HomeMy WebLinkAbout0025 FRASER COURT - Health 1
25 FRASER COURT
Bamstable
A= 317 - 079 ��
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i
Commonwealth of Massachusetts r
w25
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,` 5
Fraser Court
Property Address R
Ella J Fraser
Owner
Owner's Name
information is /
required
Barnstable ✓ MA 02630 9-26.19 ,.,
equ red for every '"
page, Cityffown State Zip Code Date of Inspection 01)
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.
``,01111 OF
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Imp9rtant:When A. Inspector Information ts��e*��(/�-g A
filling out forms
on the computer, James D.Sears JAMES
use only the tab
key to move your Name of Inspector c a
cursor-do not Capewide Enterprises �'•-r o + i
use the return Company Name l� T I , • \� ,
key. 153 Commercial Street E s
.Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623 i
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true,accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2, ❑ Conditionally.Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Falls • ,
9-26-19jOifilpe
ctors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the.buyer; if applicable, and the approving authority,
wPlease note: This report only describes conditions at the time of inspection and under the 4
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.
4 t5insp.doc•rev.7l2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser
Owner Owners Name
information is required for every Barnstable MA 02630 9-26-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1 2"3 or 5 and all of 4 and 6.
1) System Passes: _
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are -
indicated below.
Comments: r
The system is a 1000 Gal. Tank and Pit.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass' section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes', "no"or"not determined" (Y, N. ND)for the following statements. If"not
determined,"please.explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure.is imminent, System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of.
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ .ND(Explain below):
o
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser
Owner Owners Name
information is
required for every Barnstable MA 02630 9-26-19
page. City(Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cons.): r t
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed.pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced 11 Y- ❑ N ❑ Nb(Explain below):
❑ obstruction is removed ❑ Y. ❑ N ❑ ND (Explain below):,
❑ distribution box,is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval`ofthe Board of Health)`.
❑ broken pipe(s)are replaced 'V ❑ Y ❑ N ❑ ND (Explain below):'
❑ obstruction is removed ❑ Y ❑ N ❑ ND'(Explain below):
3)' Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment..
a. System will pass unless Board of Health determines in accordance with 310 CMR.•
15.303(1)(b)that the system is not functioning Ina manner which_ will protect public health,
safety and the environment:
N •
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
r• Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser t
Owner Owner's Name
information is Barnstable MA. 02630 9-26-19
required for every State Zip Code Date of Inspection
page City/Town
C. Inspection Summary (cont.)
r
❑ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b.,System will fail unless the Board of Health (and Public Water Supplier, if any) '
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply. ti
❑ 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
coiiform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes.".or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
❑ ® clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
a ,
due to an overloaded or clogged SAS or cesspool
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser
Owner Owners Name
information is required for every Barnstable MA 02630 9.26-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) `
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
I ❑ ElStatic liquid level in th&distribution box above outlet invert due to an overloaded
Iv or clogged SAS or cesspool
® Liquid depth in awl is less than 6"below invert or available volume Is less
than '/:day flow P17'
❑ ® Required pumping more than 4 times in the last year NOT due to.clogged or..
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within_100`feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence. '
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, .
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd ,
10,000 gpd.
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ A the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7,126(201a Title 5 Official Inspection Form;Subsurlace Sewage Disposal System•Page 5af 18
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
uy
25 Fraser Court
Property Address
Ella J Fraser
Owner Owner's Name
information is required for every Barnstable MA 02630 9-26-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary.(cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat,or answered "yes"to any question in Section.CA above the large system has failed. The
G owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes"or"no"for each of the following for all Inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑. Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
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?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has,
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
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Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
qSubsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
25 Fraser Court
Property Address .
Ella J Fraser
Owner Owner's Name
information Is required for every Barnstable MA 02630 9-26-19
page, City/Town _ State Zip Code Date of Inspection
D. System Information
1. 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
Description:
1000 Gal. Tank and Pit.
Number of current residents: 0
Does residence'have a.garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No '
If yes, discharges to: .
Is laundry on a separate sewage system?(include laundry system inspection -. Yes ®: No
information in this report.)
Laundry system inspected? , _ : ❑ Yes 'Z No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2017-26;000Gals
9 Y g (gam)) 2018- 1,000 Gal's .
Detail:
Sump pump?- ❑ Yes ® No
• . Last dale of occupancy, . NA
Date
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Fraser Court
`
v k
Address
Ella J Fraser
Owner Owner's Name
information is required for every Barnstable MA' 02630 9-26-19
page. City/Town State tip Code Date of Inspection
D. System Information (coat.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203);-
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
f.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons .
How was quantity pumped determined?
'Reason for pumping: . .
. '
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Commonwealth of Massachusetts
Title 5 Official Inspection Ford
Subsurface Sewage Disposal System Form—Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser
Owner owner's Name
information is required for every Barnstable MA 02630 9-26-19
i
page. Clty/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
P
® 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)
❑ InnovativelAltemative 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:
1975 Permit #303.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
3
Depth below grade: . feel
`
• „ eet
r
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on.conditiorr of joints,venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40 "
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser
Owner Owner's Name
information is required for every Barnstable MA 02630 9-26-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
6. Septic Tank(locale on site.plan):
'
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
)
I
y
If tank is metal, list age:
years ,
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1000 Gal. Precast H-10
Dimensions:
2"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 28"
011
Scum thickness
1.
Distance from top of scum to top of outlet tee or baffle 8
Distance from bottom of scum to bottom of outlet tee or baffle 18
How were dimensions determined? Asbuilt-TapeSludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level! Tank and covers at 2' below grade. In Baffle w/outlet tee. No sign of
leakage or over loading.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser
Owner Owner's Name
information Is Barnstable MA 02630 9-26-19
required for every
page- City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan): ,
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance,from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: 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.):
B. 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
p Design Flow:
gallons per day
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Commonwealth of Massachusetts i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser
Owner Owner's Name
information is required for every Barnstable MA 02636 9-26-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.' i
8. Tight or Holding Tank(oont.)
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
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No Box
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.):
15insp.doc•rev.M&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 C
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
h Subsurface'Sewage Disposal System Form-Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser
Owner Owner's Name
information Is required for every Barnstable MA 02630 9-26-19
Pap. City/Town Slate Zip Code• Date of Inspection
D. System Information (cont.)
-10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of.pump chamber,condition of pumps and appurtenances,'etc.):
If pumps or alarms are not it working order, system is a conditional passe
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located,explain why:
Type:
® leaching pits number. . 1
❑ leaching chambers number:
❑ leaching galleries ,. number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
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Commonwealth of Massachusetts
Vw Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser-
Owner Owner's Name
information is required for every Barnstable MA 02630 9-26A9
page. City/Town State Zip,Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cost,)
Comments note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. Precast Pit. Pit at 47" below grade w/30"cement cover at 19". 4"water in
pit wlstain line at 30" No sign of over loading or solid carry over. No high stain line.
12. 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
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ti
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
AV
25 Fraser Court
Property Address
Ella J Fraser
Owner Owner's Name
information is required for every Barnstable MA 02630 9-26-19
page. CitylTown State Zip Code Date of Inspection'
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
r ,
Dimensions
Depth of solids
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
151nsp.doo-rev.W2612016 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page ISO'1e
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
-I Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,v 25 Fraser Court
Property Address
Ella J Fraser
Owner Owner's Name
information is required for every Barnstable MA 02630 _ 9-26-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system,_including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below, i
® hand-sketch in the area below
❑ drawing attached separately
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Commonwealth of Massachusetts
Title 5 official Inspection Form
ts
�d Subsurface Sewage Disposal System Form Not for Voluntary Assessmen ,
25 Fraser Court
Property Address
Ella J Fraser
Owner Owner's Name
information is required for every Barnstable MA 02630 9.26-19
Page City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam: !I
l
❑ Check Slope
❑ Surface water '
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
4
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers (attach documentat o )
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Auger T H at 14' no G W Bottom of pit at 10' below grade. Bottom of pit at 4'above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Fraser Court
Property Address
Ella J Fraser
Owner Owner's Name
information is required for every Barnstable MA 02630 9-26-19
page, Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed&Dated and 1, 2;3, or 4 checked
® C. Inspection Summary: .4
1, 2, 3,or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:',
For 8:Tight/Holding Tank— Pumping contract attached
i
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Ala.
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t5insp.doc rev.7/26/20118 Title 5Offcial trrspection Form:Subnxface Sewage Disposal System-Page 180l18
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LOC&T10N 5EWoC,E PERMIT MO
VILLAGE �2�C�EiL S_av2Z s13 �� 9
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GUILDER 5 Q AME t 4DDRESS
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`DATE-PERMIT ISSUED
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DQ.TE COMPLI&f--ICE. ISSUED:'
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD F A T
-------------O F... .......... .. ................................................
Appliratiott -for 'iopoottl Workii Tonotrurtion Vantit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at
•--...-•----------•-•---...----•--•----•-----•----••------•----•--
Location-Address V or Lot No.
Owner Address.
Installer Address
Q Type of Building Size Lot.... ....Sq. feet
U Dwelling—No. of Bedrooms.......7...............................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Ga Other fixtures ...
W Design Flow............. .z.•-.-----__-_-..------gallons per person per day. Total daily flow--------- .........................gallons.
WSeptic Tank—Liquid capacity J t ._.gallons _ Length---------------- Width...... Diameter....._.._._--. Depth_.....---------
x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area.._.................sq. ft.
Seepage Pit No._-_/--- Depth below inlet............. .... Total leacl 'n area------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) db /0 G 1- -7 l - 7 T
aPercolation Test Results Performed bY..................................................................---•••• Date----------------------------.-.-....__--
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water..-...._-..---_--.....
(14 Test Pit No. 2................minutes per inch Depth of Test Pit..._-_.__...---•--- Depth to ground water.........-------.._.___-
Description of Soil------- �._.. .. .OA
. �s-lna .• a +�yj �y
U -� l ---
��- ---- `---- ..... • --- - ------ r .... ..... ,
U Nature of Repairs or Alt rations—Answer when applicable...............................•.......--..---.-.-.---.-........____....._-..__.----------------
' •---••--------------------------------------------•---••-------------------------•-•---------------•----------------•-- --------...--------------------------...-------•-----•-------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued the board of health.
gned4 --------------------------------------------------------- / s---------
Date
Application Approved BY ...... 1 ...... -�.. � .
Date
Application Disapproved for the following reasons------------------------ - --- ...............................................................
----•-----------------------•---------------------------------------------------------------------------•---------•-•••••--------••-----•------••-------•-----•-------••----------•......-----•-•••----
Date
PermitNo......................................................... Issued..................................................
Date
THE FOLLOWING
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DATA
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No......_•• ........ FEE. .. ......................
THE COMMONWEALTH OF MASSACHUSETTS
B®ARD�PF -11EA�LTjH
/ �I...............0 F............GL'l/1'i.d'�^� /1.
. pphration -fur Uhipwial Workti Tomitriartion Prrutit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
---------------------------_----...---------------.........•..--------------------------•---------. ..........................-......................................................................
_
-.Location.Address or Lot No.
r t S C y t Ira . /`.. S i
--------------------------------------•••..._._._.................... ............. —= ..................................
i Owner wAddess
Installer Address I
Type of Building _ Size Lot..... -----Sq. feet
.�__.`! __!r
p r ....Ex Expansion Attic Garbage Grinder Dwelling—No. of Bedrooms._. w_--............................. p ( ) g ( )
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures _______________________________ _ _
. -------------gallons.
W Design Flow------------- ............................gallons per person per day. Total daily flow......__:_...._____..________ g
WSeptic Tank—Liquid capacity °.`5...gallons Length---------------- Width---------------- Diameter--------._...... Depth.,'._--___-_----
x Disposal Trench—No..................... Width-------------------- Total Length.-__-__-_-___--_--- Total leaching area--------------------Sq. ft.
Seepage Pit No-Z----------- Depth below inlet------------_.,..... Total leaching area......------------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) d%� /'C 6k, —7- /G- 7 1'
aPercolation Test Results Performed bY.......................................................................... Date.--------------------..... ------------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...-_-_..__-_-..__.-----
�14 Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water__.__._--._.__-.-.-___..
W ...................r. - --- - --- -• ____ ._._........................................----••-------' ---
Description of Soil------------• - = �= �7.. ✓/ ` -- ---- --------------
x -1 if s cif __ y_ •� /���` i 'c ••- -- ri�i- J d �I_ . - F;
U ..
U Nature of Repairs or Alec ations—Answer when applicable._.-_..�--- --------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu7dy the board of health.
1 /(r
igned. r -- -------------
Date
Application Approved BY Gfi'1. C'�'`L�l �'-.1 7
Application Disapproved for the following reasons________________________________________Z_______________________
......................Date----••-•---••.
.........................................••-••---_--.--------••••-------------•-•••-•--•••••-•------.--••..--•--•--------•....._...._._•••-•----••-•-----....._.._..._._.......-----•---------•...---
Date
PermitNo--------------------------------------------------------- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF" "HEALTH
��/... . ..........O F..............1 ... .E./L' '`Z....... . ......................
Trrtifirate of (taITS-
Ii rtre
TH,1 ?S TO- '_ T'IFY% t the Individual Sewa _D" sal Sy'e le' l
ted ( or Repaired ( )
..
by.. --_..•-•--•. •-- ... G F ..........................................
----
,all
_��---------------------
has been installed in accordance with the provisions of Article NI��he State Sanitary Code as described in the
application for Disposal Works Construction Permit No.fJ-__s--_•-_- .3_.___.___ dated_-_'r.".,: ._..... ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
�� BOARD O HEALTI-J
--
,� ...........OF...... ...�-�� L ;�._:.1 ................................... //
�rk.� ,�, � fr�trti�$t rrmit
Permission i ereby granted-_ rJ------- _=`�- ....-------•-•----------------•---.._.._....-----------.......-•-----••--•-----•-----..
to ConVOCY",
or Rp. it ( ) an Ind' ual Sew ge i posal Syste7�
at No._ -------- -- -----� .:'1..�'-'�-�' ��/�.� wit.��:---_(..�.�'...............`
I �' ,
Street _ —y
as shown on the application for Disposal Works Construction Permit No....... ... D� ed__�"..._?._____/.....................
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t P � �ioar of Health l
DATE...............................................................
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