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Commonwealth of Massachusetts d
Tile 5 Official Inspection Fora.
t�I Iw
r�l Subsurface Sewage Disposal System Form Not for Voluntary Assessments
L a M
,. ` 84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name /
information is West Barnstable y MA 02668 4-27-21
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.
A. Inspector Information 1 3a--
Shawn Mcelroy
Name of Inspector '
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that) am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspectional have determined that
the system: -
1. ® Passes
2.. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority :
4. ❑ Fails
4-27-21
Inspe or's Signature _ Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
t • ,
Commonwealth of Massachusetts
r� Title 5 Official Inspeyction Fora '
;1i1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�1
r
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is West Barnstable '- ' MA 02668 4-27-21
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
sit V 2 ,• .� t ,;+
Inspection Summary: Complete 1, 2, 3, or 5}and all of 4 and 6.'
1) System Passes:'' -�
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any;failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure. r '
Y � �
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. y
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):
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official , Inspection Form i
!} Subsurface Sewage Disposal System Form =Not for Voluntary Assessments ,
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is
required for every West Barnstable MA 02668 4-27-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. -
❑ 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(sj 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):
y
j t
❑ 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 El ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts '
Title 5 Official' Inspection• Foim,
�'nI Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments a
: .T,;; f 84 White Birch Way
Property Address
Meredith Ruff d
Owner Owner's Name
information is required for every West Barnstable MA 02668 4-27-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other: ��> . _ . • .
4) System Failure Criteria`Applicabid t6 All Systems,.*
You must indicate "Yes",or+`No",to,.each of the following for all inspections:
`Yesk- 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts f ,
r f Title 5 Official Inspection Fora
f1 Mi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r ?. r 84 White Birch Way
Property Address
Meredith Ruff ,
Owner Owner's Name
information is required for every West Barnstable MA 02668 4.-27-21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El ® Static liquid level in the distribution box above outlet invert'due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow '
❑ ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 316 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. ,
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
cam"" Commonwealth'& Massachusetts
3 Title 5 Official Inspection For
11 Subsurface Sewage Disposal System Form--Not for Voluntary Assessments `
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is West Barnstable MA 02668 4-27-21
required for every '
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to anyyouestion in Section-C.5 the,system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall,upgrade the system in accordance with 310 CMR 15.304. The system owner
r should contact`the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for alit inspections:
Yes No y
® 5❑ 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?
E. ❑ r ' Was the site inspected for signs of break out?
® ❑ Were all system components,'ezcluding the SAS, located on site?
® ElWere 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?
zFi Wasthe 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)]
t r
t5insp.doc•rev.7/26/2018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts _
Title 5 Official Inspection Fohn
? I Subsurface Sewage Disposal System Form Not for Voluntary Assessments -+
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is required for every West Barnstable MA 02668 4-27-21
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: f
Number of bedrooms (design): 4 Number of,bedrooms (actual): 4
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
T
Number of current residents:
Does residence have a garbage grinder? A ❑ Yes ® No
Does residence have a water treatment unit? _, , , ® Yes ❑ No
If yes, discharges to: Unknown--goes into celing and cannot trace.
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Well Water
9 ( Y 9 (gPd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 2020
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts - ' • t = A
;. Title 5 Official Inspection Fora
N Subsurface Sewage Disposal System'Form-:Not for Voluntary Assessments "
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is
required for every West Barnstable MA 02668 4-27-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions: .f '
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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
r •
t
3. Pumping Records:
Source of information: Owner---pumped 2019
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I
Commonwealth of Massachusetts ,• -
Title 5 Official Inspection Form ,
} NI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
r K�"
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is West Barnstable MA 02668 4-27-21
required for every -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known) and source of information:
2013
Were sewage odors detected when arriving at the site? ❑, Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 42"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.):
Good condition.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Iy Title 5 Official Inspection F®'rm
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is required for every West Barnstable MA 02668 4-27-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: A.
. 36"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal list age:ge: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
i
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle = -
20"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
rill Title 5 Official Inspection Form
! r Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
.1Jr•T,�� P
Property Address
Meredith Ruff
Owner Owner's Name
information is West Barnstable MA 02668 4-27-21
required for every •
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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: , I . ' Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
ir.
8. 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
t5insp.doc-rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is West Barnstable " MA 02668 4-27-21
required for every
page. City/Town - State Zip Code Date of Inspection
D. System Information (cont.) =
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑. No - ' f
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? El Yes ❑ No
: 9. Distribution Box-(if present must be opened)(locate on,site plan) f
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.):
Good condition with water at working level and no sign of back-up from field.
r
r �
r.
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is West Barnstable MA 02668 4-27-21
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working'order: '' ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan,excavation not required):
If SAS not located, explain why:
Type: I;
❑ leaching pits number:
® leaching chambers number: 27-ARC 36's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts "
l
Title 5 Official Inspection, Form
i 1n1
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is required for every West Barnstable ' MA 02668 4-27-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.) i =
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition.of
vegetation, etc.):
Leach field in good working order and empty at inspection with no sign of back-up.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth top of liquid to inlet invert' -
k.i .
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
0 Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Meredith Ruff r
Owner Owner's Name
information is required for every West Barnstable MA 02668 4-27-21-,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
I
t5insp.doc•rev.7/26/2018. Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
c Commonwealth of Massachusetts 1
,w Title 5 Official Inspection Form M
Y'�I Subsurface Sewage Disposal System Form,-Noffor Voluntary Assessments -
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is required for every West Barnstable MA 02668 4-27-21 "
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
j _
ar3
y.
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
I
Commonwealth of Massachusetts
. , � Title 5 Official Inspection Form
N r'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
b
84 White Birch Way
Property Address
Meredith Ruff
Owner Owner's Name
information is required for every West Barnstable MA 02668 4-27-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design 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:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
a ,ri Title 5 Official. Inspection Form
' N Subsurface Sewage Disposal System Form =Not for Voluntary'Assessments'
84 White Birch Way '
Property Address
Meredith Ruff
Owner Owner's Name
information is required for every West Barnstable MA 02668 4-27-21
`
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information: `
For 8: Tight/Holding Tank-Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation'of estimated depth to high groundwater included
i
t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r
84 White Birch Way
Property Address e:
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. City/Town State Zip Code Date of Irlipection
�-.T i
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
forms on the
computer, use 1. Inspector:
only the tab key
to move your
cursor-do not Matthew F. Gilfo
use the return Name of Inspector
key. B&B Excavation
Company Name
14 Teaberry Lane
Company Address
Sandwich Ma. 02644
Bd1�' City/Town State Zip Code
(508)477-0653 S113640
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4-3-15
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
*"*This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
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 than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
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
❑ ® 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 'h day flow
t5ins•3/13 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
84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
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.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information.for example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 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
84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d WELL
9 ( Y 9 (gP ))�
Detail:
NA
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
w - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M s 84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
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-3/13 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
84 White Birch Way-
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate ace of all components, date installed (if known) and source of information:
2013
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 43"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >150'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
Septic Tank(locate on site plan):
Depth below grade: 31"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal list age:ge: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gal.
Sludge depth: 3„
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(ccnt.)
Distance from top of sludge to bottom of outlet tee or baffle
33"
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14" �
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appeared to be in working order,Tees present no sign of back-
up.Liquid level equal with outlet invert.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,.' 84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
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):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
l5ins•3113 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
84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
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 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.):
At time of inspection d-box appears to in working order no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 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 84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 27 ARC361-licaps
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appears to in working order with no sign of hydraulic failure. Chambers
were dry at time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
= y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is West Barnstable Ma. 02668 4-3-15
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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-
well
Drive
MY
A deck
0
AI- 52► �„
Ql� l`I' 2�► 3
A2-
p5
A3- ! q' 7"
AL} _ 50'2
A5- 5(ol
C35- (z, a„
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: No Gw 126"
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: permit 4-24-13
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:
Permit on file
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 White Birch Way
Property Address
Greg Hamilton
Owner Owner's Name
information is required for West Barnstable Ma. 02668 4-3-15
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information— Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
MA". ' Public Health Division
bl'°,a►�`� Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fait: 508-790-6304
Date: 5-9- 1 Sewage permit# 2-0IS I y 1-I Assessor's Map%Pareel 12 2 8
Installer&Designer Certification Form
Designer: SG TinC. Installer: uide t�Eer�cises
Address: 2854 Cccwloerf4 R-5 wU Address: t:53 51-
�osl Warc�ncrrl� t1A 02538 Mtn (L�rz
So8-Z73-0377
On Cl. 6,IA�ypfi?e) was issued a permit to install a
(date) (installer)
septic system at . re. e)C,rat UJay based on a design drawn by
(address)
-:s C E Vn 5z0ea ,ng , Tv��_ dated A Pri( 13 , 2 613
(designer)
V I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as.14teral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
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-built by designer to follow. Stripout(if required) ected and the soils
were found satisfactory.
�N OR
CJOHN�L ,
HURCHILL
JR.
nst ler's S aturZARNSTABLE
VAL
y
. ��eo
rASE
igner s Signatu (Affix De gn Here)
P RETURN TO PUBLIC REAL DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AM AS-
BUILT CARD ARE RECEIVED BY-THE BARNSIADU PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffiac fannsWesigneroortification form.doc
Town of�BaFrn table - .' P# C�
Department of RegulatoryServfces
Public Hea•Ith Division Date
MASS
200 Main-Street,. MA:02'601
J
Date Scheduled G' Time Fee Pd.
Soil`Suitability Assessment for Sewage Disposal
Performed By: I C:lt1AQi e(M"11 t L 1 T -G-S_L.. -" .Witnessed:By:
"
LOCATION&°:GENERAL ZNTOIZMATION
Location Address ('`lt{[TE �1RC.EE o0'ki Owner's Name EPU, 5 e-��uE pe
kciGS�..- _Hs�tIzNSZb�(d W
pp Address 24 cvri i
Assessor's-Map/Parcel Engineer's IVanie + ;5C �✓15iYlee(i
G40C-�wlp�: J
NEW CONSTRUCTION- REPAIR Telephone# SD 8-27 3-63 77
E
St n L QYY1l i S-1 O
• LandUse� 5 � Y dwC,��tI1� Slope, Surface Stones
Distances from: "OpemWater Body ft Possible Wet Area ft "Drinking Water Well ft
Drainage Way ft Property Line 7 10 ft Other ft
.SKETCH:(street name,.dimensions•of lot;exact locations of test holes& erc tests locate-wetlands in rokl'mi 'to holes
Sei✓ akkacd (ail
- i t
' CD
O
r-� -n
Parent material(geologic) Oukw4a�/l Depth to Bedrock _
Depth to Oroundwater. Standing Water in Hole: r Weeping from Pit Face
Estimated Seasonal.High.Oroundwater 12. b3:1
DETERMINATION FOR SEASONAL HIGH WATER WW
Method Used: i>tr�E db Sergi Et6rJ
Depth Observed standing in obs.hole: f f In, Depth to soll mnttlBy:%
Depth to weeping from side of obs.hole: In, Groundwater Adjustment B•
Index Well# Reading Date: — Index Well level "...,�.._ Adi 1lictor, ,,:_ 'Adj tlrgotidWAtdr level
PERCOLATION TESL'` note y rq-l3 Thna n
Observation
Hole#
Depth of Perc ✓y -72 T Tlme-at 6'
' Start Pre-soak Tima® ..-- ( -—
Had Pre-soak I •2 °`M
Rate Min-.Mch•,:
Site Suitability Assessment: Site Passed_ _ Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back
. I
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1) week prior to beginning.
OaSEPTICtPHRCFORM.DOC
DEEP.OBSERVATION;HOLEZOG Hole# }z
Depth=from Soil Horizon Soi'I Texture Sdil Color Soil Other
Surface(in.) (USDA)az -` (Mansell) _ Mottling (Stiucturr,Stoned;Boulders.
` .y.96'arival)
1 0 ;�`�
v.. L
Y .5 g s !v Yrs/b
5 45' 1. 5Yb�6 �D%`bra Few CalAA
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other,:
Surface(in.) (USDA) (Munsell) Mottling (Structure,-Stones,Boulders.
DEEP OBSERVATION HOLE LOG H61e#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
I
r
1 + DEEP OBSERVATION HOLE LOG Hole#
r
_ Depth from Soil Horizon. 'Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders.
consistency, gmyd)_.�_
Flood YnsurancdAatc'ly—
,Above 500 year flood boundary; No _-._ Yes
No
Within 500 pear boundary
With 100 year flood boundary No Yes
Depth of Naturally Ocenrrtnt:Pervious Material
Does atleast four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of iaturally occurring pervious material?, .
Cettiication
' on (date)I have passed the soil evaluator,examination approved by the
I certify that
Department of Environme ntal_Protection and that the above analysts was performed by me conststent'wtth
crtbed.in 10 CMR 15.017
the.required,trainin eprtse d a rce des.,
n .
DaDateSignature. y�Z3 �3
,
Q-.\ .p 'i'MERCFORM DOC
Town of Barnstable Barnstable
a 619.
Regulatory Services Department 1�'`jC
ft
'"'MAM
r Public Health Division
�fn Aim
200 Main Street, Hyannis MA 02601 `2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 1010 0000 2850 7619
April 3, 2013
Mr. & Mrs. Edward J. Perper
84 White Birch Way
West Barnstable, ti1A 02668
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
• The septic system ocated at 84 White Birch Way. West Barnstable,MA was
last inspected on 3:19/2013 by James D. Sears, a certified septic inspector for
the State of Massachusetts.
The inspection of the septic system showed that the system "Failed" under the
guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• The system is in hydraulic failure
You are ordered to repair or replace the septic system within sixty (60) days
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 T�,iE BOARD OF HEALTH
9
Cmas McKean, R.S. -HO
Agent of the Board of Health
•
Q:\SEPTIC\L.etters Septic Inspection Failures or Future Eval\84 White Birch Way W Barn Mar 2013.doc
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Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=8222
BAASTAB.LE.
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Logged In As: Parcel Detail Monday,April 1 2013
Parcel LookuD
Parcel Info
Parcel ID 128-028 _ ( DevelopeeLotr LOT 3 _ I
Location 184 WHITE BIRCH WAY I Pri Frontage �I
Sec Road �I Sec I
Frontage
Village f WEST BARNSTABLE ) Fire District(W BARNSTABLE
Town sewer exists at this address�NOI Road Index2138
Asbuilt Septic Scan: Interactive t ��
128028_1 Map ` _
- Owner Info
Owner IPE PR ER, EDWARD J& LESLIE A _-- _.I Co-Owner
Streetl 184 WHITE BIRCH WAY I Street2 i
City IWEST BARNSTABLE — I State MA Zip 02668 Country
Land Info
_ Acres�1.00 — use Single Fam MDL-01 I zoning iRF Nghbd 0105 —
Topography Above Street Road iPaved
Utilities SeptlC,GaS,Public Water _ ) Location
Construction Info
Building 1 of 1
Year 1989 Roof Gable/Hi Ext Brick/Masonry
Built Struct i p Wall
Living 3987 Roof Asph/F GIs/Cmp� AC Central
Area Cover Type
Int Bed
Style lColonial Wall Plastered Rooms�4 Bedrooms
Model Residential Int!Car et J Bath 3 Full+ 1 H J z
Floor{ p Rooms F — mm j p
ilk
Grade tal
Average Plus I Type FHot Air Rooms i9 Rooms I x
stories 2 Stories Heat(Gas Found Poured Conc.
�._,. _._._____ _..___._ Fuel i � ation��_.�__
Gross 8304
Area
Permit History
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=8222 4/1/2013
Commonwealth of Massachusetts
RIM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is required for every West Barnstable MA 02668 3-19-13
page. Cityrrown State Tip 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 . A. General Information ,,�►rrllrlrrir/
onng out forms the computer, ```\`` �....kA .....
use onlythe tab �� •'•W�'�%
key to move our Inspector:
Y y James D.Sears ��• JAMES
cursor-do not
use the return
key. Name of Inspector
CapewideEnterprises,LLC
Company Name _
db / � II1i153 Commercial St. ��,///p1III U ►►��`\```
Company Address
Mashpee MA 02649 _
City)Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
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 ection R_t.340
Title 5(310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails N -n
` =t c;o
❑ Needs Further Evaluation by the Local Approving Authority
t
` a--
3-20-13 w
spector s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable,and the approving authority.
"""This report only describes conditions at the time of Inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
912,01
Tine 5 Irspsctian Farm:SubSUIRCO sewage uspow System•Page 1 of 17
t5uts•11110
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is West Barnstable MA 02668 3-19-13
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:
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):
(Sins-1 Ili 0 Title 5 Official Inspection Farm Subsurface Sewage Disposal System•Page 2 0117
1
Z-d dtC:60 El OZaeIN
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is required for every West Barnstable MA 02668 3-19-13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cunt.):
❑ 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 th
e 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
;Sire•1 tno Title S Official Inspection Fenn:Subsudace Sewage Disposal system•Page 3 of 17
CA d9£:60£L OZ aeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is required for every West Barnstable MA 02668 3-19-13
page. City/ own 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,forfecal
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 inis less than 6" below invert or available volume is less
than 1/2 day flow 4 E4 C1111116 '
t5ins•11110 Title 5 Official Inspedian Form:SubsWface Sewaee Dispassa!System-Pape 4 of 17
t,,d d9£:60£6 0Z aaW
O
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is required for every West Barnstable MA 02668 3-19-13
page, Cityrrown stale Zip Code Date of Inspection
B. Certification (cunt.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well,
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd_
® ❑ The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone ll 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.
!Sins•11110 Title 5 Official tnspedoi Form Subsurface Sewage Disposal.System•Page 5 of 17
g'd d9£:60£I. OZ AN
n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
sl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner owner's Name —— —
information is
required for every West Barnstable MA 02668 3-19-13
page. Cityrrown 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 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 440
tsirLs•11i10 Tda 5 Of did trtspection Forn Submrfece Sewage Disposal
po System•Page6 of 17
9,d d9£:60£I. OZ J8N
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is required for every West Barnstable MA 02668 3-19-13
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal.tank D Box and four 500 Gal.dry well chambees
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)): well
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: present
Date
Corrmmerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatsipersonslsq.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-11110 Tdle 5 Official inspection Form:Subaurraw Sewage Disposal System•Page 7 of 17
L-d d9£:60 E 6 0Z aeN
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
a Subsurface Sewage Disposal System Form.Not for Voluntary Assessments
4
i
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name - —
infonna6on is West Bamstable MA 02668 3-19-13
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes 0 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•11110 Title 5 Official Inspedon Fwm Subswface Sewage Disposa�System•Page 8 of 17
9-d d9C:60 01. OZ ABN
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is required for every West Barnstable _ _ MA 02668 3-13-13
page. CitylTown state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1999 Permit#99-478
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3'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.):
Pipeing is 4" PVC SCH 40
Septic Tank(locate on site plan):
Depth below grade: 28"fret
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal list age:9 years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gal Precast
3"
Sludge depth:
t5ins-11h 0 Tole 5 Oftel hspection Form:Subsurface Sewage Disposal System-Page 9 of 17
6'd dL£:60£I, OZ JEN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
•' 84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is West Barnstable MA 02668 3-19-13
required for every
page. City/Town 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 27
II
Scum thickness 2„
Distance from top of scum to top of outlet tee or baffle
10" I'
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-TapeSludge Judge
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 at 28"below grade, outlet cover at 2". inlet cover under deck. Tank level up into outlet line.
Tank shows sign's of being full to cover in the pass.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11(10 We 5 Offirial Inspachon Forth:Subsurface Seepage Disposal Syslem-Page 10 of 17
' 01.'d dL£:60£6 07,18N
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Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
nfORiafiOn is
required for every West Barnstable MA 02668 3-19-13
r
page. Cityll-own 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 Holdin Tank tank must be pumped at time of inspection) locate on site Ian):
9 9 ( P p P )( P �
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
15ins.1111° Tille 5 official Inspection Form:Sut*urface Sewage Disposak System Page 17 of 17
l l'd dLC:60 C1. OZ1eh
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form _
Subsurface Sewage Disposal System Form.Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner owner's Name
information is required for every West Bamstable MA 02668 3-19-13
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.):
D Box rested on asbuilt, did not open.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.11110 Tide 5 Official Inspection Forrre Subsurface Sewage Disposal System•Page 12 of 17
Z I."d d8C:60 C 1, OZ JEN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is West Barnstable MA 02668 3-19-13
required for every —
page. Cityrrown State Zip Code Date of Inspection
D. System Information (coat.)
Type:
❑ leaching pits number.
❑ leaching chambers number:
® leaching galleries number. 4
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number
❑ innovative/alternative system
Typelname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
Leaching is four 500 Gal. dry well chambers 10'x40'x2'. Leaching at 11"-8" below grade wlone
cover at 2". Leaching is full, not working. Need to replace leaching.
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•11110 The 5 Offidal Inspection Farm Subsxface Sevege Disposal System•Page 13 of 17
£l,,d dg£:60 0 L OZ ABN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
N 84 White Birch Way
Property Address
Leslie Perper
Owner Owners Name
information is required for every West Barnstable MA 02668 3-19-13
page. Cityffown Slate 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.):
15ins-1111 G Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
til'd. d9£:60£6 0ZaeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name -- --- T..--
Information is required for every West Barnstable MA 02668 3-19-13
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 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
J
i
i
i
i
i
I
t5ins,11/10 Title 5 Official Inspection Forth:Subsurface Sawage Disposal Syslem•Page 15 o'17
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i
far 221311:59a p.1
1 TOWN OF B STABLE
LOCATION ___ i 1 Afliq SEWAC£it 9 Ig
V LLACE do/'11,5)'1Z6le /ASSESSOR'S MAP.&LOTIZF7297—f
INSTALLER'S NAME s PHONE NO.
SEPTIC TANK cAPACrry /JW fcL
LEACMG FAr-um: (pipe)tl0 Af lnt4 CAir/,+9
NO.OE BEDROOMS � "�
BUMDER OK OWNER p
PERMITDATE: ��' COMPLfANCE DATE, OD
Separation Distance Butween the: S~�
Maximum Adjusted CMUndwatUTnble to the Bottom of Leaching Facility )reef
private Water Supply Well and Leaching Facility (lf any wells cuim
On Site Or Within 200 fiat of lCeewas(acility) Feel
Edge of Wetland and Leaching Facility(N any wetlands edit Fee
within 300 fees of lcachipg fecifity)
Ftaaishcd by
O
t
http:!/www.town.barnstable.ma.us/assessingIHMdis.Dlay.asp?mappar=128028&seq=1 3/11/2013
Commonwealth of Massachusetts
VTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper _
Owner Owner's Name
information is required for every West Bamstable MA 02658 3-19-13
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells �v
Estimated depth t high ground water: 47'
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 propertylobservation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database-explain:
usgs well SOW 253 ZONE B
You must describe how you established the high ground water elevation-
usgs well SDW-253 at 49' Zone B 2' ADJ = 47'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ms-11/10 Title 5 Official Inspeden fern:Subsurface Sewage Disposal System-Page 16 of 17
L f'd d6£:60£L OZ]BIN
/e
Commonwealth of Massachusetts
73 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 White Birch Way
Property Address
Leslie Perper
Owner Owner's Name
information is required for every West Barnstable MA 02668 3-19-13
page. City/Town 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-1 mo rlle 5 Offidal Inspedion Form:Substafam Sewage Disposal System•Page 17 of 17
E 6 d dot,:60£I. OZ aaIN
TOWN OF BARNSTABLE
LOCATION &1 k &1'j! n Why SEWAGE# -_2 C-)13
'VILLAGE W � ���_ ASSESSOR'S MAP&PARCEL '*
INSTALLER'S NAME&PHONE NO. Qppg4idt En'4pLJ,-,
SEPTIC TANK CAPACITY Iffoo Gal
LEACHING FACILITY:(type) d7(X W,)H- ® (size) N-,6/X
NO.OF BEDROOMS
OWNER,Fdw&%"d J, + LezLo1 e- A , Peqgar
PERMIT DATE: 4-�q-,a Q l 3 COMPLIANCE DATE: 13
Separation Distance Between the: ® � ..
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility gr,6,,,y,4 61 114Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) 1 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within '
300 feet of leaching facility) Feet
FURNISHED BY
A- q=GO,d
o� .
go -' 1�-(
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplitation for MispoSal 6pstem Construction permit
Application for a Permit to Construct( ) Repair()� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. sq wwrE Nikc 4 WAV Owner's Name,Address,and Tel.No.
W eS-r 80gpjJ5tAA t C E 4j> f C.6S L i c ]PORVEM
Assessor's Map/Parcel I a Fy r4 Wes r- Aft —v** 0
Installer's Name,Address,and Tel.No.5'6$-477- 51g77 Designer's Name,Address,and Tel.No.502--273 37-1
L=�JTtW: kKcY &-c-�. SG CIS [x1Cg2t�C�etc,
Type of Building: 519 g- 01� /
Dwelling No.of Bedrooms L Lot Si 0,7 27 sq.ft. Garbage Grinder( )
Other Type of Building QES JDfi;), 7 U4.c, No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) '4 qo gpd Design flow provided gpd
Plan Date 4"a 3-a0 3 Number of sheets I Revision Date
Title 24 klfhT-F WACd LAY 13 AW-S O-48 LO
Size of Septic Tank 15 yo t,,+(-, Type of S.A.S. 07--7 Ake 9C O Leff!FT-VS S'
Description of Soil 4.0/}kt" �,¢ItJtj�[ bG/� QgAV&L ��t> e-c iALES� PLAd
Nature of Repairs or Alterations(Answer when applicable) U Sc: (ST t 0& 1.1'C' -411�3U 56-ft _DWK
To N614J 0-40 D-BQ , Tb A:7 ARC 76 I4C 4-ao bropazt7u�saa 10 A
d0P F=tG(.AADi0d
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 He t
Signed Date ' �� 02(�1-3
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �d -/7 Date Issued "—
g ) 2
y ► _ `� F Fee v
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
a LIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
PUB
ftplitation for Misposaf *pstem Construction Permit
Application for a Permit to Construct( ) Repair(Q Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. gy wofTC per. 1kc! VJAV _ Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel ear U/CCT-
Installer's Name,Address,and Tel.No.5-p12-1+77- g g77 Designer's Name,Address,and Tel.No.50 8--a73—03 7-i
G40Ewr f,)6 L=N 4lS S «L SL G�.C-r►.Jc .r�cC�
45 c r2 fug E w�
Type of Building: (z �--,rt�.,. a.7 t'"�
Dwelling No.of Bedrooms Lot SizV 413,7 2 7 sq.ft. Garbage Grinder( )
Other Type of Building QES No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 14 y() gpd Design flow provided t.�`jq . s; gpd
Plan Date Number of sheets ( Revision Date
Title TQ4 (Q 4(nie WiE i A 44zi)5Ua LC--
Size of Septic Tank I S UD C * Type of S.A.S. a2:7 AQd' a d C 1)1 U r,r,V7!'
Description of Soil 4-0A NJ SA 447) 6 00 &#Aorx E&4j <4A-w E6
<s Nature of Repairs or Alterations(Answer when applicable) V S ("'�C roc T!j j 6Z r 1;�0 oC__ :5_ L T3a n 1lG
TO - 1Vt5KJ H Zf:) C ?44M< ;?o P%npazp g lllJ A
I= I l,Zl) d0V FrG URAMoA
Date last inspected:
Agreement: }
f
The undersigned agrees to ensure the construction and maintenance of the afore de`seribed 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.
Signed Date q".aq-oZo 13
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 0 27 Date Issued
- ----------------- --- ----_
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On/--site Sewage Disposal system Constructed( ) Repaired(� Upgraded( )
Abandoned( )by D wt D E G i'c>72�[P/�I� LLC
at 84 W KfrC _�)dkCA 4.YAy has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 90 1 3`f`1(dated r
Installer GN0jPjC3f1D6 &a921PojLfVS LLCM Designer "T �f��c��„c, r�lL
#bedrooms Approved des' n flow q4 O gpd
The issuance of this p}e-r'mi shall of be construed as a guarantee that the system ion as designed �
Date �`� J Inspector //( -_ llpav 14,
J / V "
------------------------- -
-- _�---- --- - - — __ -> -- --------------------
No. �O I � l(,l q _... _ . - ---- -----------------------Fee
THE COMMONWEAL_TH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
]Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( )
System located at r M�� �,
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 pe
Date Ll r Approved b
Y
�8g FFE=85.7'±
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. PROP. H-20 D-BOX
OAK,
MAP 128
LOT 28
43,787 S.F.t .�
QQ
MAP 128 �dQ, \
LOT 26 1 —
THE TOP EDGE '
IE LOCATION OF
►TENCY WITH
NEER AND LOCAL
I TEST PIT DATA
WATERSITE
IATERSHED. PLAN
SCALE: 1'_20'
J
TOWN
OF B STABLE L
LOCATION I tJ�IG� �d4 SEWAGE #
VILLAGE zw ' Xal',vs le ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. /_7`dGOJ`f/ ��?Sf -2
SEPTIC TANK CAPACITY 15W
LEACHING FACILITY: (type)F60`•[ 1,cd (size) i0 2e1/0')1,7
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: �!��/�� COMPLIANCE DATE: O
! Separation Distance Between the: _
Maximum.Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) //1e Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) �91/ Feet
Furnished by
J0
�9ct
a. \
4�'
!1 TOWNN OF B STABLE
U`,t ATION I � ®)Ii 4Pi?V SEWAGE # �g
VIL.XAGE �' �Q��7�a�`e /ASSESSOR'S MAP & LOT 12,
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /W_ 641 /
LEACHING FACILITY: (type)�Csl lem-1 el'WiIS &Y) (size) 10- X 1%')U s
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: elle k? COMPLIANCE DATE: 0
9/QLU
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) / 1 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) i7/ Feet
Furnished by
\ yob
No. / rk Fee
-,, THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
2pprication for Migogal *p.5tem Construction Permit
Application for a Permit to Construct( )Repair/)Upgrade( )Abandon( ) ❑Complete System /Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
S y /1 i �vrG LUa y
Assessor's Map/Parcel A)/ , 14Zile
Installer's Name,Address;an d Tel.No. Designer's Name,Address and Tel.No.
C
77/ 9399 -
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinderd
Other Type of Building ft r ee,_e ' No. of Persons Showers Cafeteria( )
Other Fixtures
Design Flow` gallons per day. Calculated daily flow 7 y S gallons.
Plan Date Number of sheets Revision Date
Title
y —Size of Septic Tank FWs2' X O0 944/ Type of S.A.S.
Description of Soil A0"r4OXZ 1?1-5
t '
Nature of_Repairs or Alterations(Answer when applicable) T�
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 Certifi-
cate of Compliance has been issued th• Bo of Hpalth. ----
Signed Date
Application Approved by vn 6s4 Date K-b�n_ �T
Application Disapproved for Re follo ing reasons
Permit No.�'`/- t-/ Date Issued '
THE COMMONWEALTH OF MASSACHUSETTS 12 T—OZ g
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance q-
THIS IS TO CE TIFY, th t,the n-site Sewa a Disposal System Constru ed( )ReLpa d(✓ )Upgraded( )
Abandoned( ) Y �� le� C dam . t
at w Q h5le9 Cf has begin 'ons9cted in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. - _7 dLed 4 /
Installer Designer r I C,
The issuance of this permits 1 no c ed as a guarantee that the sy ill function as desig�e A. n„
/t
Date _� Inspector .�! I
No. / �— "1 D 7 JG•����
------------------ ---Fee �
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION = BARNSTABLES MASSACHUSETTS
]Digogal *p5tem Construction Permit
Permission is hereby ranted/to Construct( )Rppair(✓)Upgrade( )Abandon( )
System located GA1 ��1�>rI1S�Cb
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: Approved by a�
�_j
No. / - Li Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for 30igaar *pftem Comaructton Vertu
Application for a Permit to Construct( )Repair(d)Upgrade( )Abandon( ) ❑Complete System CTIndividual Components
Location Address or Lot No. � Gv ��BD� Owner's ner's Name,Address and Tel.No.
D/'• ��
Assessor's Map/Parcel I / Xk&n ��l�p
Installer's Name,Address, d Tel.No. // Designer's Name,Address and Tel.No.
77/�I3�9
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( �
Other Type of Building. �'r No.of Persons Showers( ) Cafeteria( )
Other Fixtures �L
Design Flow gallons per day. Calculated daily flow 7 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �'/5 )4 /SVe W Type of S.A.S. __ 1— 5—C"��
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 Certifi-
cate of Compliance has been issued b o f H lth.
Signed Date
Application Approved by Date 9-fi
Application Disapproved for th follo ing reasons
Permit No. - Date Issued
E
0
CiAcYA n rr—S c. -
M99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERNUT(WITHOUT DESIGNED PLANS)
-lee, -rJ hereby certify that the application for.disposal works
construction permit signed by me dated �l�l�9 , concerning the
property located at 10 ��� �Ll�� !v/Xa/W ODD eets all of the
following criteria:
k/ The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
`/
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
✓ There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
There are no variances requested or needed
V The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 3.
B) G.W.Elevation L 0 +the MAX High G.W. Adjustment.
DIFFERENCE BETWEEN A and B 3 �,e
SIGNED : DATE:
[Sketch proposed plan of system on back].
q:health folder.art
L
No....g�.'ja Fxs.....
ti
TH,F COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...---- .... .. .---...--.OF........................................................................_.................
Appliration for DiipnaFal Works TouBi.rurtion Farm#
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at: ,✓� �Y� 3 Ta h 4 if
VIM --------------------- ----------____ -- --_________------- .=r -- --------------------------_-_•---
Lo
............. .2 _ xa . ��
caner
a I x • Address
--•---------------------- ---•--....---------•--•-•-•--••-••••------• .....---..._-•----....y....--.----•---
-----
nstaler Address �
QType of Building Size Lot_... _ �_ _ -Sq. feet
U Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder
Other—Type of Building .t ''. _dro. of persons._.................. Showers ( — Cafeteria ( )
Q' Other fixtures ------------------------•------- .
Design Flow_____ . . . allons er erson er da Total dail flow__._._.... ..
W g ��---------------- --�-----g P P P Y• Y --y -- -------------------.l�lons.
WSeptic Tank—Liquid capacityiAl9gallons 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 ( )
`" Percolation Test Results Performed by.......................................................................... Date........................................
� 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-_-__-_____-____•_.____-
x _ �' � =
Description of Soil....................................�... � ... . .
------------------------------------------------------------------------•-------•-----•-•-------------------------------------...------------------------------------------------------------------•...
U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------_..........................................
Agreement:
The undersigned agrees to install the afor e ribed ndivi ewa •Vosal System in accordance with
the provisions of I .%
p 5 of the State Sanitary C d The si r agrees"not to place the system in
operation until a Certificate of Compliance has e y t e Sa I t
g
Date
Application Approved By.............. ... ------• � `
Date
Application Disapproved for the following reasons:-------•----------------•-------------------•------ ..........................................................
--•---••------•-----•-----•--•----•----------------------•---•-------------------•------........-------..._.....--•--•-•-----•••••---•-- ••••-•-•----•------------•••--•-----•-----••-•-•-•••-••-•-•---
Date
Permit No.•••-•-•T-9...~ 6 7-5-------------- Issued.......................................................
Fmc....... ....
k THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. ........................OF............--------................................................................
Appliration for Disposal Works Tonstrurtion rrrutit
Application is hereb A,/made for a Permit to Construct (X) or Repair an Individual Sewage Disposal
t
System at: a 45Tdb
��A, 3;
.....I................................. ..................................................................................................
Lo t*10 - tiddres
...s7alb-111Z Z7 4 , I P Y*- %
............ xw. ...
Owner ............................................Address
......................................................
.........................
Installer Address Lj-7
Type of Building 41 Size Lot...J.J. .2_tf7sq. feet
U
Dwelling—No. of Bedrooms -------------------------------------------Expansion Attic Garbage Grinder
04 Other—Type of Building �6.111F &o. of persons.....Z�.................. Showers — Cafeteria
Otherfixtures .................................................................................................
Design Flow.....//19.......................—_-gallons per person per day. Total daily flow.......... ---ns".
04 Septic Tank—Liquid capacity/504�9.gallons Length................ Width___............. Diameter..._............ Depth_...__.._...._..
Disposal Trench—No..................... Width.................... Total Length......_............. Total leaching area....................sq. f t.
Seepage Pit No-------------------- Diameter............___..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4
0-4 Percolation Test Results Performed by.......................................................................... Date_.........__......._.._.............__..
Test Pit No. I................minutes per inch Depth of Test Pit______._............ Depth to ground water_._-__---__-_________--.
f3;4 Test Pit No. 2................minutes per inch Depth " Test Pit---_- ------------- Depth to ground water_----._..__.....__..___.
11W.;0V-------------------
Description of Soil ---------------------------------------------------------
..........
0 .......... A
�4 .......................... f..................................................................................................................................
U .........................................................................................................................................................................................................
W
�4 .................... --------------------------------------------------------------------------------------------------------------------------------------------......................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the of eribe ndiviskIVSewage.-Disposal System in accordance with
h the provisions of'TILE 5 of the State Sanitary d he ig�
T Y��.Irs r agrees not to place the system in
r
I u y
.1 e b operation until a Certificate of Compliance has s e by/15 �P�ean
.. .............
Signed.... ... ..........................r* -101,0140f 4... ....
Date
.............................. ..............Application Approved By............... ------
J Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo.------- . ........ .............. Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.
V ....................OF...............
I-e
%Drdifiratr of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
2 by....- t)Ll•. ......
.. ........................................................................................................................
Installer
at.............. ---------- ........
......... vu— 1'L _o . , !n/-----------------------------
..... , ............ . * ....
has been instilled in accordance with the provisions of TIT1ZJ5oTThe State Sanitary Code as described in the
application for Disposal Works Construction Permit No---------:15-�-'..�--------6 _'Z).... dated_.............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................... ...... .................7.......... Inspector.....................lu---—--------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
::.....................OF.............. -tr....... ...............................
No..Zjg... FEE.-.-,�-. .........
Disposal orkg (10111ustruction "nutit
V
Permission is hereby granted............ ...... .......................................................................
to Construct 6 or Repair an Individual Sewag
e Disposal System
..............k�:........... ..................
Street
as shown on the application for Disposal Works Construction Permit Nol�.Q_�. Dated..........................................
................................................
.......................................
DATE...... jg", 6Board of Health
..........................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
z,
`l Department of @nvironmeptal Management/Division of Water Resources ,
WATER WELL COMPLETION REPORT ,It
WELL LOCATION
Address W
City/Town&UtAk yQ
G.S.Quadrangle Map �l
Grid Loc n
Ovv #qner ,
Addres
ELL USE CONSOLIDATED WELL
Domestic Public ❑ 'Industrial ❑
Type of Water-bearing Rock
Other.
Water-bearing Zones
��j� 1) From To
Method Drilled
2) From To
Date Drilled 3) From To
4) From To
&SING rr
Depth to Bedrock
Length
!_Diameter_
Type V UNCONSOLIDATED.WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surfs e Sand: fine❑ medium❑ coarse❑
Date measured Gravel: fine❑ medium❑ coarse
Screen:
GRAVEL PACK WELL
Yes ❑ No (� Slot#/J length from f 6 to/�
Split Screen (or 2nd screen)
WATER OXIALITY TESTS MADE Slot#_� length f om to _
ChemicalUl Biological IF Depth To Bedrock
PUMP TEST
Drawdown feet after pumping days hours at /,I_GPM.
How measured Recovery�l(eet after_hours.
LOG of FORMATIONS COMMENTS: (On well or water),
Materials From To
0
r
M
m
`I v DRIL ER
C
V Fir °
a
Address \
b4 city
Registration No.
"Ab
/,C,(A A ALAA 9
Operator's Signature
Please pant irm Y CUSTdIAER COPY 25M-10.85-807101
Department of Environmental Management/Division of Water Resources �t
' WATER WELL COMPLETION REPORT
WELL LOCATION / !f
Address —/)�
City/Town r'dI �A
G.S.Quadrangle Map
Grid Location
Owner., IC A.L , ' rIM (.U1 J�L-ti
Address JA"t I 11-.P Ifl P fill
WELL USE CONSOLIDATED WELL
Domestic Q Public ❑ Industrial ❑
Type of Water-bearing Rock
Other
Water-bearing Zones�(��I
/�� `J
Method Drilled �� e? V 1) From To
t 21 From To
Date Drilled l�/ 3) From To
- r
4) From To
CASING Depth to Bedrock
Length Diameter
Type �1/(, UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surface Sand: fine❑ medium❑ coarse❑
Date measured //' � Gravel: fine❑ medium❑ coarse 0�
GRAVEL PACK WELL Screen: q� ,0��
Yes ❑ No �.i
Slot# /) length 7 from to
Split Screen (or 2nd screen)
WATER QUALITY TESTS MADE. Slot# 02' length /from to
Chemical Q Biological 0y Depth To Bedrock 1W
r
PUMP TEST
Drawdown feet after pumping days hours at 1, GPM.
How measured A 11E Recovery.JA: 7/feet after J hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
(1 A
m
/ / ( c
COA 1P 5,7, �VO Ad l [ 1/1,011 D DRILLER
L�(IJ'I c
Firm °
trrnpu�.� f �j °
r n n/t L1� Address A.n-/rw 4,f..,►{.�^I�t r! Ok `
city ,Me.:/T!lvt/r />1174!
14 Registration No.
Aerator s ignature
ease pant tirmly BOARD OF HEALTH COPY 25M-10-96.907101
r
F.F. EL.= 85.7 INISH GRADE OVER D-BOX= 85.0'± 4"SCHEDULE 40 PVC MIN.SLOPE 1 % PROPOSED 4"PVC VENT FINISHED GRADE OVER BIODIFFUSERS= 84,00' - 85.93' GENERAL NOTES
PROVIDE EXTENSION RISER SLOPE @ 2% MIIN.
WITH COVER OVER INLET& REMOVABLE WATER-TIGHT COVER OVER
INSPECTION PORT WITH 1. UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION
OUTLET TO WITHIN 6"OF F.G. RISER TO WITHIN 6"OF FINISHED GRADE ACCESS BOX TO WITHIN 3"OF
FINISH GRADE F.G. (ONE PER OUTER ROW) �:
METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
@ FND. EL.= 84.0'± F.G. OVER TANK EL. = 84.0'± 5"DIA. OUTLET(S) CODE AND ANY APPLICABLE LOCAL RULES.
2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
EXISTING 4
„ PROPOSED 4"SCH. SE4.OOMAX SEE NOOMTEAX21 TOP OF SAS/B.O. = 79.93' 3. 4 SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
SEWER PI�E-
16
PVC SEWER PIPE "
�l SYSTEM UNLESS OTHERWISE NOTED.
6" 3« 3"DROP MAX 4. TO PREVENT BREAKOUT,THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
=--- - _. 2"DROP MIN 3" 9" MIN.SLOPE ,% L - 27�± PROVIDE WATERTIGHT
@ ELEVATION =79.93' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
" �-JOINTS (TYP.) ,I 10" 4 PVC IN FROM 1.33 Q 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
" \ * 4"PVC OUT TO - TYP. t�
SEPTIC TANK
THE LINER IS NO
T�� 3�.2 � LESS THAN THE BREAKOUT
OU ELEVAT
ION.
.
CONTRACTOR TO PROVIDE LEACHING FACILITY 0.90 10.75 1(TYP)
N
SPECIFIED DROP BETWEEN �` 5. SLOPE ALL SOLID PIPE AT 1.0%MINIMUM.
12
INLET AND OUTLET CONTRACTOR " CONTRACTOR SHALL OUTLET TEE 79•90� MIN. 6" 79.73' 7�•50' 78.60' (laid flat) 2.875'((34.5")--I 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
SHALL VERIFY SIZE 48 VERIFY CONDITION OF 5.0'
(TY�P•) 7• LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
GAS BAFFLE 6"CRUSHED STONE FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
AND CONDITION OF EXISTING TEES (TYP.) 4 MIN.
OVER MECHANICALLY 8.625' NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
EXISTING SEPTIC AND REPLACE AS REQ'D
TANK NECESSARY COMPACTED BASE 45.0' AND DESIGN ENGINEER.
5 OUTLET DISTRIBUTION BOXP') 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF
( TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV.= < 7 ' 84.4.50 BLODIFFUSERS END VIEW 00 ESTABLISHED AT A CHISELED SQUARE ON THE CORNER OF A CONCRETE PAD
BASE. FIRST TWO FEET OF OUTLET ( )
AS SHOWN ON PLAN.
EXISTING 1,500 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. BIODIFFUSERS (PROFILE) 9. CONTRACTOR SHALL-VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
(BY INFILTRATOR SYSTEMS, INC.) THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
CROSS SECTION VIEW 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
*CONTRACTOR IO°VERIFY
NY WORK& SEPTIC TANK PROFILE H-20 DISTRIBUTION BOX DETAIL ARC 36HC (#�3616BD) BIODIFFUSERS (H-20)
TO THE DESIGN ENGINEER.
NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC.STRUCTURES SHALL BE MADE WATERTIGHT.
d TEST PIT DATA 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
HC-1 'I D p PERC NO. 13926 REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
APPROPRIATE AUTHORITY.
i 64-� c: +► �� :yj OPR TE
INSPECTOR: Donald Desmarais, R.S.
/ ~`. - �; d► 4 : • 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
EVALUATOR. Michael Pimentel, FIT,CSE
/ LOCATED UNDER PAVEM NT-' « _= E , DRIVES OR TRAVELED WAYS IN WHICH CASE
#84 / / �.'� b ` C.S.E.APPROVAL DATE: Oct. 1999
p THEY SHALL WITHSTAND H-20 LOADING.
EXISTING 13. DOUBLE WASHED 4-BEDROOM Ps a DATE: April 19,2013
/ G �\ � HE CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
DWELLING
�.:� TEST PIT#: 1
I _
4) FFE=85.T± / _ 1 ABLE
DECK / v � r \6 � � ^, Ci .r •., 4 ELEV TOP 85.00
4 WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
,
t�
-. Y{= MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
t _ ELEV WATER= <74.50' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, !
FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
gh HC-2 // / �`' \ o `moo- ` 1 x a. Y PERC RATE_ 4 min./inch
(3 Jg / 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
68 v� a� ` ,>' DEPTH OF PERC= 54"-72" SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
MAP 128 / of \�
01 tZ :<<i co �-P O Q D\ ` �� °- 1 ° `"d x. ` TEXTURAL CLASS: 1 16 PROPOSED PROJECT 7S LOCATED WITHIN:
�,
s 1) °s O LOT 13 J cb /�. �' \ \ �� lc o . LOCUS ASSESSOR'S MAP 128 PARCEL 28
s
,�' a� `� o°' �f� ��f�' s >2 �. NO� m _ OWNER OF RECORD: EDWARD J. & LESLIE A. PERPER
f \ \, .
1 ti ,
�o�Q s�V A V �� A 4" Fill 84.67' ADDRESS: 84 WHITE BIRCH WAY
♦ : . RNSTABLE, MA 02668
CONC. PAD w/ " GAS,� �D \ ♦ �... Sandy Loam WEST BA
"_ HOT TUB o Q / ado \. \ \ \ \�. FQ a - B 10Yr 5/6 FEMA FLOOD ZONE C
SWING-TIES SCALE: 1 =20 \ \ m o 4
�� 0Ps \ \ ♦�` :. COMMUNITY PANEL# 250001 0015 C
\ ♦ Olt` 4ux ., ' �' " ...V '
\ \ v 17. DEED REFERENCE: DEED BOOK 10827, PAGE 68
t� 54 80.50
DESCRIPTION HC-1 HC-2 / / ��, \ \ \, 9 "" �, �° p
y L 'v ,; � s erc
BIODIFFUSER CORNER(1) / \ \ ♦ '. ` a > 72" .K 79.00' 18. PLAN REFERENCE: PLAN BOOK 406, PAGE o 64.5' _ 30.2.' \ \
BIODIFFUSER CORNER 2 71.1 3 O 8.5' 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
- d +►� r
, \ � , �{. , ...- � « _ _._. 20. _ PROPERTY.Lt WE\ Loamy Sa �i l�1E ORMATION],,-ONLY APPROXIMATE: THIS PLAN LS TO BE USED ONLY
BIODIFFUSER CORNER 3 55.9 66.0 ,. \ \ ,\ :. ,, ;�: ,. �, ..�.� > .;��. r.. .,:.v .: � �". r ..
O l \ �2 / C
SHED .:: -; � ,, '� i`" �- `� �. m' '�`` 6/6'i C ENGINEERING WILL NOT ASSUME ANY LIABILITY
2 5Y FOR SEPTIC SYSTEM UPGRADE J
\ / ,, m> ° gravel; FOR USE F T
BIODIFFUSER CORNER 4 47.3' 61.6'_ \ \ f ., . (10/°g a S O HIS PLAN OTHER THAN 1T5 INTENDED PURPOSE.
O , few cobble
\ \ \ w 21. IN ACCORDANCE WITH 310 CMR 15.401 -15.405,THE'FOLLOWING LOCAL UPGRADE
\ 81x9' ' \ \ \ _ \ ♦� APPROVAL IS REQUESTED FROM 310 CMR 15.221 (7):
(1.) A 3.00'WAIVER(3.00'-6.00')FOR THE MAXIMUM COVER OVER THE LEACHING SYSTEM.
LOCUS PLAN (2.) A 1.10'WAIVER(3.00'-4.10')FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX.
\ \
#84 \ \ ��S/C O SCALE: 1"= 1000' „
82x6' - EXISTING w--_w w C % 126 74.50
II 4-BEDROOM \--w-- - w
\ \ \ I DWELLING E/T/C E/T/c w No Mottling,Weeping or Standing Observed
^
DECK � FFE-85.T± �TIC �"'- E is 8 EX. WELL EX.WELL TEST PIT DATA 83x3' I � DESIGN DATA PERC NO. 13926 LEGEND
\ \ r 8"BIACH ` � Donald Desmarais R.S.
PROPOSED 4" PVC VENT PIPE; \ \ INSPECTOR: 50x0 EXISTING SPOT GRADE
EXACT LOCATION PER OWNER \ �' 8'BtR H 150 8D =�� EVALUATOR:` Michael Pimentel, EIT CSE -
- 50 - - EXISTING CONTOUR
a g6 NUMBER OF BEDROOMS(DESIGN) 4
C.S.E.APPROVAL DATE: Oct. 1999
PROPOSED INSPECTION PORT 8D 85x0 a \ `L� DESIGN FLOW 110 GAUDAYBEDROOM 50 PROPOSED CONTOUR
DATE: Apnl 19,2013
WITH ACCESS BOX(TYP OF 2) \ \ \ `� O QPO \:p TOTAL DESIGN FLOW 440 GAUDAY E/T/C EXISTING UNDERGROUND UTILITIES
\ \90 \ 8 BIR , �O�G. ;P DESIGN FLOW X 200 % = 880 GAUDAY TEST PIT#: 2 TES
\ \ TP 1 �'< G 1 ELEV TOP_ 85.00' X-X-X-X-X- EXISTING FENCE LINE
8" BIRC BIT. DRIVEWAY USE EXISTING 1,500 GALLON SEPTIC TANK ELEV WATER= <74.50'
PROPOSED TOTAL 27 ARC 36HC ` '
c� 85X0 \ W W EXISTING WATER LINE
(#3616BA I-I-20 BIODIFFUSERS IN MAP 128 PERC RATE_
A FIELD CONFIGURATION \ LOT 27 GAS EXISTING GAS LINE
DEPTH OF PERC=
_ PROP. H-20 D-Box INSTALL 27 -ARC 36HC (#3616BD) BIODIFFUSERS i(H-20)
TEXTURAL CLASS: 1 TEST PIT LOCATION
\ 6" O1,LY 1 \ SYSTEM CAPACITY y
18"OAK TI (TOTAL IL.F. OF BIOS)(4.8 SF/LF)(0.74 GPD/SQ.FT.)=GPD 0" 85.00'
Fo
EXISTING 1,500 GALLON SEPTIC TANK
Benchmark (135.0')(4.8 SF/LF)(0.74 GAUSQ.FT.)= 479.5 GAL. LEACHING/WAY A Fill PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE
Chiseled Square 4" 84.67'
\ \ VEN o \ \ Elev. =84.00' ❑ PROPOSED H-20 DISTRIBUTION BOX
\ MAP 128 I \8 �\ Approx. M.S.L. TOTALS:
\ k \ 6\ Sandy Loam
\ LOT 28 \ TOTAL NUMBER OF BIODICOUP FUSERS: 27 B 10Yr 5/6 Q PROPOSED ARC 36HC(#3616BD)BIODIFFUSER(H-20)
\ \ \\ � � TOTAL NUMBER OF COUPLINGS: 0
\ 43,787 S.F.t TOTAL LEACHING AREA: 648.0 54" 80.50'
\ EXISTING 1,500 GALLON SEPTIC TANK
a \ TO BE UTILIZED IN THIS DESIGN TOTAL LEACHING CAPACITY: 479.5 REV. DATE BY APP'D. DESCRIPTION j
so
PROPOSED SEPTIC SYSTEM UPGRADE
\6&1 NOTE:�a \ PREPARED FOR:
\ / EXISTING DISTRIBUTION EFFECTIVE LEACHING AREA OF 4.80 SF/LF OBTAINED FROM TFHE Loamy Sand
DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER C 2.5Y 6/r; CAPEWIDE ENTERPRISES
\ BOX TO BE ABANDONED
"MODIFIED APPROVAL FOR GENERAL USE" ISSUED TO INFILTRATOR (10%gravel;
SYSTEMS, INC., DATE OF ISSUANCE OCTOBER 3, 2003(LAST MODIFIED few cobbles)
�� EXISTING 4-500 GALLON LEACHING MARCH 14, 2012). TRANSMITTAL NUMBER=X235253. LOCATED AT
MAP 128 \ \ CHAMBERS TO BE ABANDONED
1 84 WHITE BIRCH WAY
LOT 26 \ WEST BARNSTABLE, MA 02668
SPECIAL NOTES: \
SCALE: 1 INCH = 20 FT. DATE: APRIL 23, 2013
1. MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE \ 126" 74.50' i
) , G 0 10 20 40 80 FEET.
OF EACH SEPTIC SYSTEM COMPONENT. , �� Mottling,Weeping or Standing Observed P�j"OF"I'gss
No
yv qc
2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF / RESERVED FOR BOARD OF HEALTH USE Q> JOHN l• yGm PREPARED BY:
THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH i CHURCHt JR. JC ENGINEERING, INC.
TEST PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL A NO.iv807 �► 2854 CRANBERRY HIGHWAY
BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA.
Q �Fs STF �� EAST WAREHAM, MA 02538
3.) ENTIRE PROPERTY IS LOCATED WITHIN THE GROUNDWATER SITE PLAN �N �- 508.273.0377
PROTECTION OVERLAY DISTRICT AND THE ESTUARINE WATERSHED. SCALE: 1"=20' Drawn By: BSM Designed By:MCP Checked By:JLC JOB No.2422
j
CAIUr
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