HomeMy WebLinkAbout0065 CRANBERRY LANE - Health 65 Cranberry Lane
Barnstable P
A = 234 026 r
t> TOWN OF B � ST- Ll; �
N L SWAGE �
LOCATION J��/ h e/Y h - --
VE:LAGE _ a�n S 6/t ASSESSOR'S MAP&LOT
INSTALLER'S NAMF,&PHONE NO.
SEPTIC TANK-CAPACITy �5U� t1
LEACf3IN6FACT-M- (typa) /e•� c�. (size) I
No.OFBEDROONtS 3 --
13t ELDER OR OWNER
PERMITDATE: C01v6LIANCE DATE:
Separation Distance Between ihe:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
011
Private Water Supply Well and Leaching F q (If any wells exist
on site or%4thin 2co feet of leaching facility)` Feet
Edge of Wetland and Leaching Facility(If any wettands exist
within 300 feet 01 leaching facility) ' �,I / 'Feet
Furnished by - wn A11-`��lra � L
,,
p
r7- 33 _ t
TOWN.OF BARNSTABLE ;t 1
LC!t;;ATION to7 (amr 6 erev ZrA N [[SEWAGE+# oj
-X,?&vgOR S MAP & LOB` 7 ZI Z
VMhAGE
INSTALLER'S NAME&•PHONE,NO.-,011 J/
SEPTIC TANK CAPACITY Sd o 0
LEACHING FACILITY: (ty (size) 7 (D U
NO.OF BEDROOMS
BUTCDER OR OWNER
PERMITDATE: Z62Z;�COMPLIANCE DATE:J �'"
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
joit site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 30Ct-feet of leaching facility) Feet
Furcushed*by '� � .1
p -
A'
1
{
♦- .iI 4 •.ice I /.
3 13 .
No. INN I �"1'�' ��r*4 r Fee
THE COMMONWEALTH OF MASSAUZ S Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASIA�iHUSETTS Yes
2pptitation for Disposal *pstrm construction Permit
Application for a Permit to Construct( ) Repair("rupgrade( ) Abandon(") E]Complete System ❑Individual Components
&tioAapsskcel
or Lot No�_'�faf,6erfy 1,� Owner's Name,Address,and Tel.No.
so [i '- �� �Lv 4, al t 4'ct
Installller''s Name,Address,and Tel.N ,.?Cil Designer's Name,Address,and Tel.No.
V "<
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) &I gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ����y Type of S.A.S. 1°✓PG let es �
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -e/ � -C
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 o the syW
in.m operation until a Certificate of
Compliance has been issued by this Board of Health -
* Date . �� j
Application Approved by Date t� �
Application Disapproved by Date
for the following reasons
Permit No. . Date Issued r
No. � ., �}� � .!? � •'(� . f'R 4 h Fee
THE COMMONWEALTH OF MASSACHUSETTS ��� � �ered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ,
2ppliLatlott for Disposal 6pstr tt Construction 3perMjt �KID'
>
Application for a Permit to Construct( ) Repair(Upgrade Abandon( ) ❑Complete System ❑Individual Components
176cation�A,ddprres_s or Lot No l ' lit�6 ej-f/ r �,,� Owner's Name,Address,and Tel:No. �
SSeS$OC s ap/Parcel �,/(.t.`n �► rw
Installer's Name,Address,and Tel.No--0 _?e-'l 5&_V 7 Designer's Name,Address,and Tel.No.
1),pe of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( f
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures "
Design Flow(min.required) AJ gpd Design flow provided gpd
Plan Date Number of sheets Revision Date f
Title
Size of Septic Tank /i! 4 Type of S.A.S. i �� i i f f/K r
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �/r�u- C 1✓ '�'�
Date last inspected:
Agreement: s
The undersigned agrees to ensure the construction and maintenance of theafore described on-site•sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Coded not•toof lases e the system-in operation until a Certificate of
Compliance has been issued by this Board of Head.,..-"''�/� /`
Steed'^ . ...Date
Application Approved by Date 7 (�
Application Disapproved by Date
for the following reasons
Permit No. 'go 97 7"" Date Issued
---------------
r THE COMMONWEALTH OF MASSACHUSETTS
0� BARNSTABLE, MASSACHUSETTS
. Certificate of Compliance
i THIS IS TO C RTIF hat the On-site Sewage Disposal system Constructed( ) Repaired(Upgraded( )
Abandoned( )by 1, lAlt n 0 � a "-A Or G
at C�0 &1 y C l vC >Pt Pn� // has been constructed in acco dance
with the provisions-of Title 5 and the for Disposal System Construction Permit Nw,2021M_ dated
Installer i Designer
. �,
#bedrooms'' � Approved desigmfl� gpd
The issuance of this;permit shall not be construed as a guarantee that the system All function
as designed.
Date Z Inspector
- -- .- ---- - _ ---- - - - ------- -- - -
NoJ�-I '� � Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal Epstein Construction Vermit
PermissioI.. eby isgranted to Construct( ) Repair( Upgrade( ) Abandon
J
System located at 65 C'/0.`'` �Gr-
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
( Provided:Con(sttruction us be completed within three years of the date of this permit. .r'
Date '► 1 f Approved by
� 0
* r + r
Commonwealth of Massachusetts «�{-.. ,-••- -
Title 5 Official Inspection Forrh
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments".. -
M 65 Cranberry Ln (Off Hucldns Neck Rd)
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Barnstable MA 02630 12=15-1.1 s`
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. X
A. General Information • ,a;
«
-1. Inspector.
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536� ..
City/Town State f Zip Code,
1-508-495-0905 S13971 w" I
Telephone Number License Number
B. Certification , .; . • u;
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CM 15.000):The`system:
® Passes„ rt l 0 :Conditionally Passes `" 0 Fails `
4
El
Needs Further Evaluation by the Local Approving Authority .+
1215 ,1 . .
Inspector's Signature' ;' S 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.
71
t5ins-11/10 0 r Title 6 Official Inspection For n:Subsurface Sewl Disposal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 Cranberry Ln (Off Huckins Neck Rd) ,
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Barnstable MA 02630 12-15-11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) -
Inspection Summary: Check A,B,C,D or E J always complete all of Section D
A) System Passes:
® 1 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.
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
fthe Board of Health,will pass.
'a
Check the box for"yes", "no or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ;, ❑ N ❑ ND (Explain below):
t5ins•11/10 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official ,Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments _
65 CranberryLn Off Huckins Neck Rd
1
( )
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448) t
Owner Owner's Name -
information is required for every Barnstable, MA 02630 12-15-11 '
page. Cityrrown State Zip Code. Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health): 44 '
❑ broken pipe(s) are replaced ``; , ❑ Y `❑ NI ❑ ND(Explain below):
❑ -obstruction is removed- - ,` : . - ❑- Y ❑,Ni ❑ ND (Explain below):
❑ distribution box is leveled or replaced ' ❑ Y ' ❑' N.f ❑ 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 ,.,. Eli Yff ,.,r -N, ❑3ND:(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
f '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,
r safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or:privy is within 50 feet of a-bordering vegetated wetland or a salt marsh-
t5ins 11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
F
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Y rY
�M 65 Cranberry Ln (Off Huckins Neck Rd)
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Barnstable MA 02630 12-15-11
page. Cityrrown 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:
r
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
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
El ® than 1/day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts .-
Title 5 Official Inspection Form _
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4
65 Cranberry Ln (Off Huckins Neck Rd) ;r h
Property Address
Bank Owned Contact.David.-Holt @•Todat Reale Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Barnstable ' MA 02630 12-15-11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) ,
Yes No
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number,of times pumped:
❑ '.,k. Any portion of the SAS;'cesspool or privyis'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.
El "'® •`''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
r. laboratory,for fecal coliform bacteria indicates absent and the presence
F'� ._. .,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-
r10000gpd.
The system fails. ) 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.-
' ' -- •' is .�'. ,�s � i .. ..3 , •
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.
► r
For large systems, you,must indicate either`yes" or"'no"to each of the following, in addition to the
questions in Sectiort.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—1WPA)or a mapped Zone 11 of a public water supply well
If you.have-answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed: The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact theappropriate
regional office of the Department.
t5ins-11/10 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 65 Cranberry Ln (Off Huckins Neck Rd)
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Barnstable MA 02630 12-15-11
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?
❑ 0 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:
. 0 ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (f 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:
rS Number of bedrooms (design): 3 r Number of bedrooms (actual): 3
j DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Foes :b
Subsurface Sewage Disposal System Form -Not for,Voluntary.Assessments
M 65 Cranberry Ln (Off Huckins Neck Rd) Z
Property Address � _i
Bank Owned Contact David Holt @ Todat Reale Estate,1-8007966-2448 t :-;,
Owner Owner's Name 2
information is MA 02630 12-15-.11
required for every Barnstable
page. Citylrown .f, State Zip Code Date of Inspection
D. System Information g
,F
Description:
Number of current residents: p
Does residence havea,garbage grinder?A. ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection.fequired], ❑ Yes ® No
Laundry system inspected?. ts., El Yes ❑ No
Seasonal use? - ,• t ,¢ ` El Yes ® No
Water meter readings, if available (last 2 years>usage(gpd)):
Detail. ,
• t: in+�. ar,n ..4 Z- 'yf'..,t 111AII.5, Pd i.•s- f's t;t"°s.
Sump pump? ❑ Yes ® No
• r �,
:Last date of,occupancy: 'r F= � �. 10-2011Date-
Commercial/Industrial Flow Conditions:
Type'of Establishment:
Design flow(based�on,310 CMR,15.203) 9j w.=,
r. Gallons per day(god)
r.Basis of design flow seats/ ersons/s ft., etc.
.Grease trap present?ra rf .�` ,, , , tom; .TM<* ❑ Yes ❑ No
Industrial wasteholding tank present?,, r., _ <, �� r 3 ` ,r ❑ Yes ❑ No
. T
Non-sanitary waste discharged to the Title 5 system?` 1 ❑ Yes -❑ No r
Water meter readings, if available:
t5ins•11/10 a - Trtie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
G W Title 5 Official Ins ecti _
� on Form
Subsurface Sewage Disposal System Form -' Not for Voluntary Assessments
wM 65 Cranberry Ln (Off Huckins Neck Rd)
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448) '
Owner Owner's Name
information is required for every Barnstable MA 02630 12-15-11
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
9
Pum in Records:
Pumping,
Source of information: N/A
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) (f yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Y
LV
Commonwealth of Massachusetts ,;!
. Title 5 Official Inspection dorm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 Cranberry Ln (Off Huckins Neck Rd) ; ,4. a,t„ -
Property Address
d•
Bank Owned Contact David Holt @ Todat Reale Estate.1-800-96672448) .:. ,.. ,
Owner Owner's Name
information is Barnstable ., MA 02630 12-15-11
required for every "
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) a
Approximate age of all components, date installed (f known) and source of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): , ,. , .r.: _;,
Depth below grade:. '. ,• t t.,feet
Material of construction:
❑ cast iron' ® 40 PVC' ❑ other(explain): : • "
Distance from private water suppiy well or suction line:' ` .
' feet
;g Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 12"
feet"
Material of construction:
® concrete ❑ metal El fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age:
y
ears
Is age confirmed by a Certificate of Compliance?•(attach a copy of certificate) ❑ Yes ❑ -No
Dimensions: 1500 gal, , � . ,
Sludge depth: 12
t5ins-11/10 Tme 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
r •
Commonwealth of Massachusetts
� Title 5 Official Inspection Form
l; Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments
,M 65 Cranberry Ln (Off Huckins Neck Rd)
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Barnstable MA 02630 12-15-11
page. Cityfrown 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
20"
Scum thickness 0-
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 16"
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.
Grease Trap (locate on site plan):
Depth below grade: feet
y
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
1 --
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :
65 Cranberry Ln (Off Huckins Neck Rd)
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448)- .
Owner Owner's Name
information is required for every Barnstable MA. 02630 12-15-11,
page. Cdy/Town State Zip Code Date of Inspection
D. System Information (cont.) ti
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 rx:
Design Flow: ,
gallons per day
Alarm present: ❑. Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
`Attach copy of current pumping contract (required). Is copy attached? ❑•Yes - ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 65 Cranberry Ln (Off Huckins Neck Rd)
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966'2448)
Owner Owner's Name
information is required for every Barnstable MA 02630 12-15-11
page. Citylrown 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.):
Good condition with water at working level and no sign of back-up from trench.
r
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
li -
1
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 Cranberry Ln (Off Huckins Neck Rd)
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Barnstable MA 02630 12-15711
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist`
Z 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
e
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
f
Commonwealth of Massachusetts . • ,
Title 5 Official Inspection Form y
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 Cranberry Ln (Off Hucldns Neck Rd)
Property Address
Bank Owned Contact David Holt @.Todat Reale Estate 17800-966-2448)
Owner Owner's Name ,
information is required for every Barnstable MA 02630 12-15-11
page. City/Town State Zip Code Date of Inspection
D. System Information(cost.)
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 ' P t
ram^^
Ott
•
„k
4.,
t5ins•11/10 „ Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M
65 Cranberry Ln (Off Huckins Neck Rd)
Property Address
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Barnstable MA 02630 12-15-11
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water s ='
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 30'
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:
USGS and town spot elevations show groundwater at greater than 30'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
r
Commonwealth of Massachusetts r '
Title 5 Official Inspection Forte
Subsurface Sewage Disposal System Form -Not for Vol untary,Assessments.,
65 Cranberry Ln (Off Huckins Neck,Rd),'
Property Address r
Bank Owned Contact David Holt @ Todat Reale Estate 1-800-966-2448), '
Owner Owner's Name ,
Barnstable :;�: MA 02630. 12-15-11 ,
information is
required for every
page. Cityfrown �, r4 r. •?, State Zip Code Date of Inspection
D. System Information (cont.) ;
Type: •1 r f
r t
❑ - leaching pits number: -
❑ ,.�` = �leachin&hambers ' f :, , ,' number:
❑, leaching galleries number:
®. leaching trenches number, length: 1-4'x60' '
❑ leaching fields number, dimensions: '
❑ overflow cesspool, number:
❑ - innovative/alternativeisystem ,.•�•,. f ;
Type/name of,technology:
Comments (note condition of soil, signs of•.hydraulic failure, level of ponding, damp soil,'condition of
vegetation, etc.):
Leach trench in good condition with no sign of back-up into d-box or surrounding stone. "
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
Dimensioris of cesspool:
Materials of construction
Indication of groundwater inflow ❑ -Yes ❑ No ,
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form l
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�M r 65 Cranberry Ln (Off Huckins Neck Rd) r.
Property Address
Bank Owned Contact David'Holt @ Todat Reale Estate 1-800-966-2448)
Owner Owner's Name
information is Barnstable MA 02630 12-15-11
required for every `
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: '
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
KL%., a.IVED
COMMONWEALTH OF MASSACHUSETTS ` JUL 2 9 2004
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR TOWN OF BARVSTAKE
HEALTH DEPT.
= W
DEPARTMENT OF ENVIRONMENTAL PROTECTI
v
d e+AP
♦ ""'^^ire..
PARC
EL:LOT
TITLE-5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 65 CRANBERRY"LANE • ;MA 02632`a
Owner's Name: DONNA MORSE
Owner's Address: 65 CRANBERRY LANE CENTERVILLE,MA 02632
Date of Inspection: 7/15/04
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS co
Mailing Address: P.O.BOX 2119 TEATICKET MA. 02536 '
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT co rn
I certify that I have personally inspected the sewage disposal system at this address and that the iriformatio 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:
X Passes
_ Conditionally ses "
_ Needs Furth valuation by the Local Approving Authority
Fails
Inspector's Signature: '� Date: 7/15/04 ~ M
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspec on. If the system is a shared system or has a design flow of 10000 gpd or greater,the
inspector and the system owner s all submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer,if applicable;.and the approving authority.
Notes and Comments .
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPINGEVERY TWO'YEARS TO PROLONG THE;
SYSTEM'S USEFUL LIFE. '
****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' se.
Titles 5 Inenantinn Fnrm(./1 S/?Mfl
1
Page 2 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A r
CERTIFICATION(continued)
Property Address: 65 CRANBERRY LANE CENTERVILLE,MA 02632
Owner: DONNA MORSE w.
Date of Inspection: 7/15/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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 PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of.Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain..
n/a The septic tank is metal and over 20 years old* or:the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tankis replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
broken pipe(s)are replaced
obstruction is removed
_ distribution box is leveled or replaced .:
ND explain: n/a ,
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health): r '
_broken pipe(s)are replacedt
_obstruction is removed
ND explain:n/a <
,
Page 3 of 11
OFFICIAL INSPECTION FORM e- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_ PART A
CERTIFICATION(continued)
Property Address: 65 CRANBERRY LANE CENTERVILLE,MA 02632
Owner: DONNA MORSE ,
Date of Inspection: 7/15/04 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, _
g
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment: .
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is-within 100 feet of a surface water
supply or tributary to a surface water supply:
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _
_ The system has a septic tank and SAS and.the SAS is within-50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than.100 feet but 50 feet or more froma private water ' ~
supply well".Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A <
CERTIFICATION(continued] _
Property Address: 65 CRANBERRY LANE CENTERVILLE MA 026
32.2
Owner: DONNA MORSE
Date of Inspection: 7/15/04 ' ,
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for IdLinspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped NOT IN THE LAST TWO YFARS.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary.to a surface water
PP Y supply.
- X Any portion of a cesspool or privy is within a Zone 1 of a public well. _
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure. a
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd: . .
You must indicate either"yes"or"no"to each.of the following:
(The following criteria apply to large systems in addition to the criteria above)_
yes no
X the system is within 400 feet-of a surface drinking water supply
_ X the system is within 200 feet.of a'tributary to,a surface drinking water supply
X•the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered'a significant threat;or answered
"yes"in Section D above the large system has failed.The owner or operator of any large'system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner-
should contact the appropriate regional office of the Department_
y .
Page 5 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.PART B
CHECKLIST
Property Address: 65 CRANBERRY LANE CENTERVILLE,MA 02632
Owner: DONNA MORSE
Date of Inspection: 7/15/04 t
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period? r
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs-of sewage back up'?
a
X _ Was the site inspected for signs of break out.? «
• .. a S.. . ., ,
X _ Were all system components,excluding the SAS, located on site
s ,
X _ Were the septic tank manholes uncovered,opened;and the interior of the tank inspected Yfor`the condition'of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenanceP
of subsurface sewage disposal systems? 1
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no a
X _ Existing information.'For example;a plan at the Board of Health. W
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance.is
unacceptable) [310 CMR 15.302(3)(b)]
.. r
14
r
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 65 CRANBERRY LANE CENTERVILLE,MA 02632
Owner: DONNA MORSE
Date of Inspection: 7/15/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3 „
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):,R�a.
Sump pump(yes or no):NO t� .Mob
0
Last date of occupancy: n/a
COMMERCIALANDUSTRIAL _
Type of establishment: n/a -
Design flow(based on 310 CMR 15.203): n/agpd '
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no):NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no):.NO -
Water meter readings, if available: n/a _
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION:
Pumping Records „. f
Source of information: NOT IN THE LAST TWO YEARS
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped:n/agallons--,How was quantity pumped determined?n/a
Reason for pumping: n/a ,
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system'° r r r a Y
_Single cesspool '
_Overflow cesspool `
_Privy '
_Shared system(yes or no)(if yes,attach previous inspection records,if ariy)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance=contract(to be obtained from
system owner) t:
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a , ,I
Approximate age of all components,date installed(if known)and source of information: r
2000 PER OWNER
Were sewage odors detected when arriving at the site(yes or no):NO a'
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 CRANBERRY LANE CENTERVILLE,MA 02632
Owner: DONNA MORSE t
Date of Inspection: 7/15/04
BUILDING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:_cast iron X40 PVC other(explain):n/a
Distance from private water supply.well or suction liner n/a
Comments(on condition of joints,venting,evidence of leakage,-etc.):
TOWN WATER _
SEPTIC TANK:X(locate on site plan)
Depth below grade: 6" y
Material of construction:Xconcrete_metal—fiberglass',polyethylene other(explain)n/a
If tank is metal li
st age: n g /a Is age confirmed by a Certificate.of Compliance(yes or no):NO(attach a copy of certificate)
Dimensions:H 10 6 H 5 7 W 5 8
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
"
Scum thickness:2"
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: 16"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. .
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a .. .
Scum thickness: n/a ,
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle:n/a
Date of last pumping: n/a u z
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
`,' _ _ .h. ... ... a .. . - - w •. y e. 2
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 CRANBERRY LANE CENTERVILLE,MA 02632 _
Owner: DONNA MORSE
Date of Inspection: 7/15/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of.construction:_concrete_metal_fiberglass_polyethylene_other(explain):n/a,,
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day '
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or.no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) w
Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution,to outlets equal,any evidence of solids carryover,`any evidence of leakage into
or out of box,etc.):
D-BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO 3
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): w
n/a
n ,
l
' Page 9 of 11
.z
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C'
SYSTEM INFORMATION(continued)
Property Address: 65 CRANBERRY LANE CENTERVILLE,MA 02632
Owner: DONNA MORSE
Date of Inspection: 7/15/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
a
Type
n/a leaching pits, number: n/a'
n/a leaching chambers, number:, n/a
n/a leaching 9 n/a
galleries, number: _
'
1 leaching trenches, number, length: 60
n ,
/a le
aching fields, number: n ,
la
n/a v o erfl w o cesspool, number: n/a'
t _
n/a _ innovative/alternative iv e/alternative system
stem
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,'condition of vegetation,etc):
LEACHING TRENCH IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO
SIGNS OF FAILURE. SOIL WAS PROBED DRY.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locat6 on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a ,
Indication of groundwater inflow(yes or no): NO F
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
.Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
r Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 CRANBERRY LANE CENTERVILLE,MA 02632
Owner: DONNA MORSE
Date of Inspection: 7/15/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet.Locate where public water supply,enters the building..
*,50
Yv�zo
in
Page 11 of 11 "
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 CRANBERRY LANE CENTERVILLE,MA 0202 r:
Owner: DONNA MORSE
Date of Inspection: 7/15/04
SITE EXAM
_Slope x
_Surface water
_Check cellar.
_Shallow wells t.
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design.plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a ,
NO Checked with local excavators, installers-(attach documentation) p.
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 10+FT.
it . .
V.
No. J_,V q/ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Y s
ZIppYication for Migpoal 6pgtem Construction Permit
Application for a Permit to Construct( . )Repair( )Upgrade(�bandon( ) qzcomplete System ❑Individual Components
Location Address or Lot No. Lo' Owner's Name,Address and Tel.No.
Assessor's Map/Parcel �
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
s
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 12;1__1�0 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 - Type of S.A.S. o �Iqc1 14
Description of Soil ��y0 c157
Nature of Re }.rs or Alterations(Answer when ap licable)
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 ha issue y of He
° Signed rk— Date 7"
Application Approved b - Date w
Application Disapproved for the following reasons
Permit No. Date Issued
Al Lj" Fee111000,
THE COMMONWEALTH OF MASSACHUSETTS i Entered in computer:
�a Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0(pprication for IDi!5po.5al *potent Con.5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade(� Bandon( ) �C�Complete System Kt Complete Individual Components
_ -, �, --,,
Location Address or Lot No. t ?GTNo dv�1��� Owner's Name,Address and Tel.No. p *' r'- � 4
C +i�i�✓�.1�' ��`''� ( C
Assessor's Map/Parcel �-•�A"'c''.__.� � a_
k
Installer's Name,Address,and Tel.ko. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons ,� Showers( ) Cafeteria( )
Other Fixtures .All
(r/r y.,f r a..sTie
Design Flow gallons per day. Calculated daily flo- gallons.
Plan Date Number of sheets 16,`I. RevtsiondD ep's�.i � J
Title A ,r 1 '"�`
Size of Septic Tank Type of S A.S. Va,
Description of Soil �•., �f1(y.
� I
Nature of Repairs or Alterations(Answer when applicable)
U o+
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 haj-pheen_issued-by s Board of Health.
Signed1i r Date
Application Approved by Date
Application Disapproved for o owing easons "
Permit No. 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 _
at IVII
has been constructed in accordance
with the provisions of Tfffe and le for D"i—sp o's A R;QtJn onstruction ermit Now ated
Installer .r' Designer
r
The issuance o t s permi shall no cons rued as a guarantee that the syste 11 function as de igned.4150
Date 49,s, �.2 r.-+ Inspecto
AV
-------�j—^-------------------------------
No. �--� ( / Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS
1witpogal *proem Construction Permit
Permission is hereby gr Inted to Construct( )Repair( )Upgrade( )nd'on( )
System located at E
PC—
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 m st be completed within three years of the date of this permit.
Date: t-7 ,, Approved by
i
rx 1/6/99
NOTICE: This Form Is To-Be Used For the Repair Of Failed
t
c'eta;r Septic Systems Only. `!
s
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated —7 ��f` , concerning the
property ylocated at , ta,
Gr���v�V�� Cesvt� meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or business
u es 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
The
re are no private wells within 150 feet of the proposed septic system
(here is no increase in flow and/or change in use proposed
There are no variances requested or needed.
• ,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
:aa plicable]
If the S.A.S.will be located with 250 of any feet a ve Q
getated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
:groundwater table elevation,
- f
Please complete the following: 2
A) Top of Ground Surface Elevation(using GIS information)-
. Y ,,ll
B) G.W.Elevation ," +the MAX. High G.W.Adjustment.#k—_ V
DIFFERENCE BETWEEN A and B
SIGNED - DATE:
[Please Sketch pro an o stem on ac
NOTICE
Based uporr the above information,a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
O'n
00
f
TOWN OF BARNSTABLE
LOCATION (D-5' ( Vr b a r � &A tip SEWAGE #
VILLAGE 1 4 ASSESSOR'S MAP & LOI!r
INSTALLER'S NAME&PHONE NO. /YI i`liJr.�l42 t o ail C
�. SEPTIC TANK CAPACITY Sd o o
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BL)TCD'ER OR OWNER �/A � �
PERMTTDATE: COMPLIANCE DATE: —2? V;?5-, >
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
,xy-- on site or within 200 feet'of leaching facility) Feet.
'Ed
ge of Wetland and Leaching Facility(If any wetlands exist
I within 30Q feet of leaching facility) Feet
y"`Furnished;by it /S
i
Ty
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i
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