HomeMy WebLinkAbout0090 INDIAN HILL ROAD - Health 90 Indian Hill Road
Barnstable r ` y
A= 318-030
L0C �TION SEWAGE PERMIT 410.
P—IL L A G E
Ib5'T°A LLER'S NAOIE A ADDRESS
B U I L D E R OR OWN Ep
DATE PERMIT ISSUED ,� �,
DATE COMPLIANCE ISSIJED
�m
UO
���� r
TOWN OF BARNSTABLE
.�,OCATION 9,t> Z;e,0JVAJ' II/%I d fbA( SEWAGE# oozy 0 d
VILLAGE ASSESSOR'S MAP.&PARCEL
INSTALLER'S NAME&PHONE NO. I_JALkL4-
SEPTIC TANK CAPACITY k3 eW 1660
LEACHING FACILITY:(type) PV L (size) S K
NO.OF BEDROOMS JG
OWNER ^' z +-- S
PERMIT DATE: /�/V,//y COMPLIANCE DATE:
T�
Separation Distance Between the: i
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist ow "
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) •� Feet
FURNISHED BY I�LSi�J�W�V y,4z4lr
t7 ' 6 �i
A•Z� 248
A -3
A_ t� - 56
S3Lu.
V4
t3
fS` � _ 45 •
y
No. /,.; Fee
7�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
OtooULAtIOU for V8p08aY 6psteUt CDUBtCULtIDU Permit
Application for a Permit to Construct( ) Repair( ) Upgrade()Q Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. f® Owner's Name,Address,and Tel.No. j��/
Assessor's Map/Parcel E ,cam
Installer's Name,Address,and Tel.No.C �y,2m_Y K4t%.7' Designer's Name,Address,and Tel.No. ::V4114/
!� i ST. ��od ?�-fT�✓ �' /1,11 �J .�1,ts�✓ ST /r�e?�J�r�Tii'��i€'� �1.� ram_" ���Z
Type of Building:
Dwelling No.of Bedrooms Lot Size /Oo-Z sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ® gpd Design flow provided �� -sue gpd
Plan Date /Tl& Number of sheets / Revision.Date
Title T/J�%G� .5— S/TE" �.�A�✓ O� ��11—wlyo,✓i 50":. Z s��f,��> �1/ �✓.0
Size of Septic Tank Type of S.A.S. � � ��f'Yc /�� ¢JTo1�FCy
Description of Soil ,G /
Nature of Repairs or Alterations(Answer when applicable) C U/VSi/.'UCT /a!CCh/ ,S'r!I S �/�/6✓f� ' ' .�/. L.�
Date last inspected: 7O /I DE��,y �od!✓n/ i ��✓iT/�� .Idi�a f���'ri . '�
Agreement: /�i✓O �.�o �r/BT.//eL�f./�N/y✓ S. ✓.C?y�1Ns� �
91
The undersigned agrees to ensure the construction dmantenan e f the of e described on s�ewa'ag�`lsp®l'gfem'�tt
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued this Board of Health.
,Si Q Date
1
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
o-
No. ..: Fee
i THE C.OMIIQNV1�i ALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
appIitation for Disposal Opstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade;( Abandon( ) ElComplete System &Individual Components
Location Address or Lot No. 1�Q/,y�y/ /.ram LPG,/ Owner's Name,Address,and Tel.No. t/ -T�,�,Q�-
ACe� M Q�icel ` t sT.
Installer's Name,Address,and Tel.No. i esigner's Name,Address,and Tel.No
�PYAn/ J�iTy^
s r` � _ rri.J cam' � y,�y/�i9i�t✓ sT, %%/+�i�JovTh`�okT. //7/j S-�...3���
Type of Building:,.
Dwelling No.of Bedrooms .. Lot Size p sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( Cafeteria'( )
a
Other Fixtures
-- Design Flow(min.required) _�," S O gpd Design flow provided gpd
Plan Date yZ-/g Number of sheets ,/ Revision Date
t Title 7.-17 r SST/ �.c.4i✓ of 1�0 Ti✓���it/fJitL �oiyO, l�//J7/J/ l//1�
1
"""` ��• Size of Septic Tank L Type of S.A.S. y��/
Description of Soil �-L ter` / �G I—�/I �'�1 A 111
� It i'V—V V
.
Nature of Repairs or Alterations(Answer when applicable) o/VSi iPy�T �Y.G-�lr/ SAS US/nil �Y"i �rFr� ,
Date last inspected: Ta 7�
.Agreement:
The undersigned agrees to ensure the construction AdXmamtenance A e afore descnbe1on-sit seTwage`disposal 45sje4rAm
accordance with the provisionsof Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health..
Sig ed / R f Q Date y
Application Approved byPr/. Date
Application Disapproved bye
for the following reasons
Permit No. Date Issued
TH E COMMONWEALTH OF MASSACHUSETTS`'
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance \/
THIS IS TO CERTIFY,that the On-site SewJa��ge Disposal s stem Constructed( ) Repa fired ) Upgraded( J�
Abandoned( )by F`,1 l
at / ��m ) as been constructed in acc,Qr ce
with the provisionsf Title 5 and t�h]e f r Disposal�System
�Construction Permit No 6?eed n�
Installer AlA M {7 Cf�ii �. /1 l FBI I Designer
1 '
# V bedrooms Approved design flow , gpd
The issuance of is permit shall not be construed as a guarantee that the system will fiction as designed. t �-
Date Q Inspector
W I - /
----- ------------ -------. ----- --------------------------------- ---------------------- -------- -------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
a
Disposal 6pstem Construction Permit ,
Permission is hereby granted to Construct( Repair( Up ade( ) Abandon
System located at , f�! 6)/l 1
r
i f
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title/5 and the following local provisions or special conditions. _
;Provided:Con ctiodlin t be completed within three years of the date of this permit.. /
Date Approved by i
6//
M
FROM :down cape engineering inc FAX NO. :15083629880 Feb. . 14 2014 02:26PM P1
w ''►of a .r Thw¢la.a 137. Ce'ijen,)}il'Ee$mY'
Drgo nu?�'i '1 hum;)&m.e.K.Cam,Director '
�. 200 I�')gin,street,Hva' ;h js, 0.2601.
O-Eklu-,: 508-962-/1.644 :f;,x: H8-790•-6304
Ins tAbir s Yl`a.ai Kerr iFo-"fiiun Fofinn
11�,911tQ:: / S9i��el���A 6: AlYI / _`r�QV �B�P$$�fl➢"��I�bU IfY�A�'(:lrl."J/
Ada sng�ien± ( A:' -_ e✓.: _ _ �rw h
y
�4.�laDa ebd: �/_. .Q.•� w (i
Oil _ ws.s iSSUed a per..rriA to install.a•
C-eptic sy;lem at_9 U1( 1 An based on a dnsic�a c)ravu by.
(addru5s)
_ T erii fy itzat the :iepfiir., system.zelcreumA Fibove 'was iaMlltd substan-willy amo'rding to
the de:sirm, wlucr.miry iur..luc�.e t�lonr. ulrvvi-�i c.L�s�7igesiirh. as la.tf:r�l _relc�catiuzl of the. -
distyihu'ban box md/or sej6t;tanL
_ l ce.1-ay t1lat the septic, sy8iQa'a xe mviced abuve wa.5 nstallRd vui'ih nsajo,: changes (J.-v.
yeater thfira 1.0',latr`:rsl zelc���ahiuri of the S.A.. , or ax�y ve'riic•a12 c:l(cabon of,9 cr)mporlent
ut the septic System) bizi in.aduard;�ne.c•wits Stivle &.Loc i.Ttegill, ions. 1'la-n i'evi, i(n�or
rr'a-t-[ied as-buil.l f y des1tT. :to follow.
OA OF
DANIE
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5 eC3 `i�tu-ce)
t, CIVIL `^
No.46602 �.
ASSSUNAL E;
(DaNi�f�er s S�.FR'�F11i igm?r'ti ;tamp LIME-) o
B,Ald!'•TS T A B $: ..:4'1rB3IJC H:'EA El 1 D INP.—QA1�- �+8•,.:1`!X 11.':.14 T��_.«1�'
4iy14�L1t'1L,i.AT�(!� 'd1IC�L_•Z�TC�►. Visa+. 1, i�41N.� gym 1tolA'I�T .T FQ?.Y,�lt!il :+slV� A�►l3IJILT .4FC�D %
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down cape engineering, inc. SIEVE SOIL ANALYSIS 90 INDIAN HILL ROAD,.CUMMAQUID, MA
i
DATE OF REPORT: 12/11/13 JOB : GRAIN SIZE ANALYSISSIEVE TEST
SITE: 90 INDIAN HILL ROAD CUMMAQUID, MA'
LOCATION: DCE TEST HOLE
SIEVE ANALYSIS Weight.Sample(Grams): 225.4
SIZE ;WEIGHT RETAINED % RETAINED % PASSED
--- - ._(sum ---
1" 0.0 0 0%+ 100.0%
0.
o 100.0%
3/4-------- -------------- ------- -OA---------------0 0/o ff---_--------------
11/21- 0.0; 0.OW 100.0%
-""- ------r........................... . r---------------------r-- --- ------
3/8" 1.9 0.8%: 99.2%
......................................... ---- ------ ---b....---- ------
#10 24.0' .10.6%: 89.4%
#20 --- - 531� 23 6%-�' -----.76 4% {{
---- ------------- ------- -------------- --- I
#40 _ 109 6 48 6% 51 4%
_ .Y -----.--- r _ _ .
#50 144 0 63 9% 36 1%
#80 187.8. 83 3% 16 7% I
................................ .......0- - --->-- --- ------
#100 201. ' 89 2%: 10.86-
#200 ; 217 9 96 7%0 . 3 3%0
--
PAN: 222.8; 100.0%; .0.0%
------ -------------- ----- ------- T------- -------. ---_-- .----.-- ------_
SAMPLE: .; 225.4;
i
NOTE:TEST ON PASSING#4 ONLY, 3.5% RETAINED ON#4<46%OX.
RESULTS:
SOIL CLASSIFIED AS AASHTO A-3(FINE SAND)(UNCOMPACTED).
PERCENTAGE OF MATERIAL PASSING#4 SIEVE
#4 100% (TEST ONLY MATERIAL PASSING#4) OK
#5010%-100% OK:.
#100 0%-20% OK
#200 0%-5% OK
SAMPLE MEETS TITLE 5 FILL SPECIFICATION
>96%SAND I
j
RESULTS: PERMEABLE MATERIAL-CLASS I<2 MINAN.MATERIAL
NONCOMPACTED gssy '
SOIL DESCRIPTION: FINE SAND; ° aAN.`L A. '� r I
o OJAL-A
U. CIVIL
I\o.46502
R
C
AL ti I
I
i
13
Town of Banisiable
dWE
y� Departimont of Regulatory.Services
]Public He' alth DIVm' 'On Date lU 1 G 113
` T6n inrMt"� 200 Main Street,Hyannis ILIA 02607�1 t f
Date Scheduled E''-' ( �; 'r�,.3 Tune Feei'rl. `U 0
p —
Soil Suitability Assessment for S ge Ibis al • �„
Performed-By. a
Witnessed By: 117
LOCATION&GENERAL INFORMATIO
Location Address Owner's Name
ClA vtn/ WN�g Address
Assessor sMap/Parcel: /�!�0 l Engineer's Name J U t,v v`
NEW CONSTRUCTION / REPAIR Telephone
Land Use:
Slopes(96) J Surface Stones Cv±
r .
Distances from: Open Water Body tt possible Wet.Areff �-t L-9 fi Drinking Water Well J/eft
( Drainage Way J �`� ft Property Llne {i.' r ft . Other —ft.
MUCH'(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands In pxoxinn ty, to holes)
7 >
l
e
� F Fr�.F•�l� �: a '
t �t`
EV z
ZV
Parent material(geologic) Depth tv Bedrock
Depth to Groundwater. Standing Water in Hole: G` Weeping from Pit Fact.
Estimated Seasonal Hlgh Groundwater
DETERMINATION FOR SEASONAL E(IGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: 1p, Doptlt to soil Irtgttles: in.
Depth to weeping from side of obs,hole: !Cj' in, Groundwater Adjutatmenk fr.
Index Well# Reading Date: Index Well 7evol .._ _._„ Adf,tetbr �„_.,•_A .araufldwaterl eval, s
PERCOLATION TEST mates,,,.,_,_, Time
Observation
Hole# Time at 9" '
Depth of Peru Time at 6"
Start Pre-soak Tune @ Time(9"-6")
End-a'rc-soak _.
Rate Nlln./Inch
site Suitability Assessment: Sitc Passed V Sitp Failed: Additional Testing Needed CX/N)
Original: Public Health Dlvlsion Observation Holy Data To Be Completed on Back— --
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(I)week prior to beginning.
QASEPTICIPIIRCFORM-DOC
DEEP.OBSER'VATION HOLF,LOG Hole#
Depth from Soil Horizon Soil Texture .Sdil Color Soil. Other
Surface(In.) (USDA) (Munsell) Mottling (structure, Stones';Boulders.
• o i ten., %' rave
ff t
f
DEEP OBSER`PA ION HOLZJ LOG Hole
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling
(Structure,Stones,Boulders. .
i �.a ansis en %Gtave
^1
r(j _ tf•
t S
. �d� 5� �J ..'till '� -'a �• �; '.•�,
% V• Z
bEEP OBSERVATION HOLE LOG Hole#1.
Dcpthfrom Soil Horizon Soil Texture Soil Color Soil Other*
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Co i to c Q e
,
t 1
r
DEEP OBSERV-ANIONROLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color SOB Other
Surface(n.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
Consistency.
Flood Insurance Rate Map-
Above:500 year flood boundary No—
Yes _
Within 500 year boundary No u+ Yes '
Within 100.year flood boundary No.V/ Yds
]depth of Naturally Occurring Pervious Material
Does at least four feet of nafurally occurring perviou�aterlal exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of haturally occurring pervious material?
Cei-tiiiication fl ��
I certify that on / t (date)I haves passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in�10 CUR 15.017.
Signature �` Datb
' Q:1S.Ll''I'lC�l'BltCPOIiM.DOC
a•
Commonwealth of Massachusetts
UTitle 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Indian Hill Road, Barnstable ,- M -318 P-30
Property Address w
Jean Stuart
t.e
Owner Owner's Name
information is S 15 Cross Street, Shrewsbury required for every .. MA .r 01545 September 24, 2013
page. Citylrown State' Zip Code' Date of Inspection
Inspection results must be submitted on this forma Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form. -
Important:When filling out forms A. General Information w
on the computer,
use only the tab 1 Inspector: ( ,O � U
.
key to move your
cursor-do not
use the return Troy Williams -
key. Name of Inspector
Troy Williams Septic Inspections
Company Name
19 Hummel Drive a
Company Address
South Dennis MA 02660
City/rown State Zip Code
(508)385- 1300 S1682
Telephone Number License Number
B. Certification T
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 inspectig. Theinspon�
was performed based on my training and experience in the proper function and n TO e a goonMe,
sewage disposal systems. I am a DEP approved system inspector pursuant t64. 4,cf.11 15-340 p#r
Title 5(310 CMR 15.000).The system:
® Passes ❑'ConditionallykPasses , ❑ Fails ''" '
_ =.70
t1
❑ Needs Further Evaluation by the.Local Approving Authority T
September•24, 2013 {
Inspector's Signatifre Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies,sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
I-S .
t5ins•W3. :�+, :' Title 5 Official Ins cGoace
peSewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°e 90 Indian Hill Road, Barnstable M -318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is required for every 15 Cross Street Shrewsbury MA .01545 September 24 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass"section need to be
f replaced or repaired. The system, upon completion of the replacement or repair, as approved by
T the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Indian Hill Road, Barnstable M-318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is 15 Cross Street, Shrewsbury MA x 01545 September 24 2013
required for every p ,
page. Cityfrown 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.):
El Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ` ❑ N ❑,ND(Explain below):
El obstruction is removed `❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in-accordance with 310 CMR.
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment: -
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or,a salt marsh
t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
t
n Commonwealth of Massachusetts
Title 5 ,official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
..'t 90 Indian Hill Road, Barnstable M -318 P-30
Property Address
Jean Stuart
Owner owner's Name
information is required for every 15 Cross Street, Shrewsbury MA 01545 September 24,2013
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier;if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a.surface water supply.
❑ The system has a septic tank,and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
Supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ®' Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
L—
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
J
90 Indian Hill Road, Barnstable M -318• P-30
Property Address
Jean Stuart
Owner owner's Name
information is 15 Cross Street, Shrewsbury MA 01545 September 24,
required for every p 2013
page. City/Town - State Zip Code Date of Inspection
B. Certification (cont.)
Yes, No
❑ ® Required pumping more than4 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.
❑ 21 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any-portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within,50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less.than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® ,The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd. .
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking waterFs6pply
❑ ❑ the system is within 200 feet of a tributary to a'surface drinking water supply
T
the system is located in a nitrogen sensitive area(Interim Wellhead Protection
�^ Area-IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 ? Title 5 Official Inspection Form:Subsurface Sewage pedi g Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection form .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Indian Hill Road, Barnstable M -318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is required for every 15 Cross Street, Shrewsbury MA 01545 September 24, 2013
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have.large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been.determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D..System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): see below
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Forte :p `
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i
90 Indian Hill Road, Barnstable• - M -318 P-30
Property Address ,
Jean Stuart -
Owner Owner's Name
information required
equ red for every is
15 Cross Street, Shrewsbury MA 01545. September 24, 2013
page. City/Town : State Zip Code Date of Inspection
D. System Information Y
k ^
Description: ,
No design plan on file. System installed in 1965 for a 3 bedroom home.'2 bedrooms added approx.
1985. System is undersized for a 5 bedroom home but meets the minimum state standards to pass
inspection at this time. Recommend upgrade of system if 5 bedrooms would be used to full capacity
in the future. Only seasonal use in the past.
Number of current residents: 0-2
.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.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 12=10,000 gals.
9 ( Y 9 (gP )) '11=10,000 gals.
Detail
Sump pump? r ® Yes ❑ No
,.Last date of occupancy:• � , - - � � occasional use
_ Date
CommerciaUlndustrial Flow Conditions:
r-' b Type of Establishment: N/A-
Design flow(based on 310,CMR15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq:ft.;-etc.):4 N/A
Grease trap present? ,•Y: F a ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: N/A
t5ins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
I1�
Commonwealth of Massachusetts
Title 5 official Inspection Form'
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
p� 90 Indian Hill Road, Barnstable M-318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is required for every 15 Cross Street, Shrewsbury MA 01545 September 24, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
N/A
Last date of occupancy/use: Date
Other(describe below):
NIA
General Information
Pumping Records:
Source of information: Last pumped in 2011 per info from owner.
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):
no d-box
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17
e
Commonwealth of Massachusetts
MR Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Indian Hill Road, Barnstable M-318 P-30
Property Address
Jean Stuart M
Owner Owners Name
information is required for every 15 Cross Street Shrewsbury MA 01545 September 24, 2013
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)Approximate age of all components, date installed (if known)and source of information:
Tank and leaching were installed approx. 5/1/65 per as-built. w
Were sewage odors detected when arriving at the site? ❑ ,Yes ® .No
Building Sewer(locate on site plan): -
24"+.
Depth below grade: feet'
Material of construction:
®cast iron ®40 PVC other.(explain): orangeburg after tank
. ® •
Distance from private water supply well or suction line: feet .
Comments(on condition of joints, venting, evidence of leakage, etc):
Flushed lines and found clear at the time of inspection. Original orangeburg from home to tank was
replaced with sch 40 pvc from cast.
Septic Tank(locate on site plan):
Depth below grade: 2'with riser to 2"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5'X9'X6' 1000 gallon
' 411 ,
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"f 90 Indian Hill Road, Barnstable M-318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is 15 Cross Street, Shrewsbury MA 01545 September 24 2013
required for every p ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
21 811
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness none
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined?
probe/measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Concrete inlet and outlet tees were found present and in working order. No evidence of leakage or
damage was found. Tank was clean and not in need of pumping at this time. No evidence of backup
from field into tank in the past was found present on walls of tank at the time of inspection.
Grease Trap(locate on site plan):
N/A
Depth below grade: feet
P '
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
t5ins-3113 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts ,
WKI f
Title 5 official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 90 Indian Hill Road, Barnstable M -318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is required for every 15 Cross Street, Shrewsbury MA 01545 September 24, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) -
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade: N/A
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
N/A
Capacity: N/A
p ty' gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes F❑ No
Alarm level: N/A Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments(condition of alarm and float switches, etc.):
N/A
*Attach copy of current purriping contract(required). Is copy attached? ❑ Yes ❑,No
t5ins•3113 Title 5 dal Inspection Form:Subsurface 1 Offs pecu S ce Sewage Disposal System•,Page 11 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
90 Indian Hill Road, Barnstable M -318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is 15 Cross Street, Shrewsbury MA 01545 September 24 2013
required for every P ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
No d-box on as-built and probed area up and into field with no d-box found present.
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.):
N/A
*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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 official Inspection form' .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .
90 Indian Hill Road, Barnstable M -'318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is 15 Cross Street, Shrewsbury MA 01545 September 24 2013
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits r number:
❑ leaching chambers,, ti number`';
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields °'<number, dimensions: 1 - 10'X30'X12"
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.):
Soil was sandy. Exposed stone and found dry and clean at the time of inspection. No evidence of
hydraulic failure or problems in the past were found at the time of inspection. Leachfield is undersized
for 5 bedroom home but meets the minimum 1/2 day flow required at the time of inspection.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert-' N/A
Depth of solids layer N/A
Depth of scum layer
_Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 official Inspection Form:Subsurface- Sewage Disposal System•Page 13 of 17
q
6
14 Commonwealth of Massachusetts
l• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°t 90 Indian Hill.Road, Barnstable M-318 P-30
Property Address
Jean Stuart
Owner owner's Name
information is 15 Cross Street Shrewsbury MA 01545 September 24 2013
required for every � ,
page. Cityrrown: n 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.): `
N/A.
Privy(locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A `
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5ins-3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts s
Title 5 official._ Inspection Forte
Subsurface Sewage Disposal System Form-Not for Voluntary Assessmentslug t
90 Indian Hill Road, Barnstable M 318 P-30
Property Address
Jean Stuart `
Owner Owner's Name F
information is 15 Cross Street, Shrewsbury µ ' MA 01545 September 24, 2013
required for every ,
page. City/Town k; State, Zip Code bate of Inspection
D. System Information (cont.)~
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.'Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
;,,,►r w 4
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17.
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"t 90 Indian Hill Road, Barnstable M-318 P-30
Property Address
Jean Stuart -
Owner Owner's Name
information is required for every 15 Cross Street Shrewsbury MA 01545 September 24, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System.Information (cont.)
Site Exam: '
® Check Slope
❑ Surface water M
® Check cellar,.
❑ Shallow wells
20.0'+
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
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health explain:
s ,
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain'
SDW 252 Zone A 46.8' .9'adjustment
You must describe how you established the high ground water elevation:
Hand augered 4.6' below bottom of leaching with no water found at a depth of 8.0'. Groundwater
adjustment at the time of inspection was .9'. Bottom of leaching at 3.4'was found not to be located in
the high groundwater elevation at the time of inspection. USGS maps for Barnstable show
groundwater to be approx. 36.5'. Bottom of basement at 5.0'was dry and clean.
t
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
p� 90 Indian Hill Road, Barnstable M-318 P-'30'
Property Address
Jean Stuart xn
Owner Owner's Name
information is 15 Cross Street, Shrewsbury MA 01545 September 24, 2013
required for every
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist m
® Inspection Summary:,A,r,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 Systemeither drawn on page 15 or,attached in separate file
a
r
J � p jag �,.. � • F
y •
4 • tr pq�♦r � 549 �� 1 t i
a
t5ins-3113 ; Jitle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 '
AsBuilt Page 1 of 1
G� s
L 0 C TION 1 �, ; SEWAGE PERMIT =NO.
V I L L A G E
INSTALLERS NAIbOE A ADDRESS
v rrd - /�i r1-14
B UILDER OR Owl!ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
0
f04
M.
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=318030&seq=1 9/25/2013
Commonwealth of IVlassachusetts•
Title 5 Official Inspecti®n Form ffi
- Subsurface Sewage Disposal System Form Not for Voluntary Assessments
90 Indian Hill Road, Barnstable M -318 P=30
Property Address
Jean Stuart a `
Owner Owner's Name `
information is 15 Cross Street, Shrewsbury 'MA, 01545 'September,24,2013
required for every
page. City/Town t State Zip Code - �. t Date of Inspection
Inspection results must.be submitted on this form. Inspection forms may not be altered_ in any
way. Please see completeness checklist at the end of the form
Important:when filling out forms A. General Information
a` •� ^'� •
on the computer, ° A
use only the tab 1. Inspector: y ,` s ,4 s %.' M
key to move your }
cursor-do not Troy Williams
use the return
Name of Inspector
key. ,.
Troy Williams Septic Inspections
Company Name
19 Hummel Drive
Company Address
j
>z South Dennis �a , MA f r '02660
City/Town State 4 .- &Zip Code
(508) 385- 1300 s" S1682
Telephone Number J-License Number
r
B. CertificationR
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 , , y❑ 'Conditionally Passes y ❑ {;Fails'
❑ Needs Further Evaluation by the Local Approving Authority'
4 September24, 2013'
Inspector's Si nature at - Date'
The system inspector shall submit a copy of thisin§pection'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 DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority o
****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-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System Pagel of 17 ,,
assachusetts
Commonwealth of M -
- - 0 Title 5 Official1h0ecti®n F®rrn
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments` ± '
°
.'' 90 Indian Hill Road, Barnstable _>', M -318 P-30
Property Address
Jean Stuart .#' _ k
Owner Owner's Name -`
information is
required for every 15 Cross Street, Shrewsbury - = v MA`' 01545September 24;2013
page. City/Town Y -`. State- Zip Code Date of Inspection
B. Certification (cont.) 4 -
Inspection Summary: Check A,B,C,D or E/always complete all of Section D ; .
A S stem Passes: f µ • • . Vim. _ �:a " •, .. ; '
y rr
a
Y: ®' 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, {. r
-
System meets minimum standards set by'Massachusetts-DEP,,at the'time of inspection only.This
inspection is not a guarantee or warranty on the future.'working conditions'of leaching, pipes,
components or the future structural;iintegrity of,said components.and only represents-conditions found
at the time of inspection only:
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 br repair,as approved by
the Board of Health, will pass. •
Check the box for"yes"; no".or"not determinedN (Y, N, ND)for the following statements. If"not
determined, please explarn: t:
The septic tank is metal and over 20 years oid* or-the septic tank(whether-metal or not)-is'structurally
unsound, exhibits substantial infiltration or e'xfiltration or tank failure is imminent. System will pass
: inspection if the existing ank is-replaced with.a•complying septic tank as appr6yed'bythe 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 thetank is lesstlian 20 years old is available. ,
❑ Y ❑ -N - " ❑.ND{Explain below): r
, K
, a
t5ins•3113 . ° Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17'
Commonwealth of Massa6husett�,
_-- -r Title 5 Official Inspection, Fora r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
< r
90 Indian Hill Road, Barnstable x'N['='318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is }
required for every 15 Cross Street, Shrewsbury ' MA 61545 September 24, 2013
page. CityrFown State Zip Code ,3, 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. a , "
B) SystemyConditionally Passes(cont.). ,
❑,-Observation of sewage backup or break out or high,static water level in the',distribution box due
to broken'or obstructed pipe(s)or due to a.broken, settled or uneven distribution`"box. System will
pass inspection if(with.approval'of Board of Health):
❑ broken'pipe(s) are,replaced ❑ Y ❑ N , "'❑ ND (Explain below):
❑ obstruction is removed "❑ Y ❑. N' ❑ ND (Explain below):
❑ distribution.box Is leveled or replaced ❑'Y El N'` ElND`(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 r '` El."
Y',: ❑ N 0 ND (Explain below):'
'❑ obstruction is removed . ❑- Y ❑ N ,y❑ ND (Explainbelow):
C) Further'Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by th'e Board of Health in,order to determine if
the system is failing to protect public healtl4safety or the environment.'.,
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will,protect public health,.
safety and the.environment:
0 Cesspool or privy,is within 50 feet of a surface water' o- ;
❑ Cesspool or priv
y is within 50 feet 'of a bordering vegetated wetland orasalt marsh r "
t5ins•3/13 ~ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17,
Commonwealth of Massachusetts �• `°
60. Title 5 Official inspecti®n Ford
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Indian Hill Road, Barnstable . M =318 P>30
Property Address
Jean Stuart a
Owner Owner's Name
information is 15 Cross Street, Shrewsbu MA. 01545'� September 24 2013
required for every ry p +
page. City/Town 'State Zip Code Date of Inspection
B. Certification (cont.) f
2. System will fail unless the Board of Health (and•Public Water Supplier,if any)
determines that.the system is functioning in a manner that protects the public'health,
safety and environment:
❑ The system has*a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface,water.supply or tributary to a surface water supply.,'
❑ The system has'a septic tank and SAS and the SAS is within-a Zone.1 of a public water
4 ❑pThe system.has.a septic tank and SAS and the SAS is within'50 feet'of a private water
supply well.
❑,,The system has a septic tank and SAS,and the SAS is less than 100 feet but 50 feet or
more from.a private'water supply well**:
Method used,to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory; for fecal
coliform bacteria indicates absent and the presence of ammonia'nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other-faiIurecriteria are triggered.A copy of the analysis must
be attached to this form. -
3. Other:
t•
D) System Failure Criteria Applicable to All Systems::✓
You must indicate "Yes or"No";to each of the following for all inspections:,
• •Yes No . „� • '.. �. • t , i
® Backup of sewage into facility or system component due to overloaded or
El, •clogged SAS or cesspool
Ei 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 ad overloaded
El N
or clogged SAS or cesspool
®El
Liquid depth in cesspool+is less than 6" below_ invert or available volume is less
v than '/z day flow •.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
. r •
I
F
Commonwealth of Massachusetts t
Title 5 Offici`a_l-Inspedi®n• For
Subsurface Sewage Disposal System Form -'Not for Voluntary,Assessrrients _
90 Indian Hill Road, Barnstable - t ;' M -318 +' �P-30: . f
Property Address
Jean Stuart
Owner Owner's Name a s
information is _
required for every 15 Cross Street, Shrewsbury,, MA .•01545 September 24, 2013 '
page, City/Town - State Zip Code s `-Date of Inspection
B. Certification (cost.)
Yes `No ;
® Required-pumping more than 4 times in the last year NOT due to clogged or-
El T
obstructed 'i e s - Number of,times um ed:;.
ti ❑ s® Any portion of the SAS,;cesspool or privy Is below high ground water elevation.
r 5- Any portion of cesspool or'privy`is within 100 feet of'a surface water supply or
® ' tributary to a surface water.supply.
❑ w ® r Any portion,of,a'cesspool or privy Is within`a Zone 1 of a public well.
® c Any portion of a cesspool-or;pnvy is within 50 feet of a private.water'supply well.
7.
❑ ® A Any portion of'a cesspool or privy is less than 1'00 feet butsgreater 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
4.; laboratory,for fecaIrcoliform bacteria indicates absent and the presence
of.ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm;
. ~ provided t6 t no`other failure criteria are triggered. A copy of the analysis
and chain of custody must bei attached to this form.]
The system is a cesspool serving a facility,with a design.flow of 2000gpd
' 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 Healthabdetermine what will be
necessary to correct the failure..,
• d" ..5 :• , j,y,. -
E) Large Systems: To lie considered a large system the system must serve a facility with a -,
design flow of 10,000;gpd to.15,000 gpd _
_For larde;systems, you!must indicate either r"yes".or.'no",to each:oAthe following, in addition to the
questions in Section D:
Yes =No r. .. �:: *.• `k,
El ❑x" the system is within 400'feet of"a'surface drinking water`supply,
❑ ❑ the- system is within`200 feet of a tributary toga urface drinking'water supply
the system is located in,a nitrogen sensitive area (Interim Wellhead Protection
}• El ❑ 'Area,—,IWPA)or a mapped Zone II of apukilic water supply,well
If you have answered `yes"to any question in.Section E the system,:is considered a significant threat,
t or answered"yes" in Section D above the large`system has failed The owner or operator"of any large
w 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. i
t5ins•3/13 s -Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
t _ n
r
Commonwealth of Massachusetts
_- Title 5 ®fficial. Inspection Form
Subsurface Sewage Disposal SystemForm -Not for Voluntary Assessments
90 Indian Hill Road, Barnstable ' M -318 ,P-30
Property Address ,
Jean Stuart
Owner Owner's Name
information is
required for every 15 Cross Street, Shrewsbury MA 01545 September 24, 2013
page. City/Town State Zip Code Date of Inspection
C. Checklist f.
Check if the following have been.done. You must indicate"yes" or"no" as to each-of the following:
Yes .No,_
Z ❑ Pum In Information was Provided by the owner, occupant, or Board of Health
❑ ® ,Were any of the system components pumped out in-the previous'two weeks?
® Has the system received normal flows in the`previous two week period?
Have large volumes of water been Introduced to the system recently or as part of
® ' this inspection?
Were as built~plans of.the system'obtained and examined? (If they were not .
❑ available note as N/A
;® ❑ --Was the facility or dwelling inspected for signs of sewage back up?,
® ❑ Was the site inspected for'signs of break out?
Were all system components, excluding the SAS, located on site?
- r
® 1,❑ Were the septic tank manholes uncovered, opened; and the interior of the tank
,inspected for the'conditiori 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
® El
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 ofHealth.
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; t . 4. Al
Residential flow Conditions:. 4,
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based`on 310 CMR 15.203 (for'example:�110 gpd x#of bedrooms): see below
t5ins•3113 W Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
-- Title 5 Official f inspection Form
Subsurface Sewage Disposal System Form - Not for Vol u ntary'Assessments.
90 Indian Hill Road, Barnstable: x ,• " M'-318 R' 30
Property Address ,•
Jean Stuart "
Owner Owner's Name
information is required for every 15 Cross Street, Shrewsbury MA 01545 'September 24,2013
page. CltyTTown .. . State -Zip Code 'Date of Inspection
D. System Information t ,
Description: ,
No design plan on.file. System insta'lle&in 1965 fora 3 bedroom home. 2 bedrooms added approx.
1985. System is undersized for a 5 bedroom home but meets the minimum state standards to pass
inspection at this time. Recommend upgrade,of system if,5 bedrooms would be used to"full capacity .
-in the future. Only seasonaluse in the past
, 0-.2
Number of current residents. M
Does residence have,a garbage grinder? ' ❑ Yes ® No
Is laundryon a separate sewage s stem? Include lau inspection p g y ( ndry system inspection 0 Yes ® No
information in this report.) ,
Laundry system inspected? ' ' ®' Yes El No
Seasonaluse� ® Yes ❑ 'No
,L , • . : '.12=10,000 gals.
Wafer meter readin s, if available last 2 ears usa e, d
9 ( _ Y 9 (9p,)), .11=10,000 gals.
Detail: .
i
Sump pump?: ® Yes :❑ No
Last date of occupancy: �,,,_ ,� occasional use
t , Date
Commercial/Industrial Flow,Conditions:,
N/A
Type of Establishment:' .'
N/A
Design flow(based on 310 CMR.15.203): Gallons pe+r day(gpd) F
; t , .
Basis of design flow(seats/persons/sq.ft., etc.):" N/A
+ � 5
Grease trap presents El Yes ❑ No- ,
Industrial waste holding tank present? ' ❑, Yes ❑ No
°
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
- N/A
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
- _-w Title 5 ®fficial: lnspecti®n 0=®rM
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
90 Indian Hill Road, Barnstable. ° �'"` • ' M-318 P-30'
Property Address
Jean Stuart ...
Owner Owner's Name
information is required for every 15 Cross Street Shrewsbury r ' MAw 01545 September 24, 2013'
page. Cityfrown State Zip Code.,„ Date of Inspection
D. System Information (cont.)
Last date of occupancy/use N/A' r
Date _
Other{describe.belowv -
r
N/A
,
General Information
Pumping Records:
Last pumped in 2011 per,info from owner.
Source of information.
Was system pumped as part of the inspection? Ll .Yes M No
r' 7.'
If yes, volume pumped: `
', tr gallons
How was quantity pumped determined
Reason for pumping:
Y
Type of System: _ . , , t r
® - . Septictank, distribution box,,soil absorption,system` -
- El Single cesspool' :
Overflow cesspool
El 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.,
0 Tight tank.Attach'a copy,of the DEP approval: ,.
® Other.(describe):no d-box
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
. Title 5 Official .Inspection Form
Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments
90 Indian Hill Road, Barnstable M'-'318 P-30
Property Address
Jean Stuart
Owner Owner's Name
information is required for every 15 Cross Street, Shrewsbury - MA ` 01545 September 24, 2013
E~ ` *- '. - -
page. Cityfrown State ,.
"Zip Code '° Date of Inspection
D. System Information (cont.)
2 .
Approximate age of all components, date-installed (if known) and source of information:
Tank and leaching were installed approx. 5/1/65 per as-bunt.' • '
ew • he site? x ❑ Yes E V NoWre 9a odorsdetected whenarrivin att
Building Sewer(locate'on site;;plan) -
Depth below grader s. r
feet.
-
Material of construction:
® cast iron ® '`` '+ orangeburg'after tank
40 PVC ® other(explain):
Distance from private water supply well or,suction line: feet
Comments (on`condition of joints,venting, evidence of leakage;etc.):
Flushed lines and found clear at the time of inspection. Original orangeburg from home to tank was
replaced with sch 40 pvc from cast. r
Septic Tank(locate on'site plan)'-'�
f r,
` 2'with riser to 2"
Depth below grade:
a _ � •R»< ,,, .: t feet� ' r s
Material of construction: 4 ,
® concrete ❑ metal "❑ fiberglass ❑ polyethylene ❑ other(explain)
If.tank is metal, list age: s t 4
years
Is age•confirmed by a Certificate of Compliance? (attach a copy_of certificate) ❑ Yes ❑ No
-
Dimensions:
;5'X9'X6` 1000 gallon
411
-
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts =
_ Title 5 Official. Inspection form.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�4 90 Indian Hill Road, Barnstable M -318 P-30
Property Address .-
. . 'rn
Jean Stuart
Owner Owner's Name ,
information is 15 Cross Street Shrewsbury MA 01545 -Se tember24 2013
required for every � rY �'' p
page. City/Town State "Zip Code Date of Inspection
D. System Information (cont:)
Septic Tank(cont.)
21 8„
Distance from top of sludge to bottom of outlet tee or baffle
none
'Scum thickness
e 6,,> r
Distance from top of scum to top of outlet tee or baffle
m bottom of scum to bottom is Distance from ttom of outlet tee or baffle 14 _ ', $
How were dimensions determined?. =�r
probe/measured
Comments (on pumping recommendations,-inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Concrete inlet and outlet tees were found present and in working order. No evidence of leakage or
damage was found.'Tank was clean and not in need of,pumping at this time. No evidence of backup
from field into tank in the past'was found present on walls of tank`at the time of inspection.
Grease Trap (locate on site plan): '
N/A"
Depth below grade: feet t
Material of construction:. , �. 'al'
❑concrete.' � ❑'metal ❑ fiberglass ❑ polyethylene; ❑other(explain):
Dimensions:
Scum thickness
Distance from top^of scum to top of outlet tee or,baffle a N/A
Distance from bottom of scum to bottom of outlet tee or baffle Jt N/A :
E, N/A
..Date oflast pumping: Date
x
t5iins•3/13 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17,
e '
Commonwealth of Massachusetts
--- Title 5 ®fficial Inspectibn R rrn: tx,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =
,.0�,•'` 90 Indian Hill Road, Barnstable„ _ ' . `_. M -318' P=30
Property Address
Jean Stuart
Owner Owner's Name -
information is r :•, n
required for every 15 Cross Street, Shrewsbury.- ,. .. ° MA `01545 September 24 '2-013
page. Cityrrown State Zip Code Date of Inspection
nt.)D. System Information co r'
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,,etc.):41
R'
,
r F
r ,
• �_- V�
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on siteplan):
Depth below grader �M. N/A
x . �~ x -
Material of construction y
❑ concrete . �0 metal x .f ❑fiberglass , ❑,polyethylene w Elother(explain):
„
w '
Dimensions - k. N/A r
Capacity:.
gallons
Design Flow: N/A 4
gallons per day
Alarm present: Y '' ❑ Yes [:].,No _
Alarm level -- Alarm in working order,'♦ - ❑:'Yes ' ❑ :No
r N/A t
Date of last pumping a.
. - ,.. ., • Date ..
,
Comments (condition of alarm and float switches, etc.): -
a
9
*Attach copy of current pumping,contract(required). Is copy attached? ❑, Yes Y ❑ No'
a
t5ins•3/13 s i' '
4-' Y 3 w.';, a: Title 5 Official Inspection Form:Subsurface Sewage Disposa]System Page 1:1 of 17 f q
Commonwealth of Massachusetts
Title 5 Official 'inspection Form'
x
S Subsurface Sewage Disposal System Forrn = Not for Voluntary Assessments
90 Indian Hill Road, Barnstable M --318'• P-30
Property Address
Jean Stuart
Owner Owner's Name
information is required for every 15 Cross Street_Shrewsbury p Shbu MA •01545 September 24, 2013
-
page. City/Town ^.W, State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):'
Depth of liquid level above outlet invert "
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.): '
No d-box+on as-built and probed area up and into field with no d-box found present.,-
Pump Chamber(locate on site`plan);
Pumps in working order: jtl ❑ Yes ❑ No*
Alarms in working order: - ❑ Yes' ❑ No*
Comments (note condition of pump clamber, condition of pumpsand appurtenances, etc.):.
N/A
gi
* 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):
s 1 If SAS not located,'explain why: ry 4
-J
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
{
Commonwealth of Massachusetts
-- Title 5 Official Inspection Fora' `
b' •2�. tr
Subsurface Sewage Disposal System Form Not for Voluntary Assessments'
90 Indian Hill Road, Barnstable M:'318 P-30"
Property Address
Jean Stuart "'
Owner Owner's Name ;.
information is „ September 24, 2013' ;
required for every 15 Cross Street, Shrewsbury - ,, . MA 01545 Se p
page. Cityfrown State Zip Code Date of Inspection.
D. System Information (cont.) }
Elleaching pits number I
❑ leaching chambers ' number:'-,
❑ ` leaching galleries number: `.
❑ leaching trenches number, length:
1 - 10'X30'X12"
® leaching fields number, dimensions `
'.rye-v c i y, 4,,:i�`" 1. "y.:: "1' ; •
❑ overflow cesspool number
❑ innovative/alternative system y
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of.ponding, damp soil, condition of
vegetation, etc.): `.
Soil was sandy. Exposed stone and found dry and clean at the time of inspection."No evidence of
hydraulic failure or problems in the past were found at the time of inspection. Leachfield is undersized
for 5 bedroom home but meets the minimum-112 day flow required.at the.time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration" r :N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer ~` �' N/A
44
t. Depth of scum layer "' ', N/A
- Dimensions of cesspool _ N/A 3.
F N/A
Materials of construction .
t� Indication of groundwater,inflow ❑ Yes ❑ No f
t5ms•3/13_ , , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
_ r
Commonwealth of Massachusetts
— Title 5 Official Inspection _ Forr a
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
,.4 90 Indian Hill Road, Barnstable " k X.M -318 P-30
Property Address R. - r
Jean Stuart #4 t
Owner Owner's Name '
information is 15 Cross Street, Shrewsbu � _ MA 01545 September 24,2013 r
required for every ry r p
page. CitylTown State t' `Zip Code Date of Inspection
D. System Information'(cont.)
Comments(note condition of soil,`signs of hydraulic failure, level of ponding, condition of vegetatij
• on,
etc.): - t
N/A
Privy(locate on'site,
plan): ,
w N/A' t
Materials of.construction: r:
Dimensions -* =f N/A
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A w .. �
r, r
a
n
a
r _ 1. > K•
41
t5ins•3113° Title 5 Official Inspection Forth:Subsurface Sewage Disposal Systein•Page 14 of 17
Commonwealth of Massachusetts
-- -� Title 5 Official Inspection F®rmY
Subsurface Sewage Disposal System Form:=;Not for Voluntart'Assessments
90 Indian Hill Road, Barnstable M -318 P-30
Property Address ;
Jean Stuart _ -
Owner Owner's Name
information is 15 Cross Street Shrewsbury ,MA M Y 01545 'September 24 2013
required for every ,
page. Cltyrrown State' ; Zip Code 'Date of Inspections
D. System Information (cont:) a -
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmark Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:- .
® hand-sketch in the area below
❑ drawing attached separately ry
• • C--}
•
t5ins•3113 , ,Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
+<,
Title 5 Official Inspection Form
. F
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
90 Indian Hill Road, Barnstable r M - 318 P-30
Property Address r
Jean Stuart
F
Owner Owner's Name
information is `` t
required for every 15 Cross Street, Shrewsbury MAc 01545 September 24, 2013
page. CitylTown State Zip Code Date of Inspection k F
D. System Information (cont.)
Site Exam: ,r
® Check Slope
❑ Surface water
` 17
® Check cellar
❑ Shallow wells 1 a
q ,,r; i! +„ a ,1•r ..
Estimated depth to high ground water: ..
s tfeetrr.. }
Please indicate all methods used-to`determine the.high ground water elevation:
❑. Obtained from system design plans on recordr..
If checked, date of design plan reviewed:, —Date
® Observed site (abutting property%observation hole within 150feet of SAS)
❑ Checked with local Board of Health -explain: k
❑ Checked with local excavators, installers ,(attach documentation) .L '
® Accessed,USGS database explain
SDW 252 Zone A�- 46.8' .9' adjustment
y
You must describe how you,established the h ighr ground water.elevation:"'``• _ ` `
Hand augered 4.6'.below-bottom,of leaching with no water found at a depth of 8.0'..Groundwater
adjustment at the time of inspection was .9'. Bottom of leaching at'3.4'was found not to be located in .
the high groundwater elevation at the time of inspection. USGS maps.for Barnstable show
groundwater to'be approx.-36.5'. Bottom of basement at 5.0 was dry and clean. `
Before filing this.Inspection Report, please see Report Completeness Checklist on next page:
t5ins•,3113 $" ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page"16 of 17
w
Commonwealth of Massachusetts
t
r Title 5 Official Inspectibn F®rr nu
Subsurface Sewage Disposal System Fo"rm Not for:Vol torYAssessments µ
� -
90 Indian Hill Road, Barnstable 318 .P, -30 r
Property Address
Jean Stuart #
Owner Owner's Name
information is * '
required for every 15 Cross Street, Shrewsbury .„ MA 04545 September 24, 2013
page. City/Town `^.•- ' , State. Zip Code -Date of Inspection
E. Report Completeness Checklist =° . -
t
Al
® :Inspection.Summary, A, B, C :D,,or E checked k
® Inspection Summary D (System Failure Criteria,Applicable to All.Systems) completed r
. 4 >� F.:- + ,d'` ' .. �._.� _r. ;• ..
t Z. System Information.—Estimated depth to high groundwater ` ;}
® •Sketch of Sewage Disposal System 4either drawn`on'page 15'or attached in separate file
w
� 4 may. t n T � ..} �L ... • � �- .^ I r
4..'•2
- c. - • - '-
t5ins•.3/13 d• > Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 1s7 '
i
Commonwealth of MassachWe,ft
We 5 Official In salon Form, 4 R:
Sulbsuftee Sewage Disposal Systrem Foirm-Not for Voluntary Assessments,
'f 90 Indian Hill Road, Barnstable r u a M_=,310 P-30
Property Address - ' - •
Jean Stuart
Owner Owner's Blame n
information is , , :
required for every 15 Cross Street, Shrewsbury ,~ = MA � 0154b- w September 24,2013
page. Citylrown state Zip Code Date of Inspection
Da 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 fhb building. Check one of the boxes below:
® hand-sketch in the area below, ,
❑ drawing attached separately
I rq
i C:
• '1`� ... ( ,� ._tom., _ r -
t5ins•3/13 aF * Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 y
Assessor's map and lot number ..` '•'••• •• P%. 1 . �pFTHE rO�♦
ewage Permit; number .........................................................
: "1
y
�.a F
MADE
......�`.,.D.:...
H se .number.. �� ..... ��i�������� � � ,° t63q. \0�
TOWN
OF lBAfly.NSTAl�]L
BRUIN- INSPECT®
APPLICATION FOR PERMIT TO
TYPEOF CONSTRUCTION ........ <: �s'rz'` '-..................................................................................................
.........19..En
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby a plies for a permit ccording to the following information:
j ��
�j , -
Location` .:.
...a.. : -:..... ...... `........ �................
✓ .........................
Proposed Use ......./�L�? — `''`''� ..... ,.�..Y ............ ...........................
.�
ZoningDistrict ............./.J.l........ ......................................Fire District ....... .... ..:..... ..........,:... .......................
Name of Owner .: �+r..��u��.'� . .�� ......... ....Address ..../..1-�.: ../y � ................. ..
41/�
Name of Builder
� Z.. ... ...:..............Address .......
..�,. .. . .............
Name of Architect ..................................................
..............Address ....................................................................................
Numberof Rooms ....... . ....................... .............'............Foundation ....,1 ! ............................................................
AIA
Exterior .....� ./'�? ..................Roofing ........... F! 411.Ce.................................................
Floor �? . r�¢� •... .<.......L............ . .............................Interior ...... .,,.V5;V, '' ...........................................
Heating .... :�. «y�l�''�? ' .............. . ...............Plumbing ....... ` """' ..........................................
Fireplace ....../..�..�............................4..............:...................... .Approximate Cost ........
Definitive Plan Approved by Planning Board ___-------___—---------------19_______. Area /.. :.............:...............
Diagram of Lot and Building with Dimensions Fee ........ ...................
SUBJECT TO APPROVAL OF BOARD OF LTH (`
P—
.13 l
.r
l �
A/
if
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I
� � I II t
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ........`: .. - :..�til.:..� L ...............
Construction Supervisor s"License ...........
ALL SYSTE
SHLL
SYSTEM PROFILE MARKED WITHC MAGNETIC TTAPEAOR BE
PROVIDE MIN. 20" WATERTIGHT
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. NOTES
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 1. DATUM IS APPROX. NGVD
Barnstable Harbor
\ TOP FOUND. EL. 43.75' 2. MUNICIPAL WATER IS EXISTING
MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 40.5' - 41.0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE
PRECAST H-10
` RISERS (TYP.) 4. DESIGN LOADING FOR ALL PROPOSED PRECAST � y
.y. 2'4 41 27' 4"OSCH40 PVC UNITS TO BE AASHO H-19 �°
t: PIPES LEVEL 1ST 2 2" DOUBLE-WASHED PEASTON
OR GEOTEXTILE FABRIC 5. PIPE JOINTS TO BE MADE WATERTIGHT. o
EXISTING " 39.76' a
10' 14 y' Locu o
'L TEE 1000 GAL H-10 TEE 39 8f* 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE c = `
SEPTIC TANK** oo00°0000000 + 0°o0°o�c°°o�°og°o°°o�°o�°o�°o�°o�°ono' °o°°o�°o�°o�°oo°a�c0u°°o�°o00°o� °oN°o°o1°o°o°O°o�°o WITH 310 CMR 15.000 (TITLE 5.)
O O o 0 0 O 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 +
GAS BAFFLE;• ,?oOCGG�0o0° 39.26 0"0�0�0�00,0,000,0,0,0,0,0,0,0,0,o,o,c, o o�oo,o, oo,o,o,o,o,o,o
�- og00000gooagog00000gogog000gogog000g000 o a0000a o0000000000000g , 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND O _
39.5' 39.33' 4" PVC SET AT .005'/" SLOPE 38 59 NOT TO BE USED FOR LOT LINE STAKING OR ANY o� a
OTHER PURPOSE.
6"MIN. SUMP ON 6" DOUBLE WASHED 3/4"- 1 1/2" STONE oute z
c 6
12" MIN. INT. DIMENSION 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
6" CRUSHED STONE OR MECHANICAL 5.49' 9. COMPONENTS NOT TO BE BACKFILLED OR
COMPACTION. (15.221 [2]) CONCEALED WITHOUT INSPECTION BY BOARD OF
HEALTH AND PERMISSION OBTAINED FROM BOARD
( 2.7% SLOPE) ( 1 % SLOPE) OF HEALTH.
G�p�it
LEACHING 10. CONTRACTOR SHALL BE RESPONSIBLE FOR
FOUNDATION- EXIST. SEPTIC TANK 1 1 D' BOX 9' CALLING DIGSAFE (1-888-344-7233) AND
FACILITY VERIFYING THE LOCATION OF ALL UNDERGROUND & LOCUS MAP
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT G-W EL. 33.1' OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WORK. NOT TO SCALE
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE NOTE: CLAYEY SOILS, FRIMPTER METHOD
DOES NOT APPLY 11. ANY UNSUITABLE MATERIAL ENCOUNTERED
CONDITIONS IF NOT SUITABLE SHALL BE REMOVED 5' BENEATH AND AROUND THE ASSESSORS MAP 318 PARCEL 30
PROPOSED LEACHING FACILITY.
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
AND REMOVED
LEGEN D
99- EXISTING CONTOUR 0")
OD
x 99.1 EXIST. SPOT ELEV. 20 U!
SYSTEM DESIGN:
99 PROPOSED CONTOUR
99 TEST HOLE 4'PROPOSED SPOT EL. GARBAGE DISPOSER IS NOT ALLOWED
4'
TH1 DESIGN FLOW: 5 BEDROOMS 0 110 GPD = 550 GPD
YYY 4' USE A 550 GPD DESIGN FLOW
2� SLOPE OF GROUND A'
UTILITY POLE A' SEPTIC TANK: 550 GPD (2) = 1100
42.C) USE EXISTING SEPTIC TANK**
FIRE HYDRANT 21,1�2 SF
NOTE. NOT ALL SYMBOLS MAY APPEAR IN DRAWING
SAS DETAIL
1" = 20' LEACHING:
SIDES:
TEST. HOLE LOGS
n, BOTTOM 37.5 x 20 (74) = 555 GPD
o_
ENGINEER:
DANIEL E. GONSALVES, SE TOTAL: 750 S.F. 555 GPD
�
WITNESS: DONNA MIORANDI, IRS EXISTING ELEC USE 4" PERF. PVC PIPE AND STONE LEACH FIELD
DECEMBER 4, 2013 DWELLING MET
DATE: TOP FNDN. +2.2o ER DIMENSIONS: 37.5' x 20' x 0.5 DEEP
PERC. RATE _ < 2 MIN/INCH GARAGE EL.=43.75' 42.63 SEE DETAIL
\ 3. No BENCHMARK
CLASS I SOILS P# 14203 1 x 43. �\,,`\`.16 \ o COR BR. LANDING
4fi'18- " X 4V EL=44.0'
ELEV. ELEV. 42.79 q4k x 43.17 " .08 x 4 05
4 440.
I I \X 41\\27 x .62
0» �/ 40.1' 0" 40.1' I I \
x 40.72 , MA
A/ A II ¢2 X 42.52 6 \ 4 3 \ X 39.90 APPROVED DATE BOARD OF HEALTH
/LS UNSUITABLE /LS I x41. 7x\41. i i \j.
41.89 \ 1 5' REMOVAL OF UNSUITABLE
1OYR 2/1 10YR 2/1 r LO "4 \ \
„ » \ SOIL REQUIRED AROUND
12 12 1 \\ \ \\ PERIMETER OF LEACHING
-4? \ \ FACILITY, DOWN TO SUITABLE TITLE 5 SITE PLAN
/ B B \ \ x; 7 x 39.81 SOIL LAYER. REPLACE WITH
CLEAN MED. SAND, TO MEET OF
�LS UNSUITABLE /LS 11 DRIV 40. 6 x 40.70 f �\0' \; \\\ 15.255(3)SPECIFICATIONS OF 310 CMR
18" /10YR 5/4 18„ 10YR 5/4 I N \ _ - „ 0 90 INDIAN HILL ROAD
/ 5
i m 1 CUMMAQUID
/C1/ C1 �1
SILTLOAM� UNSUITABLE SILT LOAM �40 81 I 41.88 x 40.30 \` RE PREPARED FOR
„ 10YR 6/2 1OYR 6/2 33.6' \ TH1 ®39.4
84 / 33.1 78 / �\ 40. '40 TH2 14 PI „40 JEAN STUART
I PI s
C2 C2 .30 4 ,
� I X 40 � 36 � / 7 DECEMBER 9, 2013
SIEVE v
40.42
y f A off 508-362-4541
4p oA OF fax 508-362-9880
MS MS I I ARNE �i. DANIELA. DANIEL `SIN o`'i� ,"R'�E \ . downcape.com
39. 6 4 ��%-'� OJALA OJALA
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„ , » \ � No. 30792 4650?. .o
No.40980 ) �f
1 OYR 5 8 10YR 5 8 +r�388 too 26348
132 / 29.1 132 29.1 40.11
40.23 - ° �� %� L civil engineers
» , 39.8 i��i ' AFL �.o- FG, S EE�F'\�ty !,q F S 0 G'�.c . �J s
Scale: 1 = 20 N �R ss/0 �o ss r �� land surveyors
GROUNDWATER ENCOUNTERED @ 84 PPRON 64
Co �QE 11vD 939 Main Street ( Rte 6A)
> 3-26 >
0 10 20 30 40 50 FEET 3 .57 DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675