HomeMy WebLinkAbout0026 CHINE WAY - Health 26 C' ii4hy
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/ TOWN OF B ABLE
LOCATION 'Z SEWAGE #
VILLAGE ASSESS R' MAP & LOT
INSTALLER'S NAME&PHONE NO. �� LA `��
SEPTIC TANK CAPACIT js- /�
Y �� �
LEACHING FACILITY: (type) ��PNC (size)
NO. OF BEDROOMS �_ r
BUILDER OR OWNER �( dl�' li Sd
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the: i
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 It '
� Te
/3A "To li
,� `T� 7 .g
No. ' r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes t
Yicatiou for ig opal ztem Cow5tructiou Permit
Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. L l.i ��N.Q WC,Z/ Owner's Name,Ay�d�dress,and Tel No./
Assessor's Map/Parcel 0-�6
Installer's Na e,Address,and Tel.No. J e ha.z.!4A/ P�Loy Designer' Namgg,Address and Tel.No. c�. ��2 6 d-e na ll
�N cl os`l'e��//l� l�v �sTevvi�l�
Type of Building:
Dwelling No.of Bedrooms Lot Size 0 sq. ft. Garbage Grinder ( )
Other Type of Building )1&6 No.of Persons , Showers( ) Cafeteria( )
Other Fixtures �✓ r�
Design Flow(min.required) �0 gpd Design flow provided l7 �i / gpd
Plan Date Number of sheets , Revision Date
Title do G if A 0 ✓' U Aj q1 A 41 1W
Size of Septic Tank Dp �� � .� Type of S.A.S. � i / Y .c
Description of Soil40
Nature of Repairs or Alterations(Answer when applicable) a q/6/,v
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 Envi mental Code and not to place the system in operation until a Certificate of
Compliance has been issued b"rof
Sig4 Date
Application Approved by ate ,
Application Disapprove by: Date
for the following reasons
Permit No. Date Issued
—. �� .eewr-ry,• �.L+'......-++.+ti/' .,.� ...•-.-,dr,a,�3.3J:y""r"c.. .,........,1e'uw.f""`�t�7,-,.,'�1`s-�r^e.irYi3. ��!�:i a.�r- ..-..^•rr+'—.t::'K'G-'• r-..r-�'Y'�ew"�..:.ais....rs�-lr'�
I � (� _ ,�.—,r. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
-PU,BLIC HEALTH DIVISION TOWN OF BARNSTABLE,+MASSACHUSETTS Yes
=
application for M•igogal *pgtem Cottgtruction Permit
'<Application for a Permit to Construct O Repair V Upgrade O Abandon O ❑Complete System ❑Individual Components
r~
Location Address or Lot No. a C ".Q �� Owner's Name,Address,and Tel.No.1
d r�Te ✓ � �/� 3'ohw� - /lJCis� ns � ,Lr� �r
Assessor's Map/Parcel 0 7,7 C/1 R ( ( ��r ad xa A� r
Installer's_Name,Address,and Tel.No. J A h to h 1 p P r' Designer's Name,Address and Tel.No.
1-6
Type of Building:
Dwelling No.of Bedrooms .Lot Size {o U sq. ft. Garbage Grinder ( )
\ Other Type of Building Pr s No:of Persons Showers( ) Cafeteria( )
` Other Fixtures
Design Flow(min.required) �3 5 U gpd Design flow provided � i l / gpd
Plan Date -/i r✓/`/16(, Number of sheets l Revision Date
Title J/ip 9� C4,-" P `� c.✓ J�;�,ie / .r�� :"' / ` i?A1� '
Size of Se tic Tank C :? '
�` P /�� /-T 4 //IJ%� Type of S.A.S.
Description of Soil C c3 Cr
Nature of Repairs or Alterations(Answer when applicable) p J e�,
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�o`fHealth.
Sig d l �/ (;t !!./�' /�l/I� `� ) n Date
Application Approved by Date /l3
- t U _ ' i
Application Disapproved by: Date i +--��/ /�c�'t
for the following reasons T W / t ,/
Permit No. f / Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that e On-site Sew ge P�,isposal System Constructed ( ) w Repaired (X ) Upgraded ( )
Abandoned( .�by� 1gY1 f �)� ,
at / /` ha been�co/nstructed i accordance
with the provisions_ of�Tiitl/e 5 a�n�d/thee for Disposal System jm Construction Permit No � / - "1�' y�da/ted
Installer � /"�j /V W Designer. � (�_/.� /V '�1I�-1 / ,
#bedrooms / Approved design flow / gpd
The issuance of this permit shhM
hot c/�A�nstrued as a guarantee that the system'will function as designed., ✓�,G ,
Date �C / Inspector % 1 �/
SIOAO Fee
THE COMMONWEALTH OF MASSACHUSETTS 4
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS "
tMigpogat *pgtem Congtruction Permit
Permission is hereby ran 'tl to Construct ( ) Re.a'r ( ) U grade Abandon ( )
System located at TYf .
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions. >
Provided: Cons ction must be completed within three years of the dateTi�permit.Date % / A roved PP
Y v /
Town of Barnstable,
Regulatory Services
Thomas F.Geiter,Director
` NAM Public Health Division
abs go.. A�0
�e Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-8624644 • Fax: 508-790-6304
Installer&Designer Certification Form
Date:
D gn esi er• �� LZ $• Installer:
Address: Address: _
4,4
On was issued a permit to install a
(date) (installer)
septic system at Z G based on a design drawn by
�(a dress)
�q S dated
(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.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' 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- uilt by designer to follow.
VJN Df A14
3TUTSON yG��
er's Signature) o R. N
" A HALL a
No.527 Q
soREDSP���4Q,
(Designer ignatiIre) (Affix Desi
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTU THIS FORM AND AS-
BUILT CARD ARE RECETED BY THE BARNSTABLE P LICALTH DIVISION.
THANK YOU.
Q:Health/SepticOftigm Certification Form
0601
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner owner's Name
information is required for osterville Ma 02655 10/18/2010
every page. Cityrrown 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 A. General Information
forms the 1 I
computer,
r,use 1. Inspector:
only the tab key
to move your Scott Campbell
cursor-do not Name of Inspector
use the return
key. Cardinal Construction
Company Name
32 Ridgetop Rd.
Company Address
Cotuit Ma 02635
'8d00 Cityrrown State Zip Code
508-420-1295 S1388
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 off
Title 5(310 CMR 15.000).The system:
tfa g e 5
•
® Passes ws,
❑ Conditionally Passes ❑ Fails" i�
❑ Needs F rther Evaluation by the Local Approving Authority
10/18/2010co
Inspectops Signatu Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. LAC
)
U
�I
t5ins•09108 Idle 5 Official Inspection Form:Subsurface Sewage isposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
❑ 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 than20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
I
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner Owners Name
information is required for osterville Ma 02655 10/18/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins-06108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I� 26 chine Way
Property Address
John Anderson
Owner Owners Name
information is required for osterville Ma 02655 10/18/2010
every 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.]
El ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,0009pd.
❑ ® 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
y o e 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•09/08 Tale 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
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for ostervilie Ma 02655 10/18/2010
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
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•09108 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
yY 26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for. osterville Ma 02655 10/18/2010
every page. Cityrrown State Zip Code . Date of Inspection
D. System Information
Description:
1500 Gallon septic tank one 3-hole distribution box leading to one row of infiltrators 7'&54'wiyh a
inspection port
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2009, 46,000 Gallons 2008, 102,000 Gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: current 2010
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-09/08 Title 5 Official Inspection Form: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
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
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:
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•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner owner's Name
information is required for osterville Ma 02655 10/18/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
12/19/2006 information on file at the barnstable board of health compliance date
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):
Depth below grade: 5" below grade
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:
Sludge depth:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
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 4.3
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 0
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? sludge stick tape measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
both inlet tees in place at time of inspection structural integrity of tank is good tank is not leaking
liquid level is at proper working level no evidence of leakage into or out of tank
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
I
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
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.):
I
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•08/08 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
' 26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
box is level no evidence of solids carryover no evidence of leakage into or out of box
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
leaching system working properly at time of inspection stone at base of leaching not holding any
water and is leaching properly
t5ins-09/08 Tide 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
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
every page. Citytrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 7'&54'
❑ 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.):
dry soil, no signs of hydraulic failure, no ponding or damp soil, normal vegetation.
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
f i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
every page. Cityrrown 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 east 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
tl
J�
t5ins•09/08 Title 5 Official Inspection Form: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
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12+feet
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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 chine Way
Property Address
John Anderson
Owner Owner's Name
information is required for osterville Ma 02655 10/18/2010
every page. Citylrown 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Tale 5 Official Inspection Form
Subsurface Sewage Disposal System/Form-Not for Voluntary Assessments
ftperty Access
�� � �tir✓ � o re
inf ner Owner's Name ( � Y
rkfoe equ ten.
forevery A1,4 w 6 ss 2Cty/Town jr State 4 Code Deft or
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checidist at the end of the form.
'P* '""'ter A. General Information
fftorms
cter,
use only the tab 1. Inspector. l (�
key to move your
cursor-do not
use the rehrrn Nana of tnspectcr -
�/�i o TC G/2
ODmpany Name
cbn wW Address
Qyfrown (TIPS)77� s boa Zip Code
Telephone Number License Number
B. Certification
1 certify that I have personally inspected the sewage disposal system at this address and that the
information repotted 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(31 R 15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
bo r'
j Daft
stem inspector shall submit a copy of this inspection report to the Approving Authority(Board
,W of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or
has a design flow of i0,000.god or greater,the inspector and the system owner shall submit the
-- report to the appropriate regional office of the DER The original should be sent to the system owner
<r 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 syste will perfo in the future under
s the same or different conditions of use.
��
t9m-3ff3 T&50f5ddhmpecbmFanaSubarface qqX0 S1 !t toff7
i
commonwealth of Massachusetts
OREM i
Title 5 OtH Jal Inspection Form
Subsurface SewageDrsp6sai System Form-Not for Voluntary Assessments
Properly Address 210
Ow ner OW Ws Name / - /1` /f/J
re�sfim is very OS�2�vt Ile- / 14 oa 6 ss 3/so 4.-
page. cdyrrown State Zip Code Date of ImpedliDn
B. Certification (cunt.)
Inspection Summary Check A,B,C,D or E/always com plete all of Section D
i
A) System saes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.1,03 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indeed below. i
Comments:
i
� I
i
i
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'�,�. W or`not deterrmed"(Y,.N, ND)for the following statements. 9°not
determined,'please Lain.
r.
The septic tank is meth and over 20 years old*or the septic tank(whether metal or not)is fly
unsound, exhibits sal infiltration or exfiitration 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):
I
i
i a
i
i
i
i
tsar sns I Tde5offidd mspectwFomi subwfsce sev+3geD'ispesd System-fie 2ot 17
i
Commonwealth of AAassachusetts
Tide 5 Official inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
c;2
Roperty AddMS I
o -1�1e' c'O
owner owners Nam
idorrnation is �/� Od-CES 3 3o
page. (�y/required Town - SW— Z�(Ade Date of ' n
�
B. Certification (cost.)
❑ Pump Chamber pumps/qjarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditlonaliy Passes(coat.):
❑ Observation of sewage backup or break out or high static water leel in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System Wil
pass inspection if(with approval of Board of Health):
❑ broken p`rpe(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):
.I
❑ 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 pipes)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y [IN ❑ ND(Explain below):
i
C) Further Evaluation is Required by the Board of Health:
[I Conditions exist which require fu her evaluation by the Board of Health in order to determine if
the system is fading 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 mannerwhich will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
0
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
3H3• T1050r6cid ImpwWam Subarta*SewageM posd SlawPW 3017
15rs
I
Commonwealth of Rhmichusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
C:� 6 C�I V1-e- Q
Property Address /
Ow rrer owner's game !/ �,�
page. �Y
irtom�ion is /( , "
pa".
�/
frown State Zip Code Date of I pecti
.
B. Certification (cont)
2. System will f3il 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 env! merit
❑ The system a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a water supply or tributary to a surface water supply.
❑ The system a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system h 3s a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has 4 septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a priva te water supply well.
Method used to dmtermine distance:
This system ppassme 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 mint
be attached to this form.
3. Other:
D) System Failure ' ria Applicable to All Systems:
You must indicate es" or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
logged 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
❑ 2tatic 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
tft-WS rrue5OMM ImpeorlimR m Suburface SewageDiq=d SOM-Np 40f17
Commonweafth of chusetts
Title 5 Official Inspection Form
Subsurface Sewage sal System Form-Not for Voluntary Assessments
Roperty A /
-/— 0
re,
Owner Aa ner's Name
itrfort is
edforevery pa". C�y/rown State Zip Code Date of pedi� n
�,
B. Certification ( nL)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to dogged or
&structed 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.
❑ ;X-"Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Arry portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ L�lAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet
em a private water supply well with no acceptable water quality analysis. [This
stem passes N 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.]
❑ ff" The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000g❑ to The system fails: 1 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 fail ure.
E) Large Syswms: To be considered a large system the system must serve a facility with a
design flow of 10,OCO 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 pubic water supply well
Nyou have answere `yes'to any question in Section E the system is considered a sigrrditWt 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 filed under Section D shall upgrade the
system in with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
OM-3n3 rjse50tfiW@spedwFarmSUbsuracese,vempmdSystem-Pop 5017
f
Commonwealth of blassachusefts
Title 10tricial Inspection Form
Subsurfacewage Disposal System Form-Not for Voluntary Assessments
c A,h-4-2 (,,,/a
RopedyAddrew O iiel-e' c/o
oWOMMM iswns owrers Narne or everye /�,�
fpage. ckffown State Zip Code Date of ftpedbon
C. Checklist
Check if the following have been done.You must indicate°yes°or°no°as to each of the following:
Yes No
❑ umping information was provided by the owner, occupant, or Board of Health
❑ ere any of the system components pumped out in the previous two weeks?
X❑❑ the system received normal flows in the previous two week period?
eve large volumes of water been introduced to the system recently or as pert of
s inspection?
Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
Vies the facility or dwelling inspected for signs of sewage back up?
as the site inspected for signs of break out?
ere all system components, excluding the SAS, located on site?
❑ ere the septic tank manholes uncovered,opened, and the interior of the tank
i pealed for the condition of the baffles or tees, material of construction,
mensions, depth of liquid, depth of sludge and depth of scum?
❑ as the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems.
T,te size and location of the Soil Absorption System(SAS) on the site has
been determined bored on:
isting information. For example, a plan at the Board of Huth.
❑ ermined in the field (if any of the failure criteia related to Part C is at issue
roximation of distance is unacceptable)1310 CMR 15.302(5)]
D. System lnforff iation
Residential Flow ditions:
Number of bedrooms (design): Number of bedrooms(actual):
3 3�
DESIGN flow based 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
One•W13 Title5Ofk 1d b'$pecftFomt SuDsvface$ewagepisposd syom•Page W 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface sewage M-s osal System Form-Not for Voluntary Assessments
C)
Property Address /
0 lql� C/o
owner arner's roamsiftfonratim is A)7v(4e1'-vj Ile Oa 6 5S �
reoredforevery State zQ Code Date of pectic
per, Qyfrown
D. System lnfbm ation
Description: 00 6-4 /0� 4-1 C.
Ao,—! W0
'7—n /�� �o/S /off c. f V_
Number of currentresidents:
Does residence have a garbage grinder? ❑ Yes B-No
Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes L7 No,
information in this re Fort.)
Laundry system inspected? ❑ Yes E No
Seasonal us e? ❑ Yes IJ�No
Water meter readings., if available past 2 years usage(gpd)):
Detail:
Sump pump?
Last date of oc cupa y:
OmmerciabIndustrial Flow Conditions:
Type of Establishmer
Design Row(based on 310 CM R 15.203): Cal=per day(Md)
Basis of design Row Ise atss/persons/sq.t., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste hold rtg tank present? ❑ Yes ❑ No
Non-sanitary waste c 11scharged to the Title 5 system? ❑ Yes ❑ No
Water meter reading;, if available:
tsm,yyg raesoF6aal aspecftaam s,eswfaceSevageDisposal sydw-Page Tan
Commonwealth of I fiassachusetts
Title 5 Off'i nal Inspection Form
Subsurface Sewage sal System Form -Not for Voluntary Assessments
Property Address f
oT �re ck
owner Ow pees f rw n /!� da &
!
eifommum is (/
mgWred for every Staff zo(� Date of to pectic
Cdy/DW- Town ---
D. System Infoffrotion (cont)
Last date of occupy /use: pate
Other(describe b ):
General Inforrnation
Pumping Records: It'll
/
Source of informatio :
Was system pumpec I as part of the inspection? ❑ Yes ff N
If yes, volume pumped: gagom
How was quanft pumped determined?
Reason for pumping
Type��Sepjc
tank, distribution box, soil absorption system
❑ Sir4o cesspool
❑ Overflow cesspool
❑ priyj
❑ Shared system(yes or no) (if yes, attach previous inspection records, if arty)
❑ vative/Altemative 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 VA system by system operator under contract
❑ Tiglit tank.Attach a copy of the DEP approval.
❑ of (describe):
15es•3N3
?7aesoffidd9speetwFarrSLb%0=S8vMeDis WdSyMr•Pa9e8017
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o� 6 �i�►��e C✓G
Property AddressOmner
�fomtefion Is �'"�ner's Flame (%�)-� F / �e— /f/J4
Vt l ? �,
regtitredforevery
Pap- Cdyfrown State zap Code Orate WhspeoHon'
D. System Wbrmaltion (cons)
Approximate age of Wl compone , date i led(if known)and source of information:
c2oo 6 vPv�mi Ao6- ?99- ✓fo6L
Were sewage odors detected when arriving at the site? ❑ Yes
Building Sewer(locate on site plan): L
Depth below grade: feet
Material of consb ucti;4'0
❑ cast iron 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 site plan):
G
Depth below grade: feet
Material c�nstructi
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list qW. yeals
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth: v�
.yt3 TWa50ffidO1nspec*Far[subustwesnmem-9mal system-Page 9W17
ComlmonwwM of Iftimehuseft
Title 5 Offic.1al Inspection Form
for Vol unta Assessments
Sewage sal ste rn Form Not ry
Subsurface Se Sy
PRM"Address
ON nor ONners Nam
infawshmis
regdredforevery State 2�Code Date of hoecW
Pap- Cdy/rown
D. System in lion (cons.)
Septic Tank(cont.) 2510
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scwn to top of outlet tee or baffle
Distance from bottorr of scum to bottom of outlet tee or baffle
How were dimension;determined?
Comments(on pum ng recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as relatel to outlet invert, evidence of leakage, etc.):
G w �j Cr vt � �2S !✓l t9v
CO„1 d /'7t'OKi
Grease Trap(locate on site plan):
Depth below grade: feet
Material of constructs :
❑ concrete 0 metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of um to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
t Date ofl as pumping Date
15rrs•3H3 T-Me50fkidMspec*nFort S bmeasSefteeD'V099 Sys4er•PA0810d17
Commonwealth of ssachusetts
Title 5 Offiilposalal Inspection Form
Subsurface Sewage Di System Forth-Not for Voluntary Assessments
Rop"Address / c/o
Cwner L
o or► a�►ners rye /y! ��e
Page-
regtiredforevery Cilylfown - state Zip(bode Date oftspeam
i
D. System Inbr lion (conL)
Comments(on ptxn 'ng recommendations, inlet and outlet tee or bale condition, structural integrity,
liquid levels as relati Id 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 gr
ade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ Other(e)(plain):
Dimensions:
Capacity: gas=
Design Flow. gaWns per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last purr ping Date
Comments(condition of alarm and float switches, etc.):
Attach-copy of curnent Pumping contract(required). Is copy attached? ❑ Yes ❑ No
truss 3M3 riice5o old bspec6mFomc Subm face SewgeDWpoar SyAem•ige lid 17
F'
Commonwealth of Abssachusetts
Title 5 Offi ial inspection Form
Subsurface Sewage Voluntary sal System Form-Not for of ry Assessments
Rop"Address
k oomubon is �ners Nam �S -e— SA)
raWndforeve y /Town Slate Tp Code Oahe hs ion
Me
D. System Infor 'on (coat.)
Distribution Box(if present must be opened)(locate on site plan): /
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
so/ C�s
-Z -
Pump Chamber(loc ate on site plan):
Pumps in working or Jer ❑ Yes ❑ f�'
Alarms in working o er. ❑ Yes ❑ No•
Comments (note cordtion of pump chamber, condition of pumps and appurtenances, etc.):
'If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
N SAS not located, o 90ain why:
t5m-3H3 TMe5CMW Impec5mFcrm Submsfaoe SewageoL000 l S)Mm-Page 12 of 17
Commonwealth of achusetts
Title 5 Offi ial Inspection Form
Subsurface Sewage sal System Form-Not for Voluntary Assessments
C41 r7f_
Roperll►Address
Omner
oT�le v
info
nations Ow ner s tinerequhw O / (/I 6 / �i/
page- forevey Qyrrown S VCR ` State Zip Code Dace of
D. System In lion (coat.)
Type: I` �✓l7�//�ia�o�f a '
❑ leaching g pits number.
❑ leachiig chambers number:
❑ leacit ig galleries number.
❑ leaching trenches number, length:
❑ leachi g fief number, dimensions:
❑ ove fl w cesspool number:
❑ irnov�tialtemative system
Typetrame of technology:
Comments (note con Ition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
C64 G S,01/ .0 G17 Q✓rV
Si O� &C'Jza'�/t c
Del
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid t D inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspxA
Materials of on
Indication of groundw ater inflow ❑ Yes ❑ No
>!us•3f13 Tile5Of dd 1Mp9CfW Fans SUWuface SewageDgXGd SysO M•Page 13 d 17
' �lassachusetts
Commonwealth of
Title 5 Offi ia! Inspection Form
Subsurface Sewage sal System Form e Not for Voluntary Assessments
Rvl"Address
Omner
information is
Qa►ner's tNamecs �, A-0 1N.4 o��j,sr' ,� �o is
requiredforavery —^—��'
Pap- Cly,rown State Zip Code Date of
D. System Information (cont)
Comments (note cor dition of soil, signs of hydraulic failure, level of ponding, cor>dition of vegetation,
etc.):
Privy(locate on site ):
Materials of construct on:
Dimensions
Depth of solids
Comments (note lion of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
u
SM-313 Title 5Of 1d9 9speCdM Fmn:SUbprfaoe Sewage Mgmal System•Page 14 Cf 77
Commonwealth of Mchuseft
Title 5 Official Inspection Form
Subsurface Sewage M posal System Form -Not for Voluntary Assessments
� t�j6�rr►.� �.t/'a
Property Address
QN ner QA ner's NMM
i form is C.S�kyj v-< /lc
Meforevery Cdy/Town State ZQ(ode Date of Mspedliofi
D. System Infoff iation (cons)
M
Tattached
posal System: Provide a view of the sewage disposal system, including ties to
reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
ply enters the building. Check one of the boxes below.area below
eparately
i
t9m-313 Tfue50fidal ftpecla Fcrm Subsufaw SevM9DispaW System-Page IS Q 17
Commonwealth of�Mchusetts
�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System/Form-Not for Voluntary Assessments
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Properly Addtess
Owner Owner's Num
forevery r�� /e ------
page. cityrrown Slate Zip code Gate orkspec
D. System In Lion (cons)
Site Exam
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated to hi round water.
depth high 9 feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
Kcheck , date of design plan reviewed: Date
❑ bserved site(abutting property/observation hole within 150 feet of SAS)
12 Checked Mth I / Board of Health explain:
� fJ0110-5
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
J I ✓1 S_� e C /A/- �/G
Before filing this Inspection Report, please see Report Completeness Checidist on next page.
1$le•3H3 McSOF6dd Impec6mFina Subsutace SewageDLvwd System-Pie 16 of 17
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Commonwealth Massachusetts
Title T
cial Inspection Form
Subsurface SewaP sat System Form/ -Not for Voluntary Assessments
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Rwrly Address
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Owner Owner's Name
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Paget Oly/rown woe Zp Code Date of kwpecdDn
E. Report Co leteness Checklist
2/a�nspection Sum marr.A, B, C, D, or E checked
"pection Surr mary D(System Failure Criteria Appkable to AN Systems)completed
l:J lr�OJim on—Estimated depth to high groundwater
Sketchof Sevage Disposal System either drawn on page 15 or attached in separAe ale
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Tmesarroa s,�esuraee o�systeaa
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AsBuilt Page 1 of 1
L%j III yr DeuuIIoAIwir:
LOCAnON �4 SEWAGE N
GE_ ASSESSOR MAP&LOTS�47—0//
STALLER'S NAME&PHONE NO..
S C TANK CAPACITY
CHING FACILITY:(type) rrek-G I (size) X s�f
:OFBEDROOMS - DD
B ' ER OR OWNER d tit' rilG��t'r $d AJ
1 ,rTDATE: COMPLIANCE DATE: '
aiation Distance Between the: �v Feet
ly.aximum Adjusted Groundwater Table,to the Bottom of teaching Facility
•vale Water Supply Well and Leaching Facility (If any wells exist Feet
n. on site or within.200.feet of leaching facility)
of Wetland and Leaching Facility(If any wetlands exist
within 300 feet 1 g facility Feet
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http.://issgl2/intranet/propdata/preb •lt.aspx?mappar-097011&seq=1 3/25/2015
i
of1►4E o Town of Barnstable Office: 508-862-4644
" Regulatory Services Department Fax: 508-790-6304
P
BA IA
` Public Health Division
v�`t^ Thomas A.McKean,CHO
O 39. b. 200 Main Street,Hyannis,MA 02601
Payment Receipt
Septic Inspection Payment received: $25.00 (Check) on 4/14/2015 Permit number: 10761
Check number: 1545 Check amount: $25.00 Name on check: Mark A Loffredo
Owner: MICHAEL A&SABRINA M LOFFREDO
Address: 26 CHINE WAY, Marstons Mills
LOCATION of _C& A SEWAGE PERMIT NO.
= 3 o'>— (6
VILLAGE �,5 iW t
`C5
INSTAL �S =& MDDS
3.
BUILDER OR OWNER ®�
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 7F-
a •Fig!p� � �,rR �nI �
l„h
No......._.... Fimx 12................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0;X) HEALT
V .4
...... .... ...............OF......... ......................
A1113firatillia flir Disposal orho Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct (1,-I-or Repair an Individual Sewage Disposal
System at.
..................... .�--
.... ........ .......... ..........
..........71----------
------- ------
.......... .... . . ----- . .. .. .......... ....... ............ ...6p..;----- .................
Own Address
<.......................... ....... ................................................. ....................................._gZ=t------- --- --------------
Installer Address
PQ
Lot ............!CSq. feet
Type of Buildin ze
U K -I'
Z No. of Bedrooms'.........Dwelling -S -----Expansion Attic ( Garbage Grinder e
Other—Type of Building ............................ No. of persons---------------------------- Showers Cafeteria
Otherfixtures ........................................................................................................3 ----_-_--------------------
r.5 . ..... - -.7d
Design Flow...............3 gallons per person per day. Total daily flow___-_-_-. _...__.... ............_._gallons.
Septic Tank—Liquid capacity 'gallons Length................ Width-----_--__--___ Diameter.._.-_..___..... Depth----------------
Disposal Trench—No..................... Wi h --------- Total Length .... Total leaching area--------------------sq. ft.
7
Seepage Pit No........./......... Diamete-,Z1,.W, ?_.. Depth below/inlet--_........._.... Total leaching area-a.!�!-Z---sq. f t.
z Other Distribution box Dosing tank
Percolation Test Results Performed by.___.Test Pit No. 1. _2.--minutes per inch D .........Atn;L.............. Date . ... ........................
Dept
Test Pit____________________ Depth to ground water_._..........___.______.--- -----------
L t of
Test Pit No. 2................minutes per inch Depth of Test Pit................_... Depth to ground water._...........___...__...
T /7------/--------------------------- ----------/A- - -I- T- - I. -0 Description of Soil----- '_0------ .......................... -----------------------------------------
. .....xj.,O.�
-------------------------- ---------
----------- ------------------*--------------------*---------------------------------------------------------------------------------------
----------------------------------------------------
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.__.............................•..............................................................
.......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been/.:,s.ue, b boar al
lo
Sign. .. . ...... .................... .... .... ... ................ ...... ...W,�....
-A D t
Application Approved BY------- .... .......... . ...................(--------
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
Permit No.. . Issued...................................................... ......�e- 7�
.................................................
Date
--------------------------------- ------------
C)
No........... FE.E.....'......:. ."'
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
ApplirFatiuu for 43i epos al Works TouBtrurtion Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
'r� , `� 1�({ � �f (JU/ Z I
........ ...................................................................... ...................................................................................�-'
Location Address /` I /� or Lot No,
/C ti1/I / � �i � r�r .� 1�!__ �Lci l G®J'- v / ......................----- -� ---
Owner Address
Installer Address
Q Type of Buildi� Size Lot----- ________'��`__Sq. feet
U Dwelling!No. of Bedrooms............................................� ______________________Expansion Attic (�) Garbage Grinder
'4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
PaOther fixtures ......................................................
W Design Flow.............4r.i ._......... __..gallons per person per day. Total daily flow_______
WSeptic Tank—Liquid capacity 2 gallons Length................ Width_--__-----_--- Diameter---------------- Depth__---_______....
x Disposal Trench—N�_____________________ Width.................... Total Length_________._ Total leaching area....................sq. ft.
Seepage Pit No_________..............Diameter_.. -__ Depth beloyinlet...... ........... Total leaching area:*2_.4!_/---sq. ft.
Z Other Distribution box ( ' ) Dosin tank ( ) Q
Percolation Test Result Performed by -►____.._ _____________ Date._ _':.l�.'4�__8________----
a Test Pit No; 1 ' '"'_.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_a a__.__.-.___.__...._.
P4 ? 1<-------- t----------- -----•--•-
,,JJyy --- ----- -
Description of Soil--.------•-O--- / _F(
W - ----------------------------------------------------------------------------------------------•-------------- ----------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.-_-___'--------------------------------------------------------------------
---------------
----.
------------------------------------------ ----------=-------------------•----------------------=-------------------------------------------------------___-_..----------------------------
Agreement:
The undersigned agrees to install the aforedescribdd Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State.Sanitary Code-The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board-of health. `;'
Sig ,d � ,, J�-,...... / ���.i�
L.. ----- ` / ..................... .................. -�.
Application Approved BY ------•••--•• - -- - -!..ft ---• --•-• -�I+ � --------
r Date
Application Disapproved for the following reasons:................................................................................................................
...........................-----------h-------------------:.............................-.._..-.---------------------------------------------------....---------- ---�^ .------------.. ---._._..
Date
Permit No.--------•.._._.....••-•--- ..... Issued. .Z 7.�
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
l
.......... .:.............OF......... Y1.....:47.....................................
(9rdif irate of fWnutp hattre
TH IS T C Z'l
`That the Individual Sewage Disposal System constructed (�or Repaired ( )
w
by --- ---•- - -•••••- = ---- -- - ---- ------- ----•--•--•--------•---------
Ins talle
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a
Aw
--------------
at...............--------------� ------ x
-has been installed in accordance with the provisio oticl X �°° he State Sanitary Code s des ibed in the
application for Disposal Works Construction Permit �IL_ ____F....... dated.___ ZR�A
._ J7__11__________
T14E ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G TEE THAT THE
SYSTEM WILL'FUNCTION SATI'SFACTORY. ., 1
DATE.........../�__.(--- -� .....................=........... _Inspector----- ------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
��f ................0 F.... Q.. I. A......................................
FEE �S...o°
No........................
Permissio hereby granted < - -••- -- ---
to Constr ) r Rep 'a an I diy ual Sewag p 41 System
�"�
atNo. a_...-- •- ----- -- ---------------------------
:i Street
as shown on the application for Disposal Works Construction Pexffilt No. ____ ___.__ DatedAl-& -7d__................
___-•--------------------
o� Health I
1r-
DATE---- -------- ... ..
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4 CAST IRON 9 4 SCHEDULE 40 P.V.C. (ONLY) 9"MIN . LEACHING TRENCH (/ )REQ. 35 MAX.
a a , ,�i OR SCHEDULE 40 M •
1 °b ' P.V.C. PIPE MIN. �..... 11 "
's -' / ?i?E-MIN. 1/8 - I/2 WASHED STON'.�L .c "E/1L3.93
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INFILTRATOR
I I N FILTRATOR '
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U AA •,,:�., l��93 PROR LE Or a
GROUND WATER TABLE G,✓G i
SEWAGE DISPOSAL SYSTEM
��� ► 1 - SOIL LOG NO SCALE
` —s XO_= I TEST HOLE z DATA
I
/ ELEV. . � ... . . =L=v. .. . . .. . ... DESIGN I
.. ,,.,. ......,,.,:.....,,....,.. NUMBER OF BEDROOMS . . ..� . . . . . . . . . . ..
1 " "
/ hl ��`� \•ALL TOTAL �STIMl:TED FLOW . . . GALLONS/DAY 3/4,CIA§HED STONE--
X�6 G' BOi,OM LF-ACEi1tiG AREA SO.:,./T,=_NCH \
SIDE LEACHING AREA . . . SQ..i./Trc=NCH -
�/�1('_ = d549 /7' DIcPOSAL .,.r/d ., (�0°o ,.REA 1NCRc"SE)GARBAGE
TOTAL LEACHING AREA .98�a.�..... SQ..-'.
PERCOLATION RATE . . .�-.Z M/�.. ... F=R. INC:i 7,0/ �`�9r
SITE PLANS 26 CHINE WAY OSTE.RVILLE, MA �ay� 7% ��p 68
LEACHING AREA�P/=R PERCOLATION i::�T'�::-:t.1r1.7 SC.r�,
GROUND WATER TABLE Fa✓C`.;
FOR /35 ld — — — — APPROVED .. . . . . . . . . . . ... BOARD OF HEAUM-1
Of
ENCOUNi_R=D DATE .0 �
AGENT-OR INSPECTOR
WITNESSED BY :JOHN & MARIAN ANDERSCN
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BOARD 0: HEALTH . . . . . . . . . . . . . . . . . . . . r N
=NGINEcR . . . . . . . . . . . . : . . . . . . . � ✓ P���Q t
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