fu11,
valuation by the Local Approving Authority'
X Fails
Inspector's Signature: Date: 6/2/03
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM FAILED TITLE V INSPECTION.LEACH PIT IS FULL UP TO PIPE AND HAS NO EFFECTIVE LEACHING
LEFT IN IT.
****This report only describes conditions at the time of inspection and undo;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.
Title 5 tnenFrtinn 1-orm rli5/?nnn 1
Page 2 of 11
OFFICIAL IN FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 180 EBENEZER RD. OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM FAILED TITLE V INSPECTION.LEACH PIT IS FULL UP TO PIPE AND HAS NO EFFECTIVE
LEACHING LEFT IN IT.
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain.
n/a 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.
ND explain: n/a
n/a 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
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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
_obstruction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 180 EBENEZER RD. OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
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
2. the Board
System will fail unless y e oa d 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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility 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:
n/a
Z
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 180 EBENEZER RD.OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped n1a.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility 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.]
YES (Yes/No)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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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.
A
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 180 EBENEZER RD.OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
Check if the following have been done.You must indicate "yes" or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site
X _ 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?
X _ 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:
Yes no
X _ Existing information.For example,a plan at the Board of Health.
X _ 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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,SYSTEM INFORMATION.
Property Address: 180 EBENEZER RD.OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents:3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO )�
Water meter readings, if available(last 2 years usage(gpd)):Rya, S1 100 a
Sump pump(yes or no): NO O� ODD
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no):NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1977 BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 EBENEZER RD.OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
BUILDING SEWER(locate on site plan)
Depth below grade:20"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 14"
Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000 GALLONS"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness:3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 EBENEZER RD.OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND.
PUMP CHAMBER:-(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 EBENEZER RD.OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LIQUID LEVEL IN LEACH PIT IS FULL UP TO PIPE.PIT HAS NO EFFECTIVE LEACHING LEFT IN IT. SAS
NEEDS TO BE REPLACED. BOTTOM IS AT 9 FT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no):NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
Page,10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 EBENEZER RD.OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two perman;;nt reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the buildit.b.
AA av
x ye
in
` Page 11 of 11
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cont.;:1ued)
Property Address: 180 EBENEZER RD.OSTERVILLE,MA 02655
Owner: MR.CARCQEENA
Date of Inspection: 6/2/03
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
No. do Q Fee 5 0 -0 0
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pprication for Mioogal *r5tem Construction Permit
Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. 1 Owner's Name,Address and Tel.No.
Assessor'8Map/PazCelnezer Rd Rodriquez/Cartagena
146-7
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Septic Service C.R. Short
P.O. Box 1089 Centerville P.O. Box 1044
y
Type of Building:
Dwelling No.of Bedrooms - Lot Size sq.ft. Garbage Grinder( nb
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
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) Install a new Title 5 leach
system to plans of C.R. Short # 1 -1000
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 E ironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this ar f Health.
Signed ✓ Date Y'6,3
Application Approved by " I Date
Application Disapproved for th�g following reasons
Permit No. 0 0 — 0 Date Issued [a—?-0
3
No. �,�. - ! Gt. .lira Fee 50-00
THE'COMMONWEALTH OF MASSACHUSETTS Entered in computer:
= PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASVACHUSETTS NO' �
- 2pplication for Mopozal bpaem ctCon!6truction Permit
Application for a Permit to Construct( . )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Fa 4 y"4q_V i t_ s Owner's Name,Address and Tel.No.
180 Ebenezer Rd Centerville Rodriquez/Cartagena
Assessor's Map/Parcel
r�
JA6-79
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson. Septic Service C.R.-Short,
P.O. Box 1089' Centerville P.O. Box 1044
q A it NA
r�
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( n):)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow, gallons per day. Calculated daily flow gallons.
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) Install a new Title55 beach
system to plans of C.R. Short # 1 -1000
Date last inspected: „
Agreement:
A
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 E ironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu d bythis ar Health.
Signed� ✓ Date
Application Approved by ,J, Date E - y'U 3
Application Disapproved for the following reasons
Permit No. 200:�=4 0 Date Issued (,) -0
Rodriquez/Cartage aCOMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS _
Certificate of Compliance',,,
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed', )Repaired( x )Upgraded( )
Abandoned( > )by W E Robinson Sentc Service 1,
at 180 EbeYS(ezer Rd Centerville has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Pef nit No. U o —A)L/ dated 1 Z 0
Installer _ Designer
The issuance f this ermit shall not be construed as a guarantee that the ystm,'1. function designed.
Date 0 3 . Inspector
No.-2�tl3=_-60`/ -- _— -------Fee --
0.00
Rodriquez/CartagTCOMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
ziopooal bpotem Conztructton Permit
Penn fission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( )
System located at 180 Ebenezer Rd
Centerville
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:Con+stru tion must be completed within three years of the date of this�ermit
Date: (� ! �0 3 Approved by '1
TOWN OF BARNSTAB E f
o :✓`� C' �C
LOCA N �� SEWAGE #
VI � � -'� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. KB 61✓ -7 '4
SEPTIC TANK CAPACITY 6--oi
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
/
BUILDER OR OWNER ��� 01 l rel t r lam' —
PERMTTDATE: .�- ' �'3 COMPLIANCE DATE: /! > � "o-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
;. sq
I
c
i
z Vp`I�
fy
II�
10
Cl
RA%--
c- %L JLoT
PL�IS A/ i-r-A -i U� Siq� Lit=1�
N�'�•�i� Ca'•/� E�Ui2 �c�TS O1= TN�' �.�/� N''� io.O -�t`T =�•`? ,T��"
TOWN OF BARNSTABLE
LOCATION ��� �'''✓�� ll A� SEWAGE#
VILLAG ASSESSOR'S MAP & LOT Nk-O 7
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) — .(size),-
NO.OF BEDROOMS-`-
BUILpER OR OWNER
PERMTTDATE: _,r: C�3 COMPLIANCE DATE: 1A ' %A o3
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
Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
J
f
E I�
4
a
ty—',.:
� r
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION gpRN
Address of property IQb �6eh 7 �,� Q� US/<<.✓; �(c :
Owner's name Ea ��
Date of Inspection
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner,
r, occupant, and Board of
None of the system components have been pumped for at least
two
and the system has been receiving normal flow rates during that weeks
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined.
available with N/A. Note if they are not
61/ The facility or dwelling was inspected for signs of 9 sewage back-up.
f The site was inspected for signs of breakout.
_! ' All system components, excluding the SAS, have been located Gated on the
The septic tank manholes were uncover
the septic tank was inspected for conditioneofdbaffles, andhorinter tees, of
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been
determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) w
provided with information on the proper maintenance of* SSDS. ere
SUBSURFACE SEWAGE DISPOSAL SYSTEH 'INSPECTION YOM
PART B
SYSTEM INFORMATION /
FLAW COND
ITIONS IONS
If residential
-� number of bedrooms
O number of current residents
. � garbage grinder, yes or no*
S laundry connected to system, yes or no
A/g seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: Syr q��°�0. eats
3 = 53�
� S Last date of occupancy
GENERAL INFORMATION
.Pumping records and source of information:, 1
h16 System pumped as part of inspection, yes or no
if yes, volume pumped
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) '
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: //
' ,c -o.
Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: V
(locate on site plan)
depth below grade:
material of construction: V concrete metal FRP other(explain)
dimensions:_ Jr X ci Joa13 g llama
sludge depth
- �/'distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from to of scum to to of outlet P P tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage recommendations for repairs, etc.
6 h G c ✓ ✓T L �, r` L Y `k �,� .� '�
k o ---A a.i, A14
DISTRIBUTION BOX:
(locate on 'site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc..)
�YJ. V(.. 111 C. ; O K i O tr V
,) .S 4-. L yc.
PUMP CHAMBER
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION coatinued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required; but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number phi �Lti A - ass
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
con4i io :Of vegetation, recommendations for mainte ance or repairs,etc.)
ai lx
CESSPOOLS (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 (cesspool must be pumped as
Part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,`~
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE E=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
31
a8 ,
35
Wes/
37'
y
o' 4z
DEPTH TO GROUNDWATER
depth to groundwater ,
method of/ eta ination or a!/ppro/ximatio�: L
/ h /( 14v y •' GUI 7 6< �p G .g. l✓ 'I /1 6 !nJ ca'�c v
u�. A
l:
'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA l
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup of sewage into facility?
.� Discharge or ponding of effluent to the surface of t
surface waters? he ground or
Static liquid level in the distribution box above outlet- invert?N=� Liquid depth in cesspool <6" below .invert or available vo
flow? luine< 1/2 day
Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structural
infiltration? substantial exfiltration? tankuns failure imminent?al
Is any portion of the SAS, cesspool or privy:
below. the high groundwater elevation?
within 50 feet of a surface water?
f� within 100 feet of a surface water supply or tributary to a surface water supply?
within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well .water analyc.
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
' SUBSURFACE SEWAGE DISPOSAL SYSTEH INSPECTION FORK 13
PART D
CERTIFICATION
Name of Inspector / r o y r C I r C` `t S
Company Name W l �� K,S Ste`T,-- k Sit �fi 4 S
Company Address d/w Z�s S
7 .
Certification Statement (n
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Chec one:
I have not found any information which
indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are As stated in
the FAILURE CRITERIA section of this form.
I have. determined that the system fails to protect public health and
the environment as defined in 310 CMR 15.303.. . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector's Signature S
Date
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
r 11..t NO. PAGE i
L4,CAT1Q N � SEWAGE P MIT N0.
VILLAGE
INSTALLER.'S N ME & ADDRESS
1 r7
BUILDER OR 6WNER
1
DATE rERMIT ISSUED
_a?o --72
DATE COMPLIANCE ISSUED
.;
7
b
NO._U� �1 1` FEB.................../....
THE COMMONWEALTH,OF MASSACHUSETTS
BOARD,,.ETTH
----------- - .... .-...OF........ .. --------------------------------------------
Applira#iou for Biipniial Workii Tomitrurtinn rranit
#4.
Application is hereby made for a Permit to ConstrAi�}lc--t cor Repair ( ) an 'Individual Sewage Disposal
System at• vda y
... ..........................., .....---- ----•-- ......... ........... - ------------------------- ...............................
Loc ti n-Address or Lot No.
r ess ddr
j
Installer dress
a�
UU Type of Building S>ze Lot_ 1.._. ..._...Sq. feet
Dwelling—No. of Bedrooms............... Expansion Attic Garbage Grinder
pa, Other—Type of Building ............................ No. of persons--------6............... Showers (/) — Cafeteria
Otherfixtures ......------•---•••.---•....---••-•-••-••----•----•-•-----•••--•---••-•---••••--------------------•--------•------•-•----••-••---•---•---•-•----•••••-
77
W Design Flow..................' .................gallons per person per day. Total daily flow.......... r __•-____-_-__-_•_gallons.
WSeptic Tank—Liquid capacity�_OW..gallons Length................ Width---------------- Diameter__ lJ._..._. Depth....
x Disposal Trench—No. ....../........... Width.................... Total Length.................... Total leaching area..Zc fa....sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.............._..... Total leaching area..................sq. ft.
z Other Distribution box ( Dosing tank )
.f /2 ��
Percolation Test Results Performed by-_..._�� . :�'-�--- -- ---:��---- Date______ _______ _______________________
aTest Pit No. 1__e.Z......minutes per inch Depth of Test Pit._._ ,......... Depth to ground water.Kp1
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
-_ ------------------------ -•r-•-----------------------
'--'--t....................... ------------------
-----------------------
0
Description of Soil.............Q^-�,-----•:- - ��--�-�'�'�.�A-��--•----------------------------------------------------------------------•---•-------------
x -z' , r
. ?4^ -------------•----------------------------------------------------------------------------
U j� Z .
W ----•----------------- - -:, �=� Q�° -----------------------------------------------------------------------------•-----
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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Si ed.•�lQ e�!.... � .. y. ------- 1------.
l
Date
Application Approved By•••••••. ` .........................
------55� 7 ��-•------
Date
Application Disapproved for the following reasons-............................................................................................ -- -------------
....----••---•••-•••-••••-•-••-••-••---•-••--••••••------•-••-•••••------...---•-•-•----•-•----•-•---•-•••-••••--••-•---•--•-----•-----•--------•••••--•••••-•-•--------••------•---•-••-•-•---•--------
Date
PermitNo......................................................... Issued.......................................................
Date
IeTo . � c Fis....3 ....
THE COMMONWEALTH .OF MASSACHUSETTS .
BOARD OF HEALTH.
-...... OF.....
. �,-, ^r ,,.......................................
Appliratiun for Bispuual Works Tomilrurtiun , rrmi#
Application is hereby made for a Permit to Construct (C1051"or Repair ( ) an Individual Sewage Disposal
System at
.' �j
1
Location-Address or Lot No. j
` a ) � o✓ Ow er~ `J� Address 411 }a
(� ,//`!3 '^�^ ..�.s�/✓✓2� t....__:r.� (fie s '` F -l t.i. l _ fd `i�.
Installer Address
QType of Building Size Lot_ a_r�_ -._....___Sq. feet
U Dwelling—No. of Bedrooms.............- _______________________Expansion Attic (,V Garbage Grinder (/(0
'4 Other—T e of Building _______________ No. of persons-_.____. Showers — Cafeteria
04 Other fixtures ---------------------------
W Design Flow.................._ ...................gallons per person per day. Total daily flow..........3,S '...................gallons.
M Septic Tank—Liquid capacity_/; ?--gallons Length................ Width................ Diameter_-,fin.s__ Depth....1.........
W Disposal Trench—No.......3........... Width.................... Total Length.................... Total leaching area...`_°�-•_,,0'_C:....sq. ft.
x
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( y" Dosing tank ( ')
Percolation Test Results Performed by...... !. _'=. ._� ` ::__._`<'�,: ::_°s:__:e.-: ~_- Date._.: ...........................
Faj Test Pit No. L.<1-------minutes per inch Depth of Test Pit-----/-.....r___ Depth to ground water. 2e'h .-_-
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -------------------------------------------•---...-------------..-..---------------------•-•----•_...........................................................
0 Description of Soil.. "' '" 4 `:4� ' _ :1.� . ................................
U v - ;
VNature 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 i i^:?.
p 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
f f
-
��'' 00 0� Date
00
Application Approved By.......... t/�k._.. - t ' .
Date
Application Disapproved for the following reasons_...............................................................................................................
-•-•----•--...••----------•---------------'- -----...._._._
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF .................. . w.... .. .......,................................
(9rdif i,rtt#r of Toutpliatta
THI TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by••••-•••-•-- f-� •�-'
Installer
at............. ........... .........
has been installed in accordance with th provisions of TI1 r. ` of T A tate Sanitary Code as described in the
.,application for Disposal Works Construction Permit N B_1 .?_S; ...... dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. -
DATE..................................:2/ -----------•--•--•---- Inspector................
/j�---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA6T/H,�
..................OF............. �.t./R.`�21`;F" dwl.t ............................
O _f •--•------- FEE.. ...........
urk� �oa��riun., rrnti�
Permission •s reby granted-------- E-..--•--- .............................------------------•----------........................................................
to Construct 1 or Repair ( ) Individual Sewage Disposal System.
atNo....... d�---_---- --------XW.---..-.---- '...- -------•------------•--------------------------------•--......--
Street
as shown on the application for Disposal Works Construction Permit No-------_----------- Dated..........................................
-----------------------•-----------•
� -
DATE--------------- ------------------�........-..............................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
Lo � �
1 .p -
S` \
ool
DO oc� 2 '
r+•e N G'\O '+�a 'fey+� \
Ac lbo
� -bS i
414
c �pH OF Mks u'
.6
ROERT yG
!�GUNIKI
�p GIST��a
LEGEND
,. EXISTING . 8P0T' ELEVATION 0A CERTIFIED PLOT PLAN
EXI$TIN6 .C6NTOUR - 0 '
FINISHED 1100T ELEVATION° . k
FIMl314,E0 CONTOUR • 0
A:PPREUQ ®OARA. AR NEALTM AN
#r'
VT
DATE AGENT :
SCALE, / +R yG. DATE /V A ;
° C DREDSE ENGi/NEER/Re Ca IN ee rh fi r,
CLIENT I CERTIFY: THAT THE PROP08F0 `.>
EDIBTERE A ®18fiERE0 Fri Q i3
JOS NO. .�. BUILDING SHOWN ON THI$' PLAN , ,.
k
CIYtL LAND CONFORMS TO THE. ZO.NI.NS LAIIYR r EE OR.®Y a
NBT
N OF BAR PLEst.MASS.
;
712 VAIN ST. CH. BY,
MYANNIS•, MASS. •
8NEETL OF
DATE RES. LAND SURVEYOR '
IV07F /F EITHER T,qE SEPT/C'T.4.,oV1< OR
20 FT. M//V. J7!�i4CH//YG P/T ARE MORE THAN 1Z"JELOH/
/Q FT .MIN RADE, .A 24..V/AME7EK CO3VCRF7.E COiiER
SWALL eF B•POUGHT TO 6/rA1>E /✓ .EXTRt1
-9 .PVC PIPE
O �NCRCTE HEAVY CAST /RON COiiER S/71ALL !3E USEO
CODERS AI N. PITCH I 1F l/V OR/VEyVA y
2�• A//N. CONC.e1'TE
G/C.�pE co✓ER CLEAN -TA/VO ;
A I •r / I BA C/C,l 49:
I_, L/!fit//O LEYEL __ ,..,• ,',.. _
z"LAYER !
4 OCAS
NP/PE •aa • p '� /�8 J�e" i
MIN.P/TcN CYA4. o a • • • • • • • r o •4� WASHFO STONE i
%4 PER rrr SEPTIC TANKBOX
D/sr. ° s • • • • • • • • e a
o
r� '•` _ � n • • • ° • � • •• � �o , • lV.95HE0 STONE
"�' " •°e' • • • • • • • p o • PRECAST SEEPAGE
a n:•u • • • • • • • • • ' a o P/T OR EQLII V.
/NfiE'RT �LEYAT/GNS a
/NYERT AT DU/LD/NG 177, Fr
INLET SEPTIC TANK '�FT. ��FTD/AM• i C(SF.`�UL.4TlON>
OUTLET SEPTIC TANK IFC, 3 FT .
I/V AFr DISTR/BUT/ON BOX `16 FT. . GROUND Itt�ITEK TA9LE
OcJTLETD/STR/BtlT/ON dOX 9,5 FT. SECT/t7/v OF
11V4"T LEACHING PIT 4 FT. SEJ�VAGE O/S'PQSA L SYSTEM TABULATION
LEACH//VG P/T
DIMENSION A
DES/G/V CR/TER/A DINE//oN B—C
NUMBER OF BEDROOMS � D/HENS/ON G `/'
GAReAGEO/SPOSAL UNIT_ SO/L LOG
,TOTAL E3T/M.�i'TEG FLOiv'_. .3�GAL.�DAY SOIL TEST At/ SOIL TEST#2
SD/L TEST
Ry
�IYf/MBER OF LEAGNINli f�/T5 f FLEK 9�Q /`-ELEY. PATE OF S.O/L TEST
SIDE LEACHING PEiZ P/7' SQ. FT. RESULTS ITV/TNESSED BY kR'
i r6UTTOM LEAGN//vG PER P/T �/ SQ. FT g �t f'tRCOLAT/ON RRTE / `S s M/NCl/NCH
_?� AEiICoLAT/oN Rwrw A2
I 'TOTAL LEACH/NG RREA SQ, FT. l.0
RESERVE GEACHlNG,q,QEA_ N�SQ. F T. � !
a• cia/
/o ROBERZ
(� P �`�.`: M•� 5�� EE.OREDGEENG/NEER/NGCO,/NG.
fit n 13UNIKI5' ^ /
No.22162�0 �! f.L7 7/2 MA//Y Sr .
G�
T P ,s .NO GI�OC/N[7 YYi4TER ENCOU/✓TE.E'ED HY.4Nn//S, MASS.
f oFF S oN,�t �-���I �l GRO UNO 1vATER AT EG�t/ - Pola
LO A ION ao
3 W A C E PERMIT NO.
V I L L A G
1L u
IN TA L 'S NAME i DDRESS
d U I L DE R OR OWNER r
DA T E PERMIT ISSUED
DATE ` COMPLIANCE ISSUED �� ^ 9/
r
1-�
lh
2c�2
LO
MCI R�
No. - Fps ' ................
I
THE COMMONWEALTH OF MASSACHUSETTS '
BOARD F HEA TH
-G��,�(,f''K•..OF. ..... - --------------------- Zisposal
Appliratioo -for Riivooal orkii Tonstrurtioo rrmit
Application is hereby"made for a Permit to Construct ( orRepair ( ) an Individual Sewage
Syst
L on- dress or Lot No./•
�/� O e A
a !!_/__ d
Installer Address
Q Type of Building Size .......Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................. Showers ( ) — Cafeteria ( )
a' Other fixtures ..... . . .. ....
Desi n Flow___.______ ___ Mons per et-son per day. Total daily flow__________.
W g � ------------------•- ----g� P P P Y• Y �--®.O.-•-----------•--•--gallons.
WSeptic Tank—Liquid capacit/vAO-0-F-- aroons Length................ Width_.............. Diameter------_- ----- Depth...___-__-._.---
xDisposal Trench—No..................... th_.._...._.__...____ 1 Length_.._..._..._____._ of eaching area--------------------sq. ft.
Seepage Pit No,�A_�__i i eaching area_�38 -----sq. it.
Z Other Distribution box ( X Dosing tank ( ) lU� C — e� —47—77
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---.--------------------------------.---
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...-----._-_--.-_._----.
(4 Test Pit No. 2________________minutes per inch Depth of Test Pit.................... ?Depth to ground water.-..-.---_-._--___-__--
P4 .......5.......------ --------- ---------------------•-•----•----
Descriptiolt pf Soil �� Cj` _-_......A.
- ... --) ---
-------------------------------------.............................................----------•-----------------------------------------------------------------------------------------------------------
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 Article XI 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 b and of health,.
Signe -- - --- � _. ..2�._..__ /ate
------ - ---- - -- - •-- -- /
Application Approved BY........�--- - - - -- - ` �----.- ---:-------------
..1�
- -A... ... 7---
Date
Application Disapproved for the following reasons----------------•-------------------------------•-------•----------•---••---------------------•------------------
..........................•-••-••----•---•-•----•------------•-•-._......-•----------------•-•-•-••••--•-------------------------------------------------........---------- -------------------•-.-----
�� \ / Date
PermitNo......................................................... Issued------------------•--- ..................
Date
TOWN OF BARNSTABLE
WCATION � £ «.,,a ztv SEWAGE #
VILLAGE ASSESSOR'S MAP&LOT t/J O 7
INSTALLER'S NAME&PHONE NO. e .
SEPTIC TANK CAPACITY
f
LEACHING FACILITY: (type) (size) C �' w
NO.OF BEDROOMS
BUILDER OR OWNER Q rc-a Ill.
PERMITDATE: COMPLIANCE DATE: 7
Separation Distance Between the:
"Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by - /�f/5�
t
w
y a'
G X C Jp'
• - w a,is�o�v.,
No.. --`3, .... FEs .. ..................
THE COMMONWEALTH OF MASSACHUSETTS
--,--,.,BOARD OF HEATH
Appliration -fir Binpagal Morks TL nstrurtion Vrrntit
Application is hereby`made for a Permit to Construct (li`)or Repair ( ) an Individual Sewage Disposal
System a y r /
.-•----... off f:
canon
L non-Address / or Lot No. ...... d
A d
r
Installer Address
d Type of Building Size Lot..f- =_---1 __..._..Sq. feet
U Dwelling—No. of Bedrooms.....�-----------------------------------Expansion Attic ( .) Garbage Grinder ( )
`, Other—Type of Building No. of persons-..--_--___________________ Showers a YP g ---------------------------- - 1 S ( ) — Cafeteria ( )
Q Other fixtures ..... .. -------------
W Design Flow------------ :..a---•___________________gallons per person per day. Total daily flow----------�_d_ ....................gallons.
Septic Tculk—Liquid capacit�-�'_.-_ a ons Length-------------_- Width-------- ------- Diameter---------------- Depth.--.--___---
xDisposal Trench—No._•-- -----9------- Vidth-------------------- btal Length--.-•--.......__._ otal4eaching area-------------.------sq. ft.
Seepage Pit No.1.A - __�Riln --_.._-���elat b"el`ctvL-ittd --r----------_- ��% --leaching area.: Dk---sq. ft.
Z Other Distribution box ( )` Dosing tank ( ) U�CI�f 0 C�t- li /,7 - 7�
Percolation Test Results Performed by---------------- -----------------------------------------------------•--• Date-----------------------------------..-..
a
Test Pit No. 1----------------minutes per inch Depth of "rest Pit-------------------- Depth to ground water_-.-_.-----.--__-.-_-
(1_1 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_.-._--______---.-.--.
9
D Description of Soil---------7.._.�_-.G_!AJ-el-d = a—f `� ---i----------------- -
U 3
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 Article XI 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.
Application Approved BY--------�' -_- ,_- ...�i�1�f�1� :� � ,�0 Ye 7
Date
Application Disapproved for the following reasons:......... -•--•-----------------------•-------•-----.-------------------------.--------------------------------
................•••-------•-•----•----------•-------•----•-••-----------••••••-------•••-•••-•------•-•••••-------------•-.----••---...........-------------•....-•--•------------•.......--------.-••--
Date
PermitNo......................................................... Issued........................................................
`` Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... OF.......fr±r. .t�ahtf', !_.......AA�....---------..............
(Plrrtifiratr of Tontphattre
THIS IS TO CERTIFYrTfat the Individual Sewage Disposal System constructed ( or Repaired ( )
by......
: ..................... _-------------- ----------------- .
X Installer
at ° °' - - ".6 --- _'--- - - --------------------------------------------------------------••------
has been installed in accordance ,with the provisions of <'it,
icl XI of The State Sanitary Code as described in the
.
application for Disposal Works Construction Permit N _71..._...37>-.i-------------- dated...._-' ?/)__77...___......._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------_--------------•-•----••---------------------•-•--•----------_.... Inspector------------------------------------------- ........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
) �. � �
3 5/ ........ .. .� .,�.-n--:.OF.. .. .......................
No......................... FEE...45'-..............
Rispa,ial Norkii Tumptrurfilln Prrmit
Permission is hereby granted_._..__.,`_ -1-✓
} ----------------------------- ........................
to Construct ,sefour Repair ( ) an Individual Sewage Disposal Sfemi-
per •=...-•- ../`"'' ._......_..,.. C... --strc t-
as shown on the application for Disposal marks Construction Per"mid Dated..._( --J_�. _._ ...........
yam .
-•--------------------•-----._...........................•.... Zt
Board of Health
DATE................................................................................ L
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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BENCHMARK SOIL TEST
TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLARDATE OF SOI!
10 FT. MINIMUM FROM SLAB OR CRAWL SPACE SOIL TEST DONE BY0FT.
ELEV. _ � 0.00_ I 0 MINIMUM I CLEAN SAND
(.A55UMED� -1 CONCRETE WITNESSED BY
COVERS LOAM AND SEED
OBSERVATION HOLE_ 1 ELEv.= 94_80
f 4" SCHEDULE 40 PVC PIPE \ PERCOLATION RATE < �_ MIN./INCH AT - 42-54 INCHES i
-�---- MIN. PITCH �/8" PER FT. \ \ 2" LAYER OF
{ 1/8" TO 1/2" LEGEND: DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
l
A I 7.50 MAX:\ r
WASHED STONE EXISTING SPOT ELEVATION 00,�0
N/A 4" CAST IRON PIPE 1< 4.50 MIN. EXISTING CONTOUR ----00---- i
(OR EQUAL) MINIMUM _ FINAL SPOT ELEVATION �9• LOAMY SAND�10YR4 1 I NO I
PITCH 1/4" PER FT. 4, I FINAL CONTOUR �--
-�_ ZABEL FILTER SOIL TEST LOCATION
I FLOW LINE s UTILITY POLE __o_
ELEV. _ _NIA _ Li 10 _ TOWN WATER w mow- �9_30" B LOAMY SAND 10YR5 6 NO _
MIN. I V - 2,0 0 0 ° ❑ ❑ ❑ ❑ C ❑ ❑ J ❑ r a_o o CATCLINBASIN
ELEV. 93�25
LEVEL ° ❑ ❑ O ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ T �.0.
_/6" SUMP Q CLEAN OU
ELEV. _ _9s3�5_ GAS ELEV. _ _93.17 ELEV' = _ __ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ° 2' I° CESSPOOL C.P O ,�•
BAFFLE DISTRIBUTION ELEV. _ °o° CD ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ° o ° C MEDIUM SAND 10YR7/6 NO
LIQUID OUTLET -- BOX _ _ ° ° ° ° o ° ELEV. _ _90.75_
DEPTH TEE
-144
4 FEET 14 INCHES `C BE WATER TESTED -
5 FEET 19 INCHES 1000 GALLON IF MORE THAN ONE OUTI-ET 2- 500 GALLON DRYWFZLS Y{7TN STONE
6 FEET 24 INCHES (TO BE PLACED ON FIRM BASE) IN AN 13� X 25 X 2 TRENCH FORMX T/ON ? WELL N/A NO WATER ENCOUNTERED Al __12__ ELEV.
7 FEET 29 INCHES SEPTIC TANK
8 FEET 34 INCHES 7.95' ZONE N/A
(EXISTING) 3/4" TO 1 1/2" CLEAN SOIL ABSORPTION u) i INDEX
DOUBLE WASHED STONE ADJUSTNZA DESIGN CALCULATIONS
FREE OF FINES & SILT SYSTEM (SAS)
. c,MB£R OF BEDROOMS 1__
USGS PROBABLE WATER TAKE ELEV. - _ �_ GARBAGE DISPOSAL UNIT N0, NQI_eILOWED
SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( / / ) ELEV. = _� _ TOTAL £sALIOBR FLOW
), ': �� BOTTOM OF TEST HO-E ELEV. _ � (110 CAL/9R./bAY X .�_ �P.� _�3Q._ GAL./DA Y
REQUIRED SEPTIC TANK CAPACITY _15Q0 GAL.
ACTUAL SEPTIC TANK CAPACITY _ %W_ GAL.
SOIL CLASS/FICA 77ON _.1__
DESIGN PERCOLA TION RA TE S5_ MIN./INCH
85.7 EFFLUENT LOADING RATF 0-7 - GAL.11DAYIS:F.
LEACHING AREA 4,77- 50. FT
TITLE 5 B.O.H. VARIANCES REQUIRED: 5'>+(76'X2')
'T SECTION 1 21 BEACHACHING CAPACITY _�52_ GAL./DAY
S
v ALLOWS ONLY 3' OF COVER OVER S.A.S COMPONENTS RESE W LEOACHING CAPACITY" N/A/A_ GAL./DAY
87.0 A 1' VARIANCE REQUESTED.
( � 3' o� die- w1,e,,� ` NOTES:
/ 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P.
W TITLE 5 AND THE TOWN RULES AND REGULATIONS FOR THE SUBSURFACE l
/ _02 3 DISPOSAL OF SEWAGE.
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
W WITHIN 6" OF FINISHED GRADE.
/ 89.2 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN
W 91•8 `�: 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS.
93.0 92, 4 ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL
7 BE MORTARED IN PLACE.
92 2 W 93 93.8 �y SEEDED OR ZbNII►JG RGU�ATIOJS t oW % LICAN f IS TO
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
93.8 k 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR
�. 97,4 ) V IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS
93.7 Q PRIOR TO COMMENCING WORK ON SITE
>> 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS
944 99.0 SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE ANY VARIATION
93 IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER
0 IMMEDIATELY.
/ 8. PARCEL IS IN FLOOD ZONE _ � _ _
4.8 96'a� r 9. LOT IS SHOWN ON ASSESSORS MAP �' AS PARCEL 79
______
10, ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNDER, AND
EXISTING FOR A MINIMUM OF 5 FEET FROM AROUND THE SOIL ABSORPTION SYSTEM,
�j 92.3
DWELLING
� ��� AND BE REPLACED WITH SAND AS SPECIFIED IN 310 CMR 15.255: (3)
VENT 4,01 I (I.E. TITLE 5) IF ENCOUNTERED BELOW S.A.S. PIPE INVERT.
�4� 11. EXISTING LEECH PIT TO BE PUMPED AND FILLED WITH SAND OR REMOVED.
DECK '-D�tiFt p,,
9 12. A ZABEL A1800 FILTER IS TO BE INSTALLED ON EXISTING SEPTIC TANK.
9 r'
ED00 GAL. / .,` CPN G a 13. CONTRACTOR ?0 PROVIDE SHORING AS NEEDED TO PROTECT BUILDING
• 97.8 SEP77C TANK -- -, 98:2 SHORT �' '� �` : AND PROPERTY LINE.
3 41 v *'1 4. CONTRACTOR TO UNCOVER TANK OUTLET TO CONFIRM ELEVATION BEFORE
98.0 GARAGE 99.5 93.5 Ct'�`PL ` .,- ////// INSTALLING S.A.S.
99.5 APPROVED: BOARD OF HEALTH
. 97.8 97.0 UC
02.3 . 93. Ia3 J#2538 DATE
i - AG N
T
100.9 No 99.0
PROPOSED SEPTIC DESIGNS
01.9 99 8 R
%101.8
98•9WM. E. ROBINSON SR.
LOC. 180 EBE;NEZER ROAD
LOT26 102.8 2
9 I
�8, 13 f s.F 8 o CENTERVILLE, MASS
_ _
L OCUS �'o - -- - ------
m CRAIG P. SHORT, P.E.
101.6
's o � 508- 235 GREAT WESTERN RI;�A
P. 0. BOX 1044
398-8311 SOUTH DENNIS, MASS. 02660 II
I
ALE
DATE
j DEC. 1, SC
c f ' REv'-_ � JOB No---1 -1 OOO�
LOCATION VAp REv ; SHEET 1 OFF 1
01-1000 R Ebenezer.dwg 02003 CRAIG R. SHORT, P.E. '
-
-.