HomeMy WebLinkAbout0114 SETH GOODSPEED'S WAY - Health 114 Seth Goodspeed1 ;
Osterville
r
�. A= 122-090
Y
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7
TOWN OF BARNSTABLE
LQCATION //LI Sed ,mil //&y SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL/ 1,2
INSTALLER'S NAME&PHONE NO.�,�/«���i�Gldi✓.�^� Sz�3-r/�J-7/Sf
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) A 5Z'o Qle'll� (size)
NO.OF BEDROOMS 3
OWNER /n,/d�,i.✓
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 61*;*e' ,4&r 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 ��(��
�oc�'-fig ley Soh��Js�o��J 1A)C,
33,S
'(3 T".29
7-53,T-
G�.-70
P
i
Ljq1 J�l
No. v Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_6Z
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Altlflratlon for MispoSal *psirm ConstrUrtlon 1Prmit
Application for a Permit to Construct( ) Repair(V111"Upgrade( ) Abandon( ) ❑Complete System �dividual Components
Location Address or Lot No. I/ 5et-11 Pe U y Owner's Name,Address,and Tel.No.
4s+-Crvt lI e
Assessor's Map/Parcel a Z -- D �Ltr ►� L d 1 A) r!.
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
lac �Us (Z, 1,,x sm_,/ 7/57 ,,, c ALC
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building -1 G` No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 30 gpd Design flow provided gpd
Plan Date /2 8 J:7 Number of sheets Revision Date
Title
Size of Septic Tank e ti C i-j a Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the.construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of 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 Health.
Signe Date A ,Z
Application Approved by 1 Date
Application Disapproved by , Date
for the following reasons
Permit No._ � / 7. VVa-L Date Issued 1 2.
s Al
rr No. f Fee ..s''
' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes
' _
� PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
—.1- Plication for sposal *psim Construction 3permit
'l ,�
Application for a Permit to Construct( ) Repa�i ,1��Vd1 x. Uipgrade( ) Abandon.( ) ❑Complete System DyTndividu'al Components
Location-Addressor Lot No. //y SeA u.)L-,,/ Owner's Name,Address,and Tel.No.
Us.tery l I e �r �, -
Assessor's Map/Parcel — Q 1 E d �4�
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
J
Type of Building:
Dwelling No.of Bedrooms .3 t Lot Size sq.ft. Garbage Grinder
Other Type of Building (PS1cJ 1 G 1 No.of Persons Showers( ) Cafeteria( )
' Other Fixture''
Design Flow(min.required) 3`30 gpd Design flow provided 3 4-18 f 7 gpd
;Plan Date /2 - —/'7 :Number of sheets Revision Date
hi L
Title '
K ize of Sep.c Tank 'k ti m 1-1 N Type of S.A.S. �. SCX� CgCc IG� - !C? f�`�Gty,�ps. (t)jt Gl
.. yP 4
Description of Soil 5} �
Nature of Repairs or Alterations(Answer when applicable) I ti71.3'fG � G N '100 0.x) x S-c a �o�
Date last inspected:
Agreement:
z.
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 Health.
�. $igne J / Date �' 1.2
d_.
Application Approved by Y ;:DDate
Application Disapproved by , Date
for the following reasons '
Permit No. Date Issued
4.
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS-
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) t Repaired( ) Upgraded( )
Abandoned( )by , `' T
-- at " d thas been constructed in ac6rdance-- -
with*the provisions of Title 5 andd the for Disposal S stem Construction Permit No. D 0 17^. .dated 1212
Installer ,a JG /4 f Designer- 4;57n ,Vrrr/�✓f
#bedrooms Approved design floes 1 grid
The issuance of this permit shall not be onstrued as a guarantee that the system ill funcc ion as�designed.
Date ram•- � / Inspector
No..., — 11 Fee' /(? 0
' THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal 6pstertt,onstructiou permit
t
Permission is hereby granted to Construct( ) Repa'r"( 1�, Upgrade( )-) Abandon(. )
System located at P j py U/l(/e
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. _
Date I �� ( -f,� Approved by
r
Town of Barnstable
Regulatory Services
Richard V.Scali,Interim Director j
• BARNSTABLE.
hra� Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,VIA 02601
Office: 508-862-4644 s Fax: 503-790-6304
Installer&Designer Certification Form
Date: I Z 10 i7 Sewage Permit#;�)01I-yN 2 Assessor's tMap\Pareel Z_
Designer: 5�ngiAeerinra Wor"L(s,jri Installer: J>./�
Address: iZ. W, Ceb,_,-C e lJ Rd Address: C, 9611- I Y.5
J:�;,esEda1Q MA 62.644
4
On 10.' Ia.`1 l /����' �'�,` � f � was issued a permit to install a
(date) / (installer)
septic system at /1 Y ,X 6e.,,4su= � Ut c�y based on a design drawn by
(address)
Evt�ins ems:n�1 Wu Lu 111 C, dated I Z Z 17
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
i
1 certify that the septic system referenced above was installed with major changes (i.e.
greater than 1 W lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&.Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
1 certify that the system referenced above was constructs nee with the terms
of the RA approval letters(if applicable) tMOF
'PETER T.
WENTi
CIVIL
alleys Signature) NO.35100
r AFGt3TE
�
, �A L— �e
(Designer's Signature) (Affix Designer tamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISIONr. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTII THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:1Scptic\Designcr Certification Form Rev 3-14-13.doe a r
, 3.
�VE Tom,
Town of Barnstable Barnstable
Regulatory Services Department
MOLL 1 11151
9� . m� Public Health Division
�FDA"A�A q 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4990 1369
December 5, 2017
WARREN, ERIN L
114 SETH GOODSPEED'S WAY
OSTERVILLE, MA 02655
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 114 Seth Goodspeed's Way, Osterville,MA was inspected
on 11/15/2017 by Chad Hathaway, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching facility with standing liquid level at or above the invert pipe (per
Town Code 360-20 h).
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
IPCK!ean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\114 Seth Goodspeeds Way
Osterville.doc
ToWn of Barnstable
+ aaarrcTtare � -
�,� Regulatory Services Department
Public Health Division
200 Main Street,Hyannis MA'02601
Office: 508-862-4644 Richard ScA Director
FAX 508-790-6304 Thomas A McKean,CEO
Feb 6, 2007
Rev. 5111116
DEADLINES TO*REPA.IR FAMED.SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000) _
An"x"marked'in the ❑is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑Discharge or ponding of effluent to the surface of the ground .
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe. :.
❑Backup of sewage into the house due to au overloaded or clogged SAS or cesspool
ONE(1)YEAR DEADLINE CRITERIA •
❑Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis.'(This system passes if the water analysis
indicates the well is free from pollution).
LINEq Smgle Ce�D��E�.AD
❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
o Leaching pit or cesspool with high liquid level, < T'below.inlet(per Town Code
§360-9.1)
Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:�SEPTIMDEADLINES TO REPAIR FAILED SYSTEMS.doc
i
Commonwealth of Massachusetts 9O
Title 5 Official Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Form
luntary Assessments
vp 41)
114 Seth Goods eed's Way CD
Property Address
o Warren
Owner
Owner's Name
information is
u
required for every Osterville
page. City/Town Ma State 11/15/17
Zip Code Date of Inspection
13
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 forma
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor- not Chad Hathawa use the return `
key. Name of Inspector
H.P.S.
Company Name
P.O.Box 151
�I Company Address
' Forestdale
City/Town , Ma 02644
774-274-2581 State Zip Code
Telephone Number 12866
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. 1 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
In ctorsSignature - 11/15/17 I
Date
The system inspector shall sub ' a cop of this inspection report"to the Approving Authority(Board
of Health design
DEP)within 30.da 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. .
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
, � vs
i
Commonwealth of Massachusetts
Title 5 Official Inspection
Form
Subsurface Sewage Disposal System Form m-Not for Volunt
ary Assessments
ugl 114 Seth Goods eed's Way
Property Address
Warren
Owner information is Cw ners Name
required for every Osterville
page. CitylIown Ma 11/15/17
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: f
❑ 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 Conditionally Passes: M
❑ 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•3113
Title 5 Official Inspedon Fore:Subsurface Sewage Disposal System-Page 2 of 17
I
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
114 Seth Goods eed's Way
Property Address
Warren
Owner information Owner's Name
is
required for every Osterville
page. City/Town Ma 11/15/17
State Zip Code- " Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health a
Pumps/alarms are repaired. pp royal if
B) System Conditionally Passes(cant.):
❑ 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 p d
❑ 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 pipes 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):
F
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.
I. 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 environments
❑ Cesspool or privy is within 50 feet of a surface wat
er
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113
Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f -
Commonwealth of Massachusetts
wiTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
114 Seth Goods eed's Way
Property Address
Owner
Warren
information is Owner's(dame
required for every Osterville
page. Wity/Town Ma 11/15/17
ki
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 but50 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
than %day flow volume is less
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sawage Disposal System-Page 4 of 17
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System For -Not for Voluntary Assessments
114 Seth Go ods eed s Way
Property Address
Owner Warren
information is Owner s Name .
required for every Osterville Ma
Page. City/Town 11/15/17
State Zip Code Date of Inspection
B. Certification (cont.)
Yes . No
11 ❑ 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 facili with
design flow of 10,000 gpd to 15,000 gpd. ty a
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 sup I
Elthe 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 an p Y
Y y 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 It 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•31.13
Idle 5 Official.inspedlon Form;Subsurface Sewage pill SY��,Page 5 of 17
f
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
114 Seth Goods eed's Wa
Property Address
Owner Warren
information is Owner's Name
required for every Osterville
page. CitylTown Ma ' 11/15/17
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?
® 0 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 3
. Number of bedrooms(actualj:
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins-3113
Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 official Inspection
Subsurface Sewage Disposal System ForVoluntary for �ry��
Assessments
'yf '- Seth Goods eed's Wa
Property Address
Owner Warren
information is Owner s Name
required for every Ostervllle
Page. Ci Y,I own Ma 11/15/17
State Zip-Code Date of Inspection
D. System Information
Description:
Number -of current
nt residents: r 5
Does residence have a garbage grinder?
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.) ❑ Yes ® No
Laundry system inspected?
❑ Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last.2 years usage(gpd)):
Detail:
v
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•3113
Title 5 Official Inspection Form:subsurface age Disposal System-Page 7 of 17
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments..
V 114 Seth Goods eed's Way
Property Address
Owner Warren
information is Owner's Name
required for every Osterville
page. Cityrrown Ma 11/15/17
State Zip Coe Date of inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
y ,
Source of information: owner pumped summer of 2017
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-3113
i
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�( 114 Seth Goods eed's Wa
Property Address
Warren
Owner Owner s Name
information is
required for every Osterville
page. Cityi I own Ma 11/15/17
State Zip Code Date of Inspection
D. System Information (Cont.)
Approximate age of all components, date installed(if known)and source of information:
tank and pit on anal to house . plastic chambers added 1993
Were sewage odors detected when arriving at the site?
- ❑ Yes ® No.
Building Sewer(locate on site plan):
Depth below grade: 2'
feet
Material of construction:
❑cast iron (D 40 PVC ❑other(explain):
Distance from private water supply well or suction line: 26+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
------------
Septic Tank(locate on site plan):
Depth below grade: 1:5'
" 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 gal
Sludge depth: 1
t5ins•3/13
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 Foolu
Not for Voluntary Assessments
114 Seth Goods eed's Wa
Property Address
Warren ,
Owner Owner's Name
information is
required for every Osterville
page. Cityl Town Mee Zip Code Date of inspection 11/15/11
D. System Information (cont,)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 33"
Scum thickness 1„
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 1811
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
um eve 2-3 ears as maint. to protect le )leaching.. s m lace no visa
P a p ble cracks or leaks
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑metal
y ❑fiberglass ❑.polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle j
' Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins•3/13 '
Date
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts `
Title 5 official Ins . ectio'n Form
`€
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
114 Seth Goods ed's Way
Property Address
Warren
Owner Owner s Name
information is
required for every Osterville
page. City/Town Ma 11/15/17
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
❑ c ete
me
❑ taCEl 4 fiberglass
_ polyethylene Yeth
Y en e othe
r(
explain).
Dim
ensions:
Capacity:
gallons
Design Flow; .
gallons per day,.
Alarm present:
❑` Yes ❑° No
Alarm level:
"Alarm in working order: El 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?
k ❑ Yes ❑ No
a
t5ins•3113
Title 5 Official Inspection Fora-Subsurface Sewage Disposal System Page 11 of 17
Commonwealth of Massachusetts x
Title 5 Official Inspection Form
ii
Subsurface Sewage Disposal System Foolu
Not for Voluntary Assessments .
i
114 Seth Goods eed's Wa
le
Property Address
Warren
Owner 's
information is Owner Name
required for every Osterville
page. Cityi I own Ma 11/15/17
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 U
Comments(note if box is level and distribution to outlets equal, any evidence of.solids carryo
evidence of leakage into or out of box, etc.): ver, any
no Dbox
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.):
3
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not loca
ted, explain why:. .
t5ins•3113
t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection F
Subsurface Sewage Disposal System For-Not for Voluntary Ary Form
ssessments-
114 Seth Goods eed's Wa
Property Address
Warren
Owner 's
information is Owner Name -
required for every Osterville
page. Cnyt I own Ma 11/15/17
State Zip Code Date of Inspection
D.System Information (cont.)
Type:
® leaching pits number: 1)6x6'pit and 3
plastic infultrators
❑ leaching chambers number:
leaching galleries' number:
leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool . r
number:
❑ innovative/altemative system
r.
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
leach pit was full to top over invert and outlet pipe to infultrators. Inspected plastic infultrators through
plastic knockout in top of chamber. plastic chamber was fuull of water.
r •
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
. i
Indication of groundwater inflow
❑ Yes ❑ No
t5ins•3/13
Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 13 of 17
.J
Commonwealth of Massachusetts
Title 5 Official Ins ectior ,
Subsurface Sewage Disposal System For-Not for Form
luntary Assessments
114 Seth Goods ed's Way
Property Address
Warren
Owner owner's Name
information is
required for every Osterville Ma
page. CitylIown 11/15/17
State Zp oCde Date of Inspection
D. System Information.(cont.)
Comments(note condition.of soil, signs of hydraulic fail
etc.): ure, level of ponding, condition of vegetation,
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•.3l13
Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts,
Title 5 Official ins �ection Form
M .
' Subsurface Sewage Disposal System For-Not for Voluntary As
114 Seth Goods eed's Way
Property Address -
Warren
Owner Owner shame -
information is
required for every Osterville -
Citylrown Ma, 11/15/17tate ` .Page S l:
P Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,'Iincluding 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
,
I _ .
' + I .O.
' 4 - O
�3 493
4 3 coo b
t5ins•X13
Title 5 official inspection Form:subsurface Sewage oisposal System-Page 15 of 17
commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
114 Seth Goods eed's Way
Property Address
Warren
Owner Owner's Name
information is
required for every. Osterville
Ma 11/15/17
page. City/Town State Zi Code
P Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 40'
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 160 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: h
town GIS Ma in 'lot is el 60. Low pond area close by el. 20
Before filing this Inspection Report,please see Report.Completeness Checklist on next page.
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth-of Massachusetts
.129 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form. Not for Voluntary Assessments
••y�< 114 Seth Goods eed's Way
Property Address
Warren
Owner Owner's Name
information is
required for every Osterville Ma
page. Cizy wn 11/15/17
State Zip Code Date of Inspection
E. Report Completeness Checklist .
® Inspection Summary:A, B, C, D, or 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•3/13
TWO 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable P# 5�5r5
oF� .
Department of Regulatory Services
;��� Public Health Division Date Z�
�A 1.6.59. ",�$' 206 Main,Street,Hyannis MA QIWI
Date Scheduled.
Tlrne Fee:Pd. `t') 60 c od
Soil Suitability Assessmen ,dot Sewa "DisPosa�
PerformedBy:-_ -ek� �� � -S�-�� � Witnessed liy:'
x
LOCATION&,GENERAL INFORMATION
Location Address" l Owner's Name,
� se%�► G�Psao-e-eo(s(t,�� Ga GIs -����S
11 Address 'ILe /!��- C9 Z(o Z
Ce�pe�'
Asscssor's`Map%Pelee(:.: Engineer's Name ���+1� �C
6,19�,�e� �5
NEW CONSTRUCTIpN REPAT c�Telephone �r/
� ..# 5 ��
Land Use a3 t C/bl��` Slopes 0b) — \ .. Surface Stones, �-
Distances from: "Open:Wafer Body--", 11 ft Possible W.et Area ft, Drinking Water Well. �t
DranageWay /v I� . " .ft :Property, '77S-"ft Other ff
SKETCH:(Street:name;,dimensionsof lot,exact locations oftest holes&percdests,locate weilands fn proximity to holes)
��u '
h-eA
1 77�g
1-��kia�
Parent material(geologic) Depth°to Bedrock:
Depth to Groundwater. Standing Water"akIole: d - Weeping from T'it Pei e Wad
Estimated Seasonil igh.Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: _ in, Depth to Sol]Mottles:
Depth to weeping from side of.otis.hole: in, Grotmdwater AdjMtment' it.
Index Well Reading Date: Index'Welf►evel � AiJ,Cactor Adj,CiroufldwaterLevel',,,,,,
PERCOLATION TEST Doe Time
Ofis&vation
Hole# I Time at 9"
Depth of Perc 1 ` `1 Time at 6"
Start Pre=soak Time.'@ - G u5' M Time(90.611
End;Pre-soak
Rate:Mih Inch
Site Suitability Assessment Site'Passed Site:Failed:. Additional Testing Needed(YLNj
Original: Pdblic Hcaith.'Di.vision ObservaEion Hole Data,To Be`Cotnpleted on Back----=-------
iic**jfpercolat on test is to lie conducted within LOU'of1wetland,.you must first notify the.:"
Barnstable:Conservation Division at Least one(1) week prior to beginning.
Q:\S EPI'ICIPERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole.# 1
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface;(in;) (USDA) (Munsell) Mottling. '(Structure;5tonesFioulders.
o • ten, ravel
0Y�' 1z
Z'l`V�'i C- tu4 6QVIJ 2,5. ly.
DEEP`OBSERVATION HOLE'LOG Hole# —`
Depth from Soil Horizon Soil Texture Soil Color- Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders:
consistency.% ;rave
D A Cc�w► Suh� la`l�- `� z
DEEP OBSERVATION HOLE LOG Hole
Depth:from Soil Horizon Soil Texture Soil Color Soil Other.
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistencv,%.Gravell
DEEP OBSERVATION HOLE LOG, Hole
Depth from Soil Horizon Soil Texture' Soil.Color Soil Other
Surface(in.) (USDA) (Munseil) Mottling (Structure,Stones,Boulders.
• on§i en
Flood Insurance Rate MU]2--
Above 500 year flood boundary No— Yes
Within 500 year boundary No,_,k Yes
Within lOQ year flood boundary No Ye5, ;.;,
Death of Naturally Oecurrinl'Pervious.Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the Soil absorption system? _ y
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)Ihave passed the soil evaluator examination approved by the.
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required expertise and experience described in.310 CMR 15.017.
Signature (rig& Date 12, 9
v
Q:\sEMWERCFORM.DOC
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE:o1q 115 Fill in please:
4 e s k1 t
APPLICANT'S YOUR NAME/S: O,5 ouJa r r-
`'r... "'�BUSIINESS/� I/_ YOUR HOME ADDRESS: I �( SC___ftn 10c)(I
1�'` I b t).."1"�"[,�J In/4
TELEPHONE # Home Telephone Number- 79 1-"7 9r71Y5
NAME OF CORPORATION: 0. &I CL o r
NAME OF NEW BUSINESS TYPE OF BUSINESS ' InU P_ P. o 0
IS THIS A HOME OCCUPATION? ES). NO
ADDRESS OF BUSINESS I C . r-vi!I—MAP/PARCEL NUMBER Iola` (Assessing) .
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this ton. -.
1. BUILDING COM�hQ
R'S OF ICE
This individu infer a y p rmit requirements that pertain to this type of business.
MUST COMPLY WITH HOME OCCUPATION
Aft oriz Sigr�at ** RULES AND REGULATIONS. FAILURE TO
OMMENTS i �'—'�� v Y _SULT IN FINES.
2 r
2. BOARD OF HEALTH
This individual has bFf
med of he ermit requirements that pertain to this type of business.
A -horiz d Signat re
COMMENTS: -�, Y`e��E'� ens . Opr o,'rca, T,,, Nlc&_
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
4 •
Commonwealth of Massachusetts
Title 5 Official Inspection Form C®
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
114 Seth Goodspeed Way
Property Address
Wade/Hudson i
Owner Owner's Name
information is C-entervltte Ll$!�IQ r�( Ile, 22 b 1V MA 02632 8/30/2012
required for
every 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: A. General Information
When filling out pp
forms on the
computer,use 1. Inspector:
only the tab key
to move your Wayne Archambeault
cursor-do not Name of Inspector
use the return
key.
Company Name
� PO Box 914
AA Hyannis MA Zip 01
Co
renen City/Town State � Zip Code
508-775-1362 355
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 16,340 df
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails+ J
❑ Needs Further Evaluation by the Local Approving Authority
8/30/2012
I ector's Signature Date
The system inspector shall submit s 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-,conditi.ons at the time of inspection and under the conditions of use
at that time. This..inspel n does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title 5 Official Insp do Forth:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is Centerville MA 02632 8/30/2012
required for
every 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: f
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"11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 2 of 17
f
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is required for Centerville MA 02632 8/30/2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): f
❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is Centerville MA 02632 8/30/2012
required for
every 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
El ® 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 %day flow
t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form-
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is required for Centerville MA ' 02632 8/30/2012
every page. Citylrown 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.
stem must serve a facility with a
Large S stems: To be considered.a large system the s ty
E9 Y Y
Y
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
,M 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is required for Centerville MA 02632 8/30/2012
every 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 4
® ❑ 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?
® El available
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
® El 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
114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is required for Centerville MA 02632 8/30/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
I
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 ears usage d na
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 8/30/2012Date
Commerciallindustrial 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 Forth:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is required for Centerville MA 02632 8/30/2012
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: owner
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 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is required for Centerville MA 02632 8/30/2012
every 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:
tank unknown SAS installed 6/23/1993
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
tank in good condition tees at proper heights
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.5'x5'x5'
3"
Sludge depth:
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
114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is Centerville MA 02632 8/30/2012
required for �-
every page. Cityrrown 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
37"
2"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? measuring rod
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 stucturaly sound all tees at proper depths
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
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
114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is required for Centerville MA 02632 8/30/2012
every page. Cityrrown 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):
a 1
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
. Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is required for Centerville MA 02632 8/30/2012
every 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 na
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.):
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.):
I
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
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is Centerville MA 02632 8/30/2012
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
® leaching galleries number: 3
❑ 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.): '
1000 gallon leach pit installed after tank in hydrulic failure used as distrbution box
3 infiltrators with 4' of stone around used as new SAS
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
M SVey'�. 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owners Name
information is Centerville MA 02632 8/30/2012
required for
every page. Citylrown 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.):
i
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.):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is required for Centerville MA 02632 8/30/2012
every page. Cityffown 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Assessing As-Built Cards Page 1 of 1
d Aexh-et X,4 v�j lkl
TOWN OF BAR�N�SiTABLE
LOCATION II y cJN C-CaOSFzL�S �{'/ /�I SEWAGE #
VILLAGE' ASSESSOR'S MAP & LOT U!D
INSTALLER'S NAME•& PHONE NO. 141000 Cbas 0
SEPTIC TANK CAPACITY U U
3 f N
LEACHING FACILITY:(type)I loco i %v e)-�
NO.OF BEDROOMS PRIVATE WELL PUBLIC WATER
BUILDER O OWN f VC-�S i= LAX L�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:: G,1 �
VARIANCE GRANTED: Yes No
0
1040,c
•'�• ffJ• 4(0�6 q
y
r
- http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=122090&seq=1 8/30/2012
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'4 M
114 Seth Goodspeed Way
Y
Property Address
Wade/Hudson
Owner Owner's Name
information is Centerville MA 02632 8/30/2012
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
>16'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
town ground water maps
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
ground water>16'
bottom of SAS 5'
seperation >11'
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
4 M s 114 Seth Goodspeed Way
Property Address
Wade/Hudson
Owner Owner's Name
information is Centerville MA 02632 8/30/2012
required for
every page. Cityrrown 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
�! 1
j Mir C. TOWN OF BARNSTABLE ,
LOCATION 6Z00ASPzf-jDS f-d SEWAGE # �;3>:3Q 2—
VILLAGE_ QS /Z(//LLL ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. 14le XO 40,�Js '�—
SEPTIC TANK CAPACITY o U
LEACHING FACILITY:(type) j o G'
NO. OF BEDROOMS_PRIVATE WELL PUBLIC WATER
BUILDER O OWN tPt� t�GS LAC' L`r
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No V
h,
e
0 b
No...�,�,, ... a, - Fsa...�.X�....
THE COMMONWEALTH OF MASSACHUSETTS
APPROVED BOARD OF HEALTH
pamstablo Corr T N OF BA RN STA B LE
trar - for Div wial Works Tomitrur#tnn Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair. n Individual Sewage Disposal
System at;''
....... Y.`7........... ............................... -------------------------------------------------•--•-------........---.....-•---•......------...
Location-Address or Lot No.
•------------------•-.._...._.._.. --• ............................ ------------------..-.-----
--
Owner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons----------------------------- Showers ( ) — Cafeteria ( )
a Other fixtures -----------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity...........gallons Length- _--.____ Width................ Diameter................ Depth................
x Disposal Trench— No. ..................... Width...:................ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) ,Dosine.tank ( )
Percolation Test Results Performed by............................................................ ............. Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fx
0 Description of Soil........................................................................................................................................................................
W ••••.._..-•••--------------•----........•---...•••-------.....------•........---...--•--•-•-•-----•-----••••--•-----••----------•--•-•-•---••-••----•-•---•••••--•••--••-•••.._.......-_.....//_...••••--
UNature of Repairs or Alterations—Answer when applicable.... -------.._-_ _--__.�^'C=`-0?'np n....... l.._........
.Z� ..._5`� ^'z-....... �� i`-j-.....-----•-----•. ..........................................•--..........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been iss ey d b the e board of,health.
Signed ........ ..v- ...............................'" ................................... ........
Dace
Application Approved Be -t.... G-.a .- .��
PP PP Y ............... .
Application Disapproved for the following reasonf: ......................................................... ........................ .................................................
...... ....... ......................... . ................................................. . ................ .......... ................................ ............... ........................................
Date
.......Permit No. 5........ 0..,�?,...... Issued ..................la.-. -.3..-. '�...........
Date
�Dt'd'JL^`►.�s'�.;,r;..—,i.'�—ui>..-..�:..�—w'-...:1+..�yr=L�.�:..\„vrv`r+�,r> ;.ri-,-..r..�.r►---..•.J?,.+:L.-i«.-e:....n::..::.��.J....�--,e..,.�....�- �Q'��"�`I--�t�.�,�r•e...J..hvY.J --r,r �<J•�.+T►+4:1'
............
THE COMMONWEALTH OF MASSACHUSETTS
s
- BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphration for Di!ipil ial Works C onstrnrtion lirrmit
Application is hereby made for a Permit to Construct ( ) or Rep-. n Individual Sewage Disposal
System at:
.. 1!.` ......... TffG�� �4_ ------------------------------- ----------•------•--------.....•-••-•---...-•-............................-------•----...------.--
Location-Address or Lot No.
aP.W.3.C20 S......................-............................ � l=- ------------------•----... --•-•••.Cam-......-?�v....... -------•--•-----------•----------......._.._...-------•
----•-----------
Owner Address
a .... . . ....... 4..........!�n,s -----•--------------------------•-•-•----- ......Yt oSk rZ 4......... _!•---- ---••H f-^►vNHS
Installer .....................
Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Pk
Other—Type of Building ____________________________ No. of persons--------------------_------- Showers ( ) — Cafeteria ( )
d Other fixtures ------------------------------------------------------
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length________________ Width---------------- Diameter.-.............. Depth................
x Disposal Trench—No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 6
aPercolation Test Results Performed by.......................................................................... Date--- ....................................
Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
fZ Test Pit No. 2................minutes.per inch Depth of Test Pit.................... Depth to ground water........................
R+' •-•-.......--•-•-•--•-------•-•---•-•-••--•-•-•-----••-----•-------••------••--••-•----•------------.........................................................
0 Description of Soil........................................................................................................................................................................
x
w
U Nature of Repairs or Alterations—Answer when applicable___ .............�__.__._(^��_.!( C�?,��aYr?_ �_! ..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed - \ -. �.a--��� -�=>r_--a.........................'........................... ------ .......
Date
Application Approved By .............
. .,... ... ......,...................................................................
v �}
�� Dace
Application Disapproved for the following reasons: .................... ...................................................-- ............................. ............
......... . .................................. . . -- - ................................ ...... . ...... .................................................... -- ........................................
Dace
Permit No. c......,......_....-................C.2..1-')V................. Issued .................. .--.�...�.-...1..'.'�......--
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cie rtifirate of Cnotttplialar e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired(()
b F�cN `t....... ..._�dS.�C'...... ........ . .. ll
... Install",
at ...............4.�`(...... .. S�Tt-� C�.b1t, �' .................... �.. . ------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ......_..r�.,3-------3.0.)- dated ..._...............................__..._..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............. ....... _. .... ....................._.. Inspector ............. ..,... Z �.............................................................
---------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
qq--,, TOWN'OF BARNSTABLE
No.... ,. FEE.... -...-----
Biquinttl Workv Tnwitr -it Vrrntit
Permission is hereby granted--------- _��.1L�=. ..........�a� S
---
to Construct ( ) or Repair .(i'epan Individual Sewage Disposal System
atNo........A. 4-----•--...S ? '= � 'P %,. Q L .............................................!•
street Cpp C
as shown on the application for Disposal Works Construction Permit Nol_�'.�f�.�-,_ Dated...... .-��-_�---/_..
.......
'lam:
Board of..Health
DATE............ .� .
FORM 36508 HOBBS h WARREN.INC..PUBLISHERS
No.........?!V-------- ....................
THE COMMONWEALTH OF 'MASSACHUSETTS
----BOARD F HEA
-4
....... OF...... .. ....:.....I& -----------------------------------------------------
Appliration -for Mipasat Workti ns otrurtion Vrrumfit
Application is hereby'made for a Permit to Construct � or Repair an Individual Sewage Disposal
System
...............
- ----------------------*......................................
ocation Ad or Lot No.
G/%%
...... . ........ .............................. ....................... M ..... .. ... ..... ..................'A
Of e f ` Address.. .......
.... .......................................................................... ............... .......................... ....................... .
Ins aller Address
Type of Building Size Lot..,/-i- 0.17-.Sq. feet
Dwelling—No. of Bedrooms--------3........................_------Expansion Attic Garbage Grinder
Other—Type of Building ---------------------------- No. of persons-------_------------------ Showers Cafeteria
Other fixtures --- ----------------------------------------------------------
------ -----------------------------------------
Design Flow-----------6n.2.............. ga ons per pet-son per day. Total daily flow..........7a__0__0--_-----_-------gallons.
a 0 Septic Tank—Liquid capacity/it gi-----gg 'Ions Length................ Width.._....___.-. Diameter.._.__....__... Depth.__._._...._.
x Disposal Trench—No. ............ ... ------- T Len
gth._....._.....___............
W01------------- T_o�teaching area--------------------sq. ft.
97 -,§ "ezl��_;V -- area. :3
Seepage Pit No .............. "M _11, ... W 70 �1 0 lung,......... --- -------------- 0 _1_ _ak_.sq. ft.
) � , 1. 77
PWeAC" er-A
Z Other Distribution box ( )0 Dosing tank (
Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------
a Test Pit No. I................minutes per inch Depth of Test Pit_.__--_-_-__--____-. Depth to ground water...._...................
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-.----__------.-_....----I-----_------------ - --------------------------------- ...e.1
0 r ___-Z ...........
�, , ----------- /............
0',, ----i_
Description of Soil-......(!:�:4------I -.&e- ._—d, ------- ----------- --- -----
U ........................N . .. !----------------------------------------:------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 and Y health.
-----An 21>
........ _�..... ------------------------------- --- --- -- -------
at
Application Approved By---------- V- ................... ...... .. ... _77------
e Date
Application Disapproved for the following reasons:-----------------------------------------------------------------------------------------------------------
.........................................................................................................I-----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued-----------------------------------------------L......
Date
——----------—------------ ..........
No............. /--- X° F .......................
THE COMMONWEALTH OF MASSACHUSETTS
,BOARD OF HEALTH
'r'..h ...................................................
Appliraf ,an -fur Biquoml Works Tonstrurtton Vanift
Application is. hereby made for a Permit to Construct (;-'Repair ( ) an Individual Sewage Disposal
S stem at•i f - .
Sy stern
.. ,.� r .....`-�-ta .•r, ..'�.�.,,fir?
i Location-Address ,�" f or Lot No. <
(. ... . C.
Owner'♦ / Address
Installer i Address
U Type of Building Size ... __Sq. feet
Dwelling—No. of Bedrooms---___-;................................Expansion Attic ( ) Garbage Grinder ( )
Other—a Type of Btilding ------------------ -------- No. of persons.------_-.------------------ Showers Cafeteria
Other ( )
fixtures �-------------------=----------------------- ---------- ------------------------------------------------------------------------------------
W Design Flow------------ .......................gallons per person per day. Total daily flow---_.___._.-__O_.Q...___......___,..gallons.
R: Septic Tank—Liquid capacity,Z� ons Length................ Width---------------- Diameter------.--------- Depth.___--._.------
Disposal Trench—No........... ....... NVidtll.............. Total-Length------------------ Total leaching area-.--.--_-_ -_. sq. ft.
Seepage Pit No —/ D amete "_'`.r......... De'Pth�bel inle�'""r� "y' L'�To at 1 teaching area.... ft.
Z Other Distribution box ( )' Dosing tank ( ) �!'� " `�h'p.
Percolation Test Results Performed bY----------------------------------........................................ Date--------------------------------- ------
a Test Pit No. 1................minutes per inch Depth of "Pest Pit_----------------- Depth to ground water_._..._-------..--.....
!� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--....__-----..--___.
r - f - ----
D Description of Soil.......0.!! j -� t+� `'fie tt,`. __-----P � - --•-- � /- -
x
V ____--••-------------- e_.._.__.._.... .
••-•--••--•-------------- -------------------------------------------------•-•-----------------------------------------------------------------•-•--= .------------•---•---------------------__-----
U Nature of P.epairs 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 irl
operation until a Certificate of Compliance has been issued by the board of health.
igne -' --------- --•------------------•_-------- -----
�f. r ate
Application Approved B
f/ Date
Application Disapproved for the,f ollowing reasons---------------------------------•- -----------•-------•-----------•-----•-•------------ ---------------_---
•-•-....••.•••-••--••-•-•---...---•---•-•-•....._•._.---•-----__.-•---•------------•--------------------•--••-•-••---•---------------------------------•••----•---------•--•---•------------••--_-----
Date
•�x
Permit No............................. ......................... Issued........................................................
' Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................ r ../ ' L. .�dGl.Wit"' ..OF....:--�,..,.,-.............'.."...�..c.:...............................................
P t` -
rt prtt$tratr of W."oMpliaurr ,..
OT
THIS IS TO CERTIFY;' .,,j 'hat the`Individual Sewage Disposal System constructed (41) or Repaired ( )
fi r a Installer
at........ .rr- - � ------ �.�,-�^- -��--fir---------�/��� `.
------------------------- ----- :-_-------- ---#-- ------ ,,--- ------•--------
has been installed in accordance with the provisions of A XI of�The State Sanitary Code as described in the
.:2 dated t L""�''...
-77
application for Disposal Works Construction Permit No. .____�� _______________
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE_. t ' Inspector ` �'fi ra._., , ,', . __1
y 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NO. �1.. FEE-
�i���r,�ttl �rk� ����#r�trti�xt rri�tit
Permission is hereby granted____.__..._ . "'-
to Construct O or Repair ( ,) an Individual Sewage Disposal System -�
at No........-! --t
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------------------------------------- -------------- -=----------=--
as shown on the application for Disposal Works Construe ionr
lit. N . _..__ .. D ited-__._-...................................
of Health �►;-..._..---••----_.__...—
DATE......................................._.......................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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6,CAT10N z SEWAGE nPEnRMIT NO.
V`LLAGE
I N S T A LLER'S NAME & ADDRESS
'7 Z �vit IN fL a �na
B U I'L DE R OR- OWNER
DATE PERMIT ISSUED S - l6 � �7
DATE COMPLIANCE ISSUED
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--64-- EXISTING CONTOUR N
x 60.98 EXISTING SPOT GRAD
W -- EXISTING WATER SVC.
S 00.35'50" E +' H.1V OVERHEAD WIRES
64,8 I 100.50' chainlink fence 63, 3 -� TEST PIT LOCUS b
64,0�r_-0 I I dzQ .873 BENCHMARK Carlisle Or
XXX���--���-���"' N LEGEND N W
EXISTING INFIL TRA TORS
TO BE ABANDONED I I y o
EXISTING LEACH PIT 64,67 I o I TI-TP-�25' _ w y Rebecca �n
V)
TO BE PUMPED, FILLED WITH I I0 6'`4- - PL 311 - PG 77 m
r .: ---
SAND & ABANDONED S.A.S:,•. T
pldeo e
EXISTING SEPTIC TANK 64.80 ;`;:�01° • coP
TO REMAIN \ / �.:::'; :-:,:,•'.' •. J.L.1 Route 28
TOP OF TANK, EL.=64.68E TP-1
IN V.(OUT)=63.35E
65.20 +.64'86 GENERAL NOTES: LNOT OCUS MAP
SCALE
BENCHMARK 65.55 .® 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
COR.�BOTTOM STEP __fob- .`r2 UIR M T
SHED BOARD OF HEALTH AND THE DESIGN ENGINEER.
EL.=67.42 - 66.51 `' 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE RE
x Q E EN S
-, 66.41 x 66, OF THE STATE ENVIRONMENTAL CODE, TITLE V,-AND ANY APPLICABLE
W LOCAL RULES AND REGULATIONS.
66.44 x DECK M TIO x _\ - 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
6742 p TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
66.44 Shr. 66,49 ~Z� } DESIGN ENGINEER.
i. I 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES.
00 x 66,1
�p EXISTING x 66,62 Z 5. ALL ELEVATIONS BASED ON BARNSTABLE G.I.S.t..
N x 66,95 HOUSE#I1 t 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
• T.O.F.=68.22E GARAGE THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
a�0 SHED 7. WATER SUPPLY- PROVIDED BY TOWN WATER SERVICE.
X ,Z67,32 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
x "67,62v.:' 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
67.30 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
WALK DIRECTED BY THE APPROVING AUTHORITIES.
67.62 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
\ THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
�MASSq�yGs� CONSTRUCTION.
TERT �� 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
g PE s IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
LOT 59
0:.. ..: McENTEE REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
15,037±S.F. 67.01 �,;.:.' x 66, 5 N0.g5109 12. AS INSPECTED ED REQUIRINGDESIGN I EONGINOEERUPRIOR BLE TO BACK MATERIALS .SHALL BE
13. THIS PLAN IS TO B
O FGISTE E USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
NOT CONSIDERED TO BE A PROPERTY LINE SURVEY.
I 14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC
I � SYSTEM COMPONENTS NOT SHOWN ON THE PLAN
66,82
66,59 ��1 .53' _ 66.02 39.63 - PARCEL ID: 122=090
x 66.004, .._,..._... " �
R 38 15_ _____ :. 00'35 50 E IP FND UP PROPOSED SEPTIC SYSTEM UPGRADE PLAN
6.6-- 114 SETH GOODSPEED WAY OSTERVILLE MA
65,80 Edge of 65 77 pavement
1 66.04
Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
OWNER OF RECOED 65.55
WARNER, ERIN L 65.39 9 i Engineering by: SCALE DRAWN JOB. NO.
OST114 SETH GOODSPEED'S WAY SETH GOODSPEED S WA Y Engineering Works, Inc. 1"=20' P.T.M. 302-17
114 S TH MA 02655 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 12/8/17 P.T.M. 1 Of 2
,y
` NOTE: TO PREVENT IIBREAKOUT, FINAL GRADE
SHALL
A DISTANCE T OR 5' FROM 6 M THE
2.5
FOR O EDGE / /EX%STING
SEPTIC TANK PROPOSED D—BOX OF THE PROPOSED S.A.S.. GARAGE HOUSE(#114)
INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT PROPOSED S.A.S. # back of house
OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE INSTALL RISER & COVER OVER ONE CHAMBER AND
T.O.F.=68.22t SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT
F.G. EL.=67.0t F.G. EL.=65.9t F.G. EL.=64.6t F.G. EL.=64.5t DECK
/ IMAINTAIN 2% SLOPE OVER S.A.S.
aka . , IS
L = 31' _ 5' ED@4"SCH 0(PVC) O(P C) 2" LAYER OF 1/8" TO 1/2"DOUBLE WASHED STONE;:7
aaB�aaa (OR APPROVED FILTER FABRIC) ,14" W � 6'
aaaaaaa -3/4" TO 1-1/2" DOUBLEEXISTING 48" LIQUID 4, i i4' WASHED STONE Cr ^•���ZLEVEL ADD INV.=62.27PROPOSED .= 2.10 a? i
GASH EFFECTIVE WIDTH = 12.8'
INV.=63.35t D—BOX w
EXISTING INV.=62.00 i ROP. S.A.S.
EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS
SURROUNDED WITH STONE AS SHOWN 1�-25' - 1
NOTES: H-16 RATED
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP CONC. ELEV.=62.8t
INVERTS, PRIOR TO INSTALLATION. BREAKOUT ELEV.=62.50
INV. ELEV.=62.00 aaaa SEPTIC LAYOUT
2) D-BOX SHALL BE SET LEVEL AND TRUE TO aaaaa
®®®®aaaaeaa
GRADE ON A MECHANICALLY COMPACTED SIX aaaaaaaaaaa
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.=60.00
310 CMR 15.221(2). 4' 2 x 8.5' = 17.0' 4'
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.'01
PERVIOUS MATERIAL
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 5' (MIN.) ABOVE G.W. ! ®®®® 0
AS MANUFACTURED BY TUF-TITE; ZABEL OR EQUAL. LEACHING SYSTEM SECTION 37"
NO G.W., EL=52.9 S ®®®®®E@ E3 E0
w ®®®®®Ea ® ®®®®
SEPTIC SYSTEM PROFILE N Z ®�
N.T.S.
102"
DESIGN CRITERIA -SOIL LOG
4" KNOCKOUT
DATE: DECEMBER 7, 2017 (REF#15,555) 20" OIA. COVER
NUMBER OF BEDROOMS: 3 BEDROOMS SOIL EVALUATOR: PETER McENTEE PE
SOIL TEXTURAL CLASS: CLASS I WITNESS: DONALD DESMARAIS R.S..HEALTH AGENT
DESIGN PERCOLATION RATE: <2 MIN/IN ELEv. TP— 1 DEPTH ELEV. TP-2 DEPTH 4" KNOCKOUT 0
/ 4" KNOCKOUT 58"
DAILY FLOW: 330 G.P.D. 64.5 A 0„ 64.4 A 0"
DESIGN FLOW: 330 G.P.D. LOAMY SAND i LOAMY SAND
1 10YR 4/2
GARBAGE GRINDER: NO—not allowed with design 64. B 5., B 63 9 10YR 4/2 6„ 4" KNOCKOUT
LOAMY SAND LOAMY SAND
LEACHING AREA REQUIRED: (330) = 445.9 S.F. 10YR 5/8 10YR 5/8 500 GALLON CAPACITY, H-10 LOADING
74 62.5 C 24" 62.5 C 23"
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY PERC 28"/46° CHAMBERS
'
PROPOSED D—BOX: 1 INLET 3 OUTLETS H-10 RATED
> • N.T.S.
USE "2-500 GALLON LEACHING CHAMBERS IN SERIES M-C SAND M-C SAND PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 2.5Y s/s 2.5Y s/s
114 SETH GOODSPEED WAY, OSTERVILLE, MA
SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F.
Engineering by: SCALE DRAWN JOB. N0.
TOTAL AREA:.................... .. 471.2 S.F. 53.0 138" 52.9 138'` Engineering WoYkS, Inc. 1"=20' P.T.M. 302-17
PERC RATE 2 MIN/IN. 12 West• Crossfield Road, Forestdale, MA 02644 DATE
DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD CHECKED SHEET N0.
NO GROUNDWATER ENCOUNTERED (508) 477-5313 .12/8/17 P.T.M. 2 Of 2