HomeMy WebLinkAbout0043 FAIRWINDS DRIVE - Health 43 Fairwinds Drive
Osterville P
A = 165 021007 ,
x
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"tf 43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
(�
on the computer,
use only the tab 1, Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
C y e Enterprises
ffiy Company Name
153 Commercial St.
Company Address
Mashpee Ma. 02649
City/Town State Zip Code
508-477-8877 SI 4522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/10/2011
Inspectors 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,toj'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 tt""tee will perf_ •yin the future under .
the same or different conditions of use:
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal Syst •Page 1 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is
required for every Osterville Ma 02655 8/10/2011
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:
The dwelling located at 43 Fairwinds Dr. Osterville Ma. is served by a Title V septic system
consisting of a 1500 gallon septic tank, distribution box and 7 500 gallon leach chambers.'
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 exMtration 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.
El 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 Foam
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
J" 43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osteiville Ma 02655 8/10/2011
page. Cityrroan State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of,Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11110 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of'Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. Cityrrown State Zip Code Date of Inspedion
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
❑ ® iDischarge 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 %day flow
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r -
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
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 11 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•11/1 t) Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official-Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as 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): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd
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
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
,Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑l Yes Z No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
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 day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 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
°t 43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. CityRown 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: 1500
gallons
How was quantity pumped determined? size of tank
Reason for pumping: routine maintenance
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 1/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 Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owners Name
information is required for every Osterville Ma 02655 8/10/2011
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:
Original system installed 8/11/2000 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 4
feet
Material of construction:
El 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.):
Joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade: 3
feet
Material of construction:
® concrete ❑ metal ❑fiberglass [I polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate.of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallons
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Forth: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
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owners Name
information is required for every Osterville Ma 02655 8/10/2011
page. Cityrrown State Zip Code Date of Inspedion
D. System Information (cont.)
Septic Tank(cunt.)
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? Tank was cleaned as part of
inspection
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 as part of inspection and should be done every 2-3 years as maintenance.water
level was at bottom of outlet invert, tank was not leaking and was structurally sound, outlet tee intact.
Inlet and outlet covers are on risers.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass El 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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owners Name
information is required for every Osteryille Ma 02655 8/10/2011
page. Cityfrown State Zip Code Date of Inspedion
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 El 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.): r
' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. Cityrrown State Zip Code Date of inspection
D. System Information (cons.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was video inspected and found to be functioning as intended.Water level was even with 3
outlets, box showed no staining higher than the outlet invert. Cover to d-box is 4'below grade, it is
recommended that risers be installed to bring cover closer to grade.
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 Forth:Subsurface Swage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. Cityr town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 7
❑ 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.):
Leaching chambers were located but not excavated due to depth. Soil and stone surrounding s.a.s.
was found to be dry with no sign of past hydraulic saturation.Vegetation was normal
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 Irmpection Forth: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
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. Cityrrown 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•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
UpTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
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
�o
l
P,
'T�sJ K
ND
,4'Za (cy
ei (�
13-Z r 'Zfc(p
ern '7S P16 ,
5AS
A 7S
13 4 z 46 Z
t5ins-11/10 Tice 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water. 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:
❑ 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 maps.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•11110 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
43 Fairwinds Dr.
Property Address
Andrew Putnam
Owner Owner's Name
information is required for every Osterville Ma 02655 8/10/2011
page. Cityfrown 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•11r10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS.
x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
A
RECEIVED
MAY 15 2003
TU,,vrw:if-BARiJSrAOLE_
TITLE 5 H�ALTi e[ F�'r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A'
CERTIFICATION
Property Address:
Owner's Name:
Owner's.Address: 3
Q
Date of Inspection: MAP
Name of Inspect p. lease print n60 rf Jc�� t° PARCEL ; 'C3 0:Q.
Company.Name �� Le . LOT `
Mailing Address:
Telephone Number:
CERTIFICATION.STATEMENT.
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page l
f
Page 2 of I I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Y CERTIFICATION (continued)
Pro'perty Address:
. Owner•
Date of I spection:
Ins.pection'Summary: Check A;B,C,D or E J ALWAYS complete all of Section D
A.`;SJystem Passes:
1P 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:
B. System Conditiofialroasses:
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.
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:
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 Boai•d of Health):
broken pipe(s)are.replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
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:
2
Page 3 of.11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:.
0�•l iQ _
Owner
Date ofIns ection: ,
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. System will fail unless.the Board of Health (and Public Water Supplier, if any)..determines that the
system is functioning in a manner that protects the public health,safety.and environment:
The system has a septic tank.and soil absorption system(SAS)and the SAS is within 100 feet of a.
surface water supply or tributary to.a surface water.supply:.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS.and the SAS is.within.50 feet of a private water supply well.
_ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a,
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified,laboratory, for.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.
I Other
. 3
Page 4 of I I.
OFFICIAL.INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART A
CERTIFICATION(continued)
,n
Property Address: %%::5 }�/ ✓`i✓
rC1.
Owner:
Date of Ifispectiow7,
. D. System Failure Criteria applicable to all systems:
You must indicate".yes or"no"to each of the following for all inspections:
Yes Ng
1/ 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 invertdue to an overloaded or clogged SAS or
/ cesspool
1/ Liquid depth in cesspool is Tess than 6"below invert or available volume is,less than./z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
blof 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.
19 . 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.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.]
k (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 corredthe 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 dither"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 threavunder 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,
4.
3
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: o% %)
Owner:.
Date of Inspection: fJ
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
— i"Were:any of the system components pumped out in the previous two weeks
-4 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 breakout
V _ 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:
Yes o
( 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(3)(b)]
5
Page 6 of 1]
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
A4 A
Owner.:
Date of Inspection:
FLOW CONDITIONS
I E RES D NTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow.based on 31 O.CMR 15.203 (fore ample: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no . ►-f if yes separate inspection,requ.ired]
Laundry system inspected es or no
Seasonal use:(yes or Q2)
Water meter readings, if ilable(last 2 years usage(gpd)): (��`ZP ��� �Z 'Z� ja��j
Sump pump(yes or no .
Last date of occupancy
COMMERCIAL/INDUSTRIA
Type of establishment:
Design flow(based on 310 CMR15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: � ffiwd cp4)/
Was system pumped as part of the inspection(yes or no)>. ,2®:
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason'for pumping. .
TYPE OF SYSTEM
_U,!�eptic 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):
Approximate age ofall components,date installed(if known)and source of information:
Were Sewage odors detected when arriving at the site(yes or no): O-
6
it _.
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM
PART C
SYSTEM.INFORMATION(continued)
• Property Address: 7� T
Owner
Date of Inspection: CJ
BUILDING SEWER(locate on site plan//
Depth below.grade:
Materials of construction:_cast iron 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints;venting;evidence of leakage,etc:):.
SEPTIC TANK: Iocate on site plan)( P )
Depth below grade�,,tt�
Material of construction: C ncrete_metal_fiberglass_polyethylene
other(ex,plain).
If tank is metal list'age: Is age confirmed by a Certificate of Compliance(yes or no):_.(attach a copy of
certificate)
Dimensions:
Sludge depth: /d
Distance from top of sludge to bottom of.otitlet tee.or baffle: 7iU
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tec���oa�r b,,,a,,ffll�e: _� // P
How were dimensions determine4�� �4141
Comments(on pumping recomme ations, nlet and outlet tee or baffle condition,structural integrity, liquid levels
related to outlet invert, vidence of leakage, etc.) (�
i a- f d6 tT N
i V
GREASE TRAP;/J�Xlocate on site plan)
Depth below grade:
Material Material of construction:—concrete,—metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
" 7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address:
A
Owner:
Date of Inspection:
TIGHT or HOLDING TANS%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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):)
Date of last pumping:
Comments(condition of alarm and float switches, etc,):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distri ution"outle equal, any evidence of solids carryover, any evidence of
akage into or out of bo ,ete.):
PUMP CHAMBER locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): .
8
Page 9 of 11
OFFICIAL INSPECTION FORM—`NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
11 _
Owner: YA —
Date.of Inspection: �a O
SOIL ABSORPTION SYSTEM (SAS):�ocate on site plan,excavation not required)
If SAS not located explain why:
Type
..-........
leaching pits,number:
:Zleaching chambers,number:
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,
et ): r
av
�.
CESSPOOLS (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth'—top of liquid to inlet invert: si
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool; .
Materials of construction:
Indication of groundwater inflow(yes or no)::
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):"
PRIV�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.).
9
Page 10 of 1 I,
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEMJNSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
94
Owner:
Date of I spection: --7-� �3
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
✓2
�> i4a,
10
r;
Page 11 of I 1
OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: V3
`1
Owner:
Date of In pecti0n:
SITE EXAM
Slope }
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:"
Obtained from system design plans on record-If checked,date of design plan reviewed:
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:
12�if'//l�JCl /bl
t.
S
I1
Permit Number: Date:
Completed by: ���
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: /t / 1�r10� /. ��) �Ufl� Lot No.
Owner: �/'� Address:
Contractor: Address: Z/✓—.2�l ,G/ /"-)//;
Notes:
STEP 1 Measure depth to water"table
to.nearest 1/10 ft. ................ Date....................................... .
month/day/Year
STEP 2 Using Water-Level Range Zone
and.Index Weli'Map locate
site and determine:
OAppropriate index well.............
OB Water-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current"depth to
water level for iridex well .......::.................. Z
®,
month/year
STEP 4 Using Table of.Water-Ievel.Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3)., ,
and.water-level zone (STEP 213)
determine.water-le.vel adjustment-............................:..............................................................
STEP 5 . Estimate depth to high"water
by subtracting the water
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) .............................................:....:.............................................................
Figure 13.-- -
Reproducible computat)on form:
. 15 :.
� r'
y' f�
�...,....., .w��.ws�..��.�.aexva.�.mawu���.u�..w.....•...n. .._..vw+.�••.�e e..�....�.•...w.. �.v —..m..-«•�-.+_..�:_...- �. ...w�.::w�f.G��.....mv�..�cxrr z..,a w�f lNtll✓�!�j;fit`L�...ewrw..u..
M,.,�
� �.,_m_T� .a .a , 7�, 7
i
TOWN OF BARNSTABLE
LOCATION 7 3 ��,I"�� �J� di: SEWAGE # .S—'
VILLAGE Dv 8�/'V ' /A—SSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. �CGU ` ��✓` 7�I �99 �a
SEPTIC TANK CAPACITY D -
/
LEACHING FACILITY: (type) AA 1 MMX size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 2� 'R 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
¢ LO F
N®�sC
P� r�a,�-r �► �. -3 /
Iv
�-y 171
�✓ �l�j�S' OWN OF STABLE
LOCATION
f [r wi • ; roVt SEWAGE #
VILLAGE ' �U I • ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 221 m
r
SEPTIC TANK CAPACITY I
LEACHING FACILITY: (type)AU101/Ze'd 41.111 �Ysize)
NO.OF BEDROOMS 3 w j
Az'
BUILDER OR OWNER
1
PERMITDATE: Z 1-23-22 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
r;
Private Water Supply Well and Leaching Facility (Ifany wells exist
on site or within 200 feet of leaching facility)-.,. Feet
Edge of Wetland and Leaching Facility(If any wands exist
within 300 feet of leaching facility) Feet
Furnished by
10
�6�o,�
,
G�D _
t 1
} No._01e��? � THE COMMONWEALTH OF MASSACHUSETTS.;.---^ FEE '
BOARD OF HEALTH'`
ION OF ZC051 QIUE
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (-<Repair ( ) Upgrade ( ) Abandon ( ) - B Complete System [:]Individual Components
1'IA RI��N 1> 'Fe.EO -7ocJSfa,L Qc"
ocaL--` o3 's Name
T'ONA10s lGild. N4
M ap/Parcel# 3 , r ss
X- 309
40 L i Rss b C (
Installer's Name 3 D g is N
ddre
Telephone# Telephone#
Type of Building: Q)I nq IQ Omt tm l\ k�w L 1 o t, Lot Size JS0 Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required) gpd Calculated design flow gpd Design flow provided-*,5758 gpd
Plan: Date b-5-00 Number of sheets n Revision Date 5-'18-00
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 0,'5-0,Lo
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place them in operation until a Certificate of Compliance has been issued by theBoard of Health.
Signed
— Date 6
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
V I NO. JJ THE COMMONWEALTH OF MASSACHUSETTS ._ s • ~
BOARD -OF HEALTH
�TToLv ,
� rY15TA
_ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Applicat+on for a Permit to Construct ( Repair ( )AUUpgrade ( ) Abandon ( ) - Complete System ❑Individual Components
d
Location '� S(�—E�+(QR Name
[r n
� O 1 to 5�
Map/Parcel# r
1 'BSI - 830- Gd�'�ss- x- 30q
r
Aer il
20-PZ&Lam: . f 6'1 1 AG6ASSe_h�afa eS
Installer's Name � D g is N '�
✓'
Address
�� A
t �/- � j9 �� 540-3c�
1 Telephone# Telephone#
Type of Building: Q)I Yld� } ML bt.t)�(l 11(1(.�. Lot Size J' 1,JSD6 Sq.feet �
= �
Dwelling—'No.of Bedrooms 5Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
' Other fixtures
_. Design Flow(min.required)55o gpd Calculated design flow gpd Design flow provided-5.`�a gpd
Plan: Date FJ -J`'OD Number of sheets Revision Date 5"-18-00
Title SIA=kwe b(SDUCat Sk steryi plan nr�rPA, QDC tREb j nv1Sh?T_&
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 9-:
DESCRIPTION OF REPAIRS OR ALTERATIONS
,. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further,agrees not to pla the system in operation until a Certificate of Compliance has been issued by the Board of Health.
I - 6
Signed Date '.
Jnspeetion�- Cr iG
r
FORM 1 APPLICATION FOR DSCP DEP APPROVED FORM 5/96
h
` __f,/t"-10T' THE COMMONWEALTH OF MASSACHUSETTS FEE
h SIB /BOARD OF HEALTH
CERTIFIC,.ATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) mplete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( )
by: D!
at
has been installed in accordance with the'pro ' ions of 310 CMR 15.00 (Title 5) and the approved design plans/ .-built
plans relating to application No. 7,600- 0 dated <-- Z 2 tea-' Approved Desi n Flow 1(gpd)
Installer °
Designer: Inspecto Da e_W0 I
The issuance of this certificate shall not be construed as a guarantee that system will function as designed. .,' r
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. 105 THE COMMONWEALTH OF MASSACHUSETTS FEE AV t'"r'
16 S-0 2 / AG 0� ,� BOARD OF HEALTH
r DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby rantato'Construct (L.4ol6pair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at �` f•�t .� i7r• (�,S 24Y v�%ep as described
in the application for Disposal System Construction Permit No. 10'00'70 dated I'll 7/ZV0'Q.
I Provided: Construction shall be completed within three years of the date of this pe All local condi�'6n/s%ws be met.
Date ' - Board of Health / (/ 4i
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON
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r{ r{ r-I rd Id rd Id rd rd .d rd i d rd rd rd CHECKED BY:
i
a{ Ord Iv-0 Kd and DATE:
APRIL 29. 1"S
REVISED:
PRWECT NO:
FIRS - FL-OAR P a N -
SNEET NO:
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DATE:
APRiL 29. 1998
SCALE: .
REVISED: ',..
.t GOND Ff,QQR P Ag
PROJECT NO:
SHEET NO:
A5
TOWN OF BARNSTABLE
LOCATION q3 2 C lrw)A05 JoO SEWAGE # ? �-30-5
VILLAGE VnI����i' ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. Gd�i�Gvll C��1S 77/ .�99
SEPTIC TANK CAPACITY
LEACI-7—NG°FACILITY: (type) t si e)
I NO. OF BEDROOMS
i BUILDER OR OWNER
i
PERMIT DATE: fi - 2 COMPLIANCE DATE: I /ZPQCI
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
1 Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished'by
y
TO
7s^0N
AREA PLAN
S YS TEM PROFIL E
- - FINISt GRADE NOT TO SCALE
48,0 FINISH GRADE FINISH 6RADE '
NO TES:
-__- 49.5 :. ►.: —- C'VER TANK OVER TRENCHES _
TOP FAD '.; /k w�, ` /� /�J +//��� �` �/�, /♦�Y/� ,"// //W �M/ �/ r/w /
1. ELEVATIONS BASED ON N6V0 . •., ..• :�;�.:•. ., .:... ..;:�, ::.• ; ` ( . /
f
2. TOWN MA TER ON SITE " /L n •, `'' °:-;•: ,:,
4 3. FLOOD HAZAA0 ZONE 'C' {,� SCH 40 PVCOR
-- ,
., INi CAST IRON LEES `, _
C44 I�i 1 43_ 4
F nI� BSM' r FLR S 44 4
f �F ':` ( '� 1500 GAL ., EOUAL IZERS
4 i.' •' ►: REINFORCED ,�
� . ►. sAs DIST.BOX
.° CONCRETE BAFFLE '• S-
LINE BEARIN6 DISTANCE •K':___ :�• �'. �-°• _ .:. ' = �':, ''%t
r - TO BE INSTALLED ON A s
J N 54°05.19'E 43.06 / LEVEL STABLE BASE
CL49VE RADIUS ARC ' ` SEPTIC _TANK _ 41,0 I TRENCH LENGTH
1 52.50 22.59 10
E / / 51 TO BE INSTALLED ON A
1
LEVEL STABLE BASE "fig° - 0
`CA rCN�fiASJW 5'MIN.HEIGHT
p
F Q B EL. 51.80 - NOTE., DO NOT RUN HEAVY EOUI_ PME_N T _OVER SYSTEM ABOVE OBSERVED
09 `! GROUND WATER
L EA CH.ING INFIL TPA TOR SECTION
/ - NOT TO SCALE SOIL AND PERCOLA TION DA TA `
FOR FINISH GRADE , ♦ , .
�R 5 CEE SYSTEM }AOFI t F - APIAf ICA TIAN AV. P - B7B7 .•
+
«' �� �' P•r ^rrp«>• ,� �a'i,K'r� rrV �i.(/i�rcc i N'�/�`u�`` 1�"ri, rn�+;�Ce� S C. RA T _ y
> �r lip
WA EG rt?TiF PR H E � � 5 MIN/IN.
� .
` •�� ti /,c+ _ (12"MIN.l 'Y TAKEN BY
_ / r/ :,. ;,,,.•:, .• WITNESSED BY So,
f� 4"DIA.PIPE /a' �g•:;•. ,?:�-_r__ DATES&prEAjNR ---
.,, ,
TEST PIT ELEV. EL.47.0
1
• � _ _� / T: • `�• -• e•.� MST LADLE 1 AEL.17.01 TEST MOLE 2 (EL.I7.0)
NA TURAL SOIL °•0 °,. ,o EFFEC
DEFTHT IVE 0' E- - --'_ _ -- -- o'
i / •E • O A/ 'A/
SANDY LOAM 10YR 41*2 _ � SANDY LOAM 10Y14 4/2
WASHED STONE -- 1 /•.•Y'::.�'.'•:�:.�;: . %•. ';� .. ';;.;`. �•',•� ':tw• •B• Y B'
EFFECTIVE WIL'TH SANDY LOAM 10YR 5/6 SANDY LOAM 10YR 5/6
EXCAVATED SIDEWALL so'-t0' _ — _ 30• '
f S�• NVMBL;H OF rR NCHES SANG 2.3Y 7/9 SAND 2.3Y 7/9
g coarse sand ; coarse send
LOT 5 NUMBER OF INFIL TPA TORS -_7
LOT 7
5.1, 508'SF _ —___._. -. . . _., __...-__ _. _ 120
_AQm
N p• DESIGN DA T HATER
A
ti _-PY.,?5 S. F. SIDEWALL AREA , GAL S/SF �� GAL S.
� t � ��\ � s NO. OF BEDROOMS 5
i 1
( _ 52�_ S. F. BO T TOM AREA DISPOSAL
� , \ .._74 GAL S/SF_3B4 GALS. �--
�"" _755_ S. F. T17 TA L AREA GAL S/SF . 55B GALS. SETT TOTAL DA Ia G L Y rEFADENT Q_ GALS.
SEPTIC TANK GAL .
GENERAL NO TES
Qm
64� �,�\ •' NO TE.° 1 . ALL S YS TEM COMPONENTS SHALL BE INSTALLED IN
ACCORDANCE WI TH TI TLF 5 OF THE S TA TE SA NI TARY CODE
EXCA ATE TO E L E V. OR LOWER AS REQUIRE D
TO Pr-MOVE ALL LOAM AND CLAY vON r4 THING DATED MARCH 1995 AND ANY LOCAL RULES APPL ICABL.E
Z ( � `-r ••'' BgsFy�sF Y ! MATEdIAL BENEATH THE LEACHING AREA.REPLACE cam., A/VY CHANGE IN THIS PLAN MUST BE APPROVED
EXCA -"A TED MA TERIAL wr TH CLEAN CL A Y FREE G'RA VEZ BY THE BOARD OF HEALTH AND FERREIRA A SSOC.
Arm / MECHANICALL Y COMPACTED IN' PLACE
-3 WHEN CONS TRUC TION IS COMPL.E TED, PRIOR TO BA CKFI L L ING
NOTIFY BOARD OF HEAL TH FOR INSPECTION
4. FND. EL E V. MUS T BE CHECKED WHEN COMPL E TED
LEGEND 5. THESE EL E V. MUS T NO T BE CHA NGED WI THOU T
— THE BOARD OF HEA L TH APPRO VA s
T 4E1 A°`' mrm (7' 6. BOARD OF HEA L TH INSPEC TION REO 'C WHEN EXCA VA TED
t IWA rRA rORS MYYN
+ —44 i sraE ALL AMX#WV 48 EXIST, GROUNL ELEV.
y x W-10/ • x 2'
(REVISED: 5/18/00 SHOVING (5) BEDROOMS - ADDITIONAL LEACHING)
4 � ! " „--- / ;� /r fez a+�rL�. �•
12 •F, FINISH GROUAV ELEV.
/ Zo• .20 Sf '�-- --, , SEWAGE DISPOSAL SYSTEM PLAN i
j Z•Zh PIPE INVERT ELEV. '
L__ G G IRA — PREPARED FOR 4
1 I r TES T PI T L OC'A TION
/ 5 !n�► 31309
SEPTIC TANK FRED TONSBERG
, _<•- +S� 30
�F n DISTRIBUTIOf BOX ---% LOT 7 FA IRMINDS DRIVE
4 C. I.OR SCH 40 PVC BARNS TABL E - MASS.
44 OF
�A 4"BIT FIBER PIPE-TIGHT JOINTS
O �/- F r
PROPER L Ih/ES o �a( '} Sw --- _ � 01�9'�` DESIGNED� SAP DATE : MAY '.� 2000
.IFT LAB„ --- -_ 4.------- �...�. SETBACK DISTANCE �i � � ' F �° ;e- FERREIRA ASSOCIATES
165 21 7 � Q/S T SY, `��, DRAWN : SCALE.'AS SHONN 131 SPRING BARS ROAD
MAP SEC PCL HSE
?VAL ENO CHECKED : ORANING NO.' FALMOUTH - MASS.
_ LOT ._ • r � ososoo