HomeMy WebLinkAbout0090 CRANBERRY LANE - Health 90 CRANBERRY LANE
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Commonwealth of Massachusetts
Title 5 Official Inspection. Form
ill Subsurface Sewage Disposal System,Form,-Not for Voluntary Assessments
•�.,_•.�_ , 90 Cranberry Ln 1 - .�. �•
Property Address
Steve& Pam Miles #,
Owner Owner'A Name +,:•<�
information is C�q,bl� �+
required for every C r�" ^y-s,, MA 02632 7-27-18 , ,
page. City/Town tz' State ' Zip Code Date of Inspection .
Inspection results must be submitted on this form. Inspection forms may riot be-altered in any faµ
way. Please see,completeness checklist at the end of the form.
A. General Information 13,21�P
1. Inspector:_
' Shawn•Mcelroy '
Name of Inspector '" 4'
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
Cityrrown State Zip Code
1-508-495-0905 S13971
Telephone Number -License Number
B. Certification
t certify that I have personally.inspected the sewage disposal system at,this address and that the
-, 4information�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).T_te system:, &
Passes J], Conditionally,Passes ❑ Fails,-
❑ Needs Furt I tion,by the Local Approving Authority ;
7=27=18
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 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.doc-rev.6116 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System,-Page A of 17
Commonwealth of Massachusetts - «
r� Title 5 Official Inspection Form
! 161 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Cranberry Ln -
Property Address
Steve& Pam Miles
Owner Owner's Name
information is Centerville MA 02632 ` 7=27-•18.
required for 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: ' �^
® 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
the Board of Health, will pass: t
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. -
A, r ❑ Y ❑N ❑ ND (Explain below): z°nrf
t5ins.doc•rev.6/16 « Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
i
Commonwealth of Massachusetts ;
i Title 5 Official Inspection Fore _ ;�.
Subsurface Sewage Disposal.System Form:-Not for Voluntary Assessments.
' 90 Cranberry Ln
Property Address
Steve&Pam Miles
Owner Owner's Name
information is required for every Centerville ' MA 02632 7-27-18 '
. '•-
page. City/Town , 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 sevvage'backup"or break out or high static water level in El the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled,or uneven distribution box. System will
' 1 'pass inspection if(with approval of Board of Health): '
❑• ` ''broken pipe(sj are replaced ' ` ❑ Y '❑N ❑ ND (Explain below):
1
i 1
El obstruction is removed „ ' '❑ Y' ❑N El 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.'Sy`stem 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
r� y Title 5 Official Inspection Forme
i� wa _
Q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f ir'J�
90 Cranberry Ln
Property Address
P Y
Steve &Pam Miles
Owner Owner's Name
information is required for every Centerville MA 02632 .7-27-18
page, City/Town State Zip Code Date of Inspection
B. Certification (cost.)
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: r • _ ,< "
❑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 _ -
El The system has aseptic tank and SAS and the SAS is less than,100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:.
** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.
6
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each'of the'following for all inspections:
• F., .l . ., '�. .. - yr �, ' , '.
Yes No
E] ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool . 1,
,
Et® Discharge or ponding.of effluenfto the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official.. Inspection Fors
hI Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments;
90 Cranberry Ln
Property Address
Steve&Pam Miles ... 4,
Owner Owner's Name
information is Centerville . + MA 02632 7-2Z-18.
required for every t
page. City/Town -_*r State Zip Code Date of Inspection
B. Certification (cont.) f-
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
Lf, tr`ibutary tofa'surface`water supply. t' '
4 t; ❑ ® • Any portion of a,cesspool or privy-is within a Zone 1 of a public well.
El
® Any portion of'a cesspool or pnvy is within 50 feet of a private water supply well.
❑` ® ' Any portion of a cesspool o,r privy is less than f 00 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, 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-
tt ti 0 ® . 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
,.., •, ,�: a.,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.
„ For large systems, you-must indicate either"yes" or"no"to each of the following, in addition to the
questions.in Section D.F
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
U El AreaIWPA) or a mapped Zone II of a public water supply well
If you have answered es"to an y y y question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts -
��� Title 5 Official Inspection -Form
i�l Subsurface Sewage Disposal System Form -Not-for Voluntary Assessments
90 Cranberry Ln
Property Address
Steve&Pam Miles
Owner Owner's Name
information is ,
required for every Centerville MA . 02632 7-27-18
City/Town/Town State Zip Code Date of Inspection
page. Y p P
C. Checklist ' a
Check if the following have been done. You must indicate "yes" or"nb" 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?
r ® ❑. 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?
- -• �.
® ❑`•`i"-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?
® Or ' 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
f} been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
' ®' 0 Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information .,
Residential Flow Conditions:
Number of bedrooms (design): , , ; .3 i d Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd-x#of bedrooms):, 330
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
r
Commonwealth of Massachusetts
l Title 5 Official Inspec$ion; l=o�
p Subsurface Sewage Disposal System Form:Not for,Vol untary,Assessmentsi•,,
r
90 Cranberry Ln
Property Address
Steve&Pam Miles
Owner Owner's Name ;
information is required for every Centerville , MA 02632 7-27-18 - ', }
'
page. City/Town o• , State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.) •
� ..si
Laundry system inspected?" ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? El Yes ® No
Last date of occupancy: - y F 7-2018
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
„Design flow(based on 310 CMR.15.203): Gallons per day(gpd)
f, Basis ofkdesign flow,(seats/persons/sq.ft.,retc.):. r
Grease trap present?, ❑ Yes ❑ No
Industrial waste holding tank present?'p t , , ElYes ❑ No
Non-sanitary waste discharged to the Title 5 system?. f - ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts i
y Title 5 Official Inspection Form t:
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments,
90 Cranberry Ln
Property Address
Steve&Pam Miles `
Cwner Owner's Name
information is Centerville MA 02632 7-27-18
required for every
page. City/Town ' State Zip Code Date of Inspection
D. System Information (cont.) a a, R
Last date of occupancy/use: . '
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner--pumped 2015
Was system pumped as part of the inspection? ` - ❑ Yes ® No
If yes, volume pumped: w r _
gallons
t .
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool d.
❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17'
c Commonwealth of Massachusetts
Title 5 Official Inspection Form'
f� wa
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t'
•. -'`
�:,_•T, ;> 90 Cranberry Ln - •
Property Address
Steve& Pam Miles
Owner Owner's Name -
information is �,
required for every Centerville ' , r _ MA 02632 7-27-18
page. City/Town +• _ .- State Zip Code Date of Inspection
D. System Information (cont.) , r
Approximate age of all components, date installed (if known) and source of information:
1970's with second leach pit added in.1995
Were sewage odors detected when arriving at the site? Yes ® No
Building Sewer(locate on siteplan):,,.i 9 .
18"
Depth belowrgrade: _ ., ,: , t' feet
t
Material of construction:
cast iron ® 40tr PVC ❑ other(explain): ,.
4.
Distance from private water supply well or suction line: feet
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 ❑ fiberglass polyethylene,,, G ❑ other(explain)
If tank is metal; list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: .* ,,. - , 1000 gal
Sludge depth,
12'' .,
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
c � Commonwealth of Massachusetts
y Tile 5 Offici�l Ins�ec�io� Form'
�h Subsurface Sewage Disposal System form -Not for Voluntary Assessments .,r
fir',•`
90 Cranberry Ln
Property Address
Steve & Pam Miles
Owner Owner's Name
information is required for every Centerville MA 02632 7-27-18
page. City/Town s 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
' 2011
1„
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 -'..
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.
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.doc-rev.6/16 + Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
PL
Commonwealth of Massachusetts .
(. Tine 5 Official Inspection Form
Pl Subsurface Sewage Disposal,System Form.-Not for.Voluntary Assessments.
90 Cranberry Ln
1
Property Address
Steve&Pam Miles .,, .' .
Owner Owner's Name
information is ,
required for every Centerville MA 02632 7-27-18
page. City/Town' j State Zip Code Date of Inspection
D. System Information (cont.) : . s�1�
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,'etc:):
° _f,P e� •t ,-t,,.q .y...,.t. ,'i t.. - t.�•I' ♦_, ale i .:i..rsf..
7f 1 •r, f .1 i. t .f .4?Y
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: r .,Xt tS .,`t ta.D1 r r v i• aY uat 1 .+r r
gallons per day'
Alarm present: ❑ Yes ❑ No
Alarm•Ievel: 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 El No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts ,
p Title 5 Official Inspection Forin'
%I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
}
l� r" 90 Cranberry Ln
Property Address
Steve& Pam Miles 3
Owner Owner's Name
information is Centerville MA 02632 7-27-18
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be'operied)(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 pits.
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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts : , : ,�_ �, .",4 <<
.r Title 5 Official Inspection' Form' ' -
ll
�i Subsurface Sewage Disposal System"Form -Not for Voluntary Assessments.%' �. ..
�:a_•T,.> 90 Cranberry Ln -
Property Address
Steve& Pam Miles
Owner Owner's Name
information is Centerville : ' = 1 MA 02632 7-27-18 -
required for every
page. , City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type: ,
leaching pits number: 2-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
-leaching trenches number, length:
❑ leaching fields i- number,.dimensions:,":
❑ overflow cesspool number:- #' :r, ;
❑ innovative/alternative system
Type/name of technology: k .
l •.Commentsl(note condition of soil;signs of hydra6licfailure;level of,ponding, damp soil, condition of
vegetation, etc.): _
Leach pits in good condition with water level and stain line at 18" off bottom of pit in pit numbered 4.
In pit numbered 5,water level and stain line was at 30" below inlet invert.
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
cam" Commonwealth of Massachusetts
Title 5 Official Inspection. Ford
%I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
90 Cranberry Ln
Property Address
Steve'& Pam Miles
Owner Owner's Name
information is Centerville MA 02632 7-27-18
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.):
Privylocate omsite
( plan):
,
Materials of construction: _
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
s
Y
1
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
sue` Commonwealth of Massachusetts .:. ,
Title 5 Official Lnspection. Form
hf Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i
90 Cranberry Ln {
Property Address
Steve& Pam Miles -
Owner Owner's Name
information is >';
required for every CentervilleMA 02632 7-27-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) .,
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal'system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
Ir ® hand-sketch in the area below
❑ drawing attached separately
L_j
• ,may r r -
t ,: t` o
t5ins:doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
'Ile \ Commonwealth of Massachusetts
7 ,w� Title 5 Official Inspection Form
i.i Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments
r. ,> 90 Cranberry Ln
Property Address
Steve& Pam Miles -
Owner Owner's Name
information is Centerville '' MA 02632 7-27-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) �•�- �•
Site Exam`.
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated.depth to high ground water: 20'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® ; Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
R4 Title 5 Official Inspection Form
! r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>r 90 Cranberry
Property Address � —
Steve&Pam Miles
Owner Owner's Name
information is required for every Centerville MA 02632 7-27-18
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
r
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is
required for every Centerville 4w;. MA 02632 1-13-11
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.
A. General Information
I�10
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services t=
P P
Company Name
29 Atwater Dr -. r
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification r
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
1-13-11
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.twner
t z 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.
l � I
,l
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
^� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G'M 90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
required for
is Centerville MA 02632 1-13-11
required for 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:
® 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
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If."not
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
r
* 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:
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
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is "
required for every Centerville MA 02632 1-13-11. _ f
page. City/Town State Zip Code 'Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system,will pass inspection if(with approval of the Board of Health):,
❑ broken pipe(s) are replaced
❑ obstruction is removed '
ND Explain: r
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(l)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
' ❑ F` 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;
' t • `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.
t5insp official document•03108 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 90 Cranberry Ln
Property Address
Bank Owned (Contact Daryl[ Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Centerville MA 02632 1-13-11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool '
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than day flow
El ® 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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 90 Cranberry Ln
7M
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-89,16)
Owner Owner's Name
information is Centerville a c
required for every MA 02632 1-13-11
page. City/Town- State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No s
❑. ® '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
❑ ' m ®" ` `1 criteria exist as described in 310 CM 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 '
Elr. . .:Elthe 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 Elthe system is located in a nitrogen sensitive area (Interim_Wellhead Protection
Area IWPA)or a mapped Zone It 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.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
L ,
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owier Owner's Name
information is required for every Centerville MA 02632 1-13-11
pace. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
' ® ❑ Was the facility or dwelling inspected for signs of sewage backup?
® ❑ 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)]
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
P
Commonwealth of Massachusetts
Title 5 Official Inspection . Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is Centerville + ;'
required for every MA '02632 1-13-11_.
page. City/Town State Zip Code Date of Inspection
r
D. System Information
Residential Flow Conditions: .
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110.gpd x#of bedrooms): 330
Number of current residents: 0 .
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? - w ❑ Yes ® No
Water meter readings;if available (last 2 years usage (gpd)):.
Sump pump?. . . ❑ Yes ® No
Last date of occupancy:' 10-2010
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: ,
.Design flow(based on 310 CM 15.203): Gallons per day(gpo)
Basis of design flow(seats/persons/sq.ft.;etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? - ;, '7 ❑ Yes. ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑„Yes ❑ No
Water meter readings, if available:;
i
Last date of occupancy/use: Date
Other(describe):
t5insp official document-03/08 Title 5'Official lnspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
u . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Centerville MA 02632 1-13-11
page. City/Town State Zip Code Date of Inspection
Q. steep Infor ration cent. .
Y ( )
General Information
Pumping Records:
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) (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:
1995 Pit was added
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
I
Commonwealth of Massachusetts
. Title 5 Official Inspectionforrb
_ Subsurface Sewage Disposal System Form -Notfor-Voluntary Assessments
�M 90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ DR Enterprises 1-508-776=8916)1� , �• x
Owner Owner's Name
Information Is required for every Centerville' MA 02632 1-13-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) {
Building Sewer'(locate on"site plan):
22"
Depth below grade: ',. �... feet _
Material of construction: v '
cast iron ® 40 PVC _ ❑ other(explain): . .
Distance from private water supply.well or suction line: x feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site.plan):,9,
16"
Depth below grade:
feet
Material'of construction;
® concrete ❑metal ❑ fiberglass ❑ po.lyethylene-,;, ❑ other (explain)
1f tank is metal,list age:
•.:years '
Is age confirmed by a Certificate of Compliance?(attach a copy-of certificate) , ❑ Yes ❑ No
---- ----- ----------------- -------------------------
3 5 r• "4 }
Dimensions:
. . 1000 gal
12'
Sludge depth:
-20PP
Distance from top of sludge to bottom of outlet tee or baffle `
- s -
Scum thickness 0
Distance from top.of scum to top of outlet tee or baffle f.
6'�
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape
t5insp official document•03/08 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M r 90 Cranberry Ln
Property Address
Bank Owned (Contact Daryl[ Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Centerville MA 02632 1-13-11
page. City/Town 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.):
Tank is in good condition with baffles installed and no sign of leakage.
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 scum of to to of outlet tee or baffle
P
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
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.):
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):
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
l
P
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) .-
Owner Owner's Name t
information is Centerville MA 02632 ' 1-13-11 .
required for every
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions: ,
Capacity: j gallons
Design Flow:
c 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? t❑ Yes ❑ No ,
Distribution Box (if present must be opened) (locate on site plan): i
`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-tip.
` A Pump Chamber(locate on-site plan): '
t
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'aM
90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Centerville MA 02632 1-13-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number: 2-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pits in good condition with stain line in second pit at 30" below inlet invert.
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
f
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916),
Owner Owner's Name
information is Centerville MA 02632 1-13-11
required for every '
City/Town State Zi Code Date of Inspection
'
page. . P. P
D. System Information (cont.) _
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration 1
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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
41
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.): k
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owrer Owner's Name
information is regt.ired for every Centerville MA 02632 1-13-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.
84C k
f
1
a:
1
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'~ 90 Cranberry Ln
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Centerville MA •02632 1-13-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
4 i .
El
Check cellar
N
❑ Shallow wells '
Estimated depth to high-ground water: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local,Board of Health -explain:
{
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database - explain:
f
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at 20'.-
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
q �«ti �2mY �r.� SEWAGE#
LOCAT'LQN 1
t• o f e!' y c��f e ASSES.^C}ft'S MA &€.QT '
VJLLA..
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N, P,� :: (sue) • � 10��.,��::
LEACH.,
i
NO UgBE+I3f�tX7IyiS
EEJSL FaR OR OW'riER
P�?RMFFDATE {3MPLf iNCfi DA'�Ec'
S+. .. , on Distance gefixesn`Fhe Feet
MaximamAd�ustes}Cxra�xidwatgxTabteto theBattom ofLeachinFty
g . an gyres east
PIIY$tetater:Supplyde11 ariding ► y ,
an srta cr wtt�un?AQ feet 6f Ieag f )
Edge of Wetland and Leaching Faa't�ty.(IfY watlaiids exisi Feet
wittLis�3t3(I`,feet leaclungf
rT
L
( 6 G D C
� 0 3
� r
A • a -a(' .6-.1 -
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10_�r_
c� /TO`Vd'N OF//E TSTABLE
LOCATION r ( /��� �P�'� !� SEWAGE
i
V1LLA�sEer� e�v,lC� ASSESSOR'S MAP&LOT
INSTAL J E:R'S NAME&PHONE NO.
SEP11C TANK CAPACITY
LL - /VV-o
LEACHING FACILITY: (type),_-A 7 (size)
NO.OF'E EOROOMS--Z—..�..,
BUILDER OR OWNER,
PERNSd'TI3f TES:. _..,�..�....�. ,:; OYbEi'C 1AiCE BATE
Separation Distance Between the:
Maximum Adjusted,,Groundwater Table to the Bottom of Leaching Facility Fee'
Private Water Supply Well'and Leaching Facility (If any%liclis gist
on site or within 200 feet of leaching facllity) Fee!
Edge of Wetland and Leaching Facility(if any wetlands exist
witiain 300 feet�kaabing fari �c / i:•'cTurialsbed by �w r �6��
a.G
,
A-0- 17 � �' 0. 8
j�j /F�J4 /
`j TOWN.OF BARNSTABLE
I:0CATION gQ C i r4h,b erru1 k' SEWAGE #
VILLAGE L�L1 �As� ASSESSOR'S 'MAP & LOT
INSTALLER'S NAME & PHONE NO. Sty i► 1�7 C
SEPTIC TANK CAPACITY ju00
- LEACHING FACILITY:(type) `j, .. (size) 1000
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER � �• �j�lj
(DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED-,
VARIANCE GRANTED: Yes No
b. S-
• ri
E
' F
P
No......(�' ....g �1 Fmic �....3 3..0...0.0..
// — THE COMMONWEALTH OF MASSACHUSETTS
`7 (� BOARD OF HEALTH
TOWN OF.BARNSTABLE
Appliratiun for Bi_npaiml Workii Tuntrnr#inn Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair h(XX) an Individual Sewage Disposal
System at:
90....ralla errx....ane...Centearyril e...-------•----. -•---------------------------------------•----•-------•-------•--•----.........-------•-------....
Location-Address or Lot No.
Alice Schaffer
Owner Address
.....,Macomber J ....................................................... ---------•....------------------•--------.....-•-•-••-•--•---------•-•-•------•------•-----•-.....
Installer Address
Type of Building Size Lot............................Sq. feet
►� DwellingX—No. of Bedrooms...........3-------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------- ................. Showers ( ) — Cafeteria ( )
Q, Other fixtures ------------------------------------------------------.....-----------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------------- Diameter---------------- Depth................
x Disposal Trench—No. .................... Width....--....--.-----.. Total Length--------_-.--.---. Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter...............--.-- Depth below inlet---......--......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit...........--.-----. Depth to ground water----...---..............
44 Test Pit No. 2................minutes per inch Depth of Test Pit.-.-------------_- Depth to ground water........................
Pr' --------------------------------•------------------•---•--------•-------••--.................................................................................
0 Description of Soil----------- --------•------•----------•------------•---•-•--------------------------------------------•----------------- ..............................................
v •----------------Sand...&---Grave.l..............................................................................................................................................
W
x .......................... ----------------------------------------------------------------------------------------------------------------------------------------------------•------------------------
U Nature of Repairs or Alterations—Answer when applicable.-Addi ng---1---1.0 GJa---ge-11.Da...p-i-t...and...one-
•.da..9tzbution..box...to---a n....exis-ting...tank...&...Pit--................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned fur the agrees not to place the
<= system in operation until a Certificate of Complia e has b e sued the board f he h.
Sign --------- ............ 2 4.f 9-5....
ApplicationApproved By -------- --------------- --- ----- --------------------- ................................... ----.. ------------------- .... 2._`. P...-:�s..
l Dare ..........
Application Disapproved for the following reasons: .. ...................................._---............--------................---------------------------------
---------------------------------------------------------------------------------------------------------- -----------------
/y s-F � 2 Dace -
Permit No. ............................... Issued ..............�:.... ..- .. ................
Dace
J� /J THE COMMONWEALTH OF MASSACHUSETTS
� 3
t (/ BOARD OF HEALTH
TOWN OF, BARNSTABLE
I Appliration for Bi-nVaiial Work.5 Towitrnr#iun rami#
Application is hereby made for a Permit to Construct.( ) or Repair(XX) an Individual Sewage Disposal
System at: LL N-
9. ...
0 Cranberry Lame enterville
.... .............•-----•-. ••........
C....
Location-Address or Lot No.
Alice Schaf e.r
Owner Address
aJ.P._Macomber Jr.=...................................................... ----------------------------------------------•-•-•••-•---•------------•......-•--•-••--•----•----
Installer Address
Type of Building .� Size Lot............................Sq. feet
Dwelling`-No. of Bedrooms....-.\.3. Attic ( ) Garbage Grinder ( )
aOther—Type
of Building -=----------- ------------ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures -----•--------------•--•---------------•--- ........................................... ..............................................................
W Design Flow............................................gallons per'person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity--___---_-_gallons Length---------------- Width_-------------- Diameter.-.------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------._.. _-.-.- Diameter-----------_----_-- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ------------------------------------------------------------------•----------------------•-•-•-----•....................................• ------------•-----
0 Description of Soil.............................................................................................................................................
----------------------•---
U ....................... and:-- Gra3Lal-•--•--------••-----•-•-•---------------•--------•-•--•------•---••--•-------------•--•••-------------..................
W
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable---A,d 3.P.jt...1---•00-0--- a..1.-Inn...it.__-andi...on.e_
ditrbuton--boy: t �? exat _
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned furthet,� agrees not to place the
system in operation until a Certificate of Compliance has b e>�sued by the board of hea!I'th.
�' 1 /24/95
Sign �: L� `f �!G!. %--------------------------- ----------------�-e-----------------
Application Approved By .......:. .. = ------------'--' -------------- ------------------- ----�..------ `.�
Date -----
Application Disapproved for the following reasons- -----------------------------------------------------------------------------------------------------------------------------------
................. .................................................. .... ....... ....................... .... . . . ........ ........................................
- � Date
PermitNo- ---------- ---------------------- ------------------------------ Issued ................I--... ; Tl5.... ..........
W Date
---------------------------------------------- -----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TlOWN OF BARNSTABLE
(IL��ertifirate of lloraylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�XX )
bY ... ................
J.P.Macomber Jr. - -
_--------------------------------------------------------- ----------------------------...----------------------._.._....__--
1—all,
at ......90 Cranberry .LaneCenterville---- -------------- ----------------------- -----------------------.........
... ....
has ....
been installed in accordance with the provisions of TITI.E 5�f Th State Environmental Code as des in
the application for Disposal Works Construction Permit No. ...� :. �... ........ dated _ _.... .. _...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
Ins ect r , �--`
DATE -���, . .... %'.. �.`. t j _ P
--------------------------I----------------------------- --------;---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
S TOWN OF BARNSTABLE $ 3000
No..... :............. FEE.........................
�i��n��t1 nrk� C�,an��r�r#uan �rrmi�
Permission is hereby granted....J.P.-MaComber Jr.
to Construct, ) or Re ai '(,X� an Individual Sewage Disposal System
�u an err do Centerviller
atNo................................................................... --•---------.---•--•-------------------------------------------------------------------------------------------.---------
Street
as shown on the application for Disposal Whorls Construction Permit No. = :�__ Dated____. .` S - -
,� .
` Board of Health
DATE.---•--•---------••-------------•--------------------------•------------••--
FORM 36508 HOBBS h WARREN.INC..PUBLISHERS
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