HomeMy WebLinkAbout0193 MIDPINE RD - Health 193 Midpine Drive, Barnstable
A= 356-016
1161
i
4
61 (0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments h
w� 193 Midpine Road _
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaquid 13AIZNSTAE;L£ MA 02630 4-11-19
page. City/Town State Zip Code Date of Inspection ,T7
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.
\``�pp�►ttOF►li -1111i
1.
Important:When ���
A. Inspector Information
filling out forms �I / _ y
on the computer, # `� 'Z" �:' JA M E S u'
use only the tab James D.Sears A
key to move your Name of Inspector r;
Jim The Inspector Man oc
cursor-do not *'t o
s �, o
key the return Company Name
y P.O.Box 784
r� Company Address
West Yarmouth MA 02673
City/Town State Zip Code
508-364-4398 S1623
Telephone Number License Number
i
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. ❑ Fails
al,v�X�YJe� 4-12-19
pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
�?} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaguid MA 02630 4-11-19
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:
Note: Outlet Tee has a zable filter. The system is a 1500 Gal. Tank D Box and two chamber's.
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):
t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 193 Mid pine Road
Property Address
Charles Dever
Owner Owner's Name
information is Cummaguid MA 02630 4-11-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more'than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑. N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
`i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is Cumma uid
required for every q MA 02630 4-11-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) `
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tarok and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^; 193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaquid MA 02630 4-11-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in a4aspgMis less than 6" below invert or available volume is less
than 1/z day flow A 4C#ING
❑ ® 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
❑ ❑ 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 Il of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface D Sewage Di
sposal System Form Not for VoluntaryAssessments
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaquid MA 02630 4-11-19
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
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?
® ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V 193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaguid MA 02630 4-11-19
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:
1500 Gal. Tank D Box and two chamber's.
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 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 2017-96,000Gal
g ( Y g (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is Cummaquid MA 02630 4-11-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
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
Was system pumped as part of the iInspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
0
u
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is Cumma uid MA •02630 4-11-19
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1997 Permit # 97 - 131.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 3'feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaquid MA 02630 4-11-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
26"
Depth below grade: 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: 1500 Gal, Precast H-10
Sludge depth: 31.
Distance from top of sludge to bottom of outlet tee or baffle
27"
1
Scum thickness
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Plan-Tape
Sludge 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 at 26". Below w/both covers at 2". In and outlet tee's. No sign of
leakage or over loading. Note: Outlet tee has a zable filter.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�jle Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaquid MA 02630 4-11-19
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.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
r
f
cam, Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary p Y y Assessments
!% 193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
required for
is every
Cummaquid
required for eve MA 02630 4-11-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-32" below grade w/one line out. Box is clean and solid w/no sign of over loading
or solid carry over.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
I� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y<
.� 193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaquid MA 02630 4-11-19
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
- lid Title 5 Official Inspection Form
Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is Cumma uid MA 02630 4-11-19
required for every q
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two 500 Gal dry well chamber's w/4'stone. Cover at 17" below grade. Chamber's are
clean and dry. Chamber's are 4' below grade.
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.):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. 193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaquid MA 02630 4-11-19
page. City/Town State Zip Code Date oil'Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is required for every Cummaguid MA 02630 4-11-19
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:
® hand-sketch in the area below
❑ drawing attached separately
A -3
0
0
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
required for
is every
Cumma uid
required for eve q MA 02630 4-11-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 8-1-96
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
T.H. on Design plan 8-1-96- 12' no G.W.. Bottom of chamber's at 6'-6" below grade. Bottom of
chamber's at 5'-6"above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
193 Midpine Road
Property Address
Charles Dever
Owner Owner's Name
information is Cummaquid MA 02630 4-11-19
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
GRAM
r�r
/ N
r3ON 4. 4
C HAA►8C/R3
II
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
� -
�•f 27 TOWN OF BARNSTABLE
LOCATION SEWAGE # Z3 J
VILLAGE-am r-a Lal4 ASSESSOR'S MAP & LOT 3&• (� t�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 450-ty,
LEACHING FACILITY: (type) *_ 9A�= -r-"A(size)
NO.OF BEDROOMS
BUILDER OR OWNER Z"ff �
PERMIT DATE: 3 . In 7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist .
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
LL--f
� s ,
Z Z O
p , o s
3 o t
IF C7
,6 �• w
I
�•� 2� TOWN OF BARNSTABLE
LOCATION All c' SEWAGE #
VILLAGE /�_�S'f`s G f 4 ASSESSOR'S MAP & LOT . 3G 1G
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Z104PI
LEACHING FACII.TTY: (type) '� � .r (size)
NO..OF BEDROOMS �
BUILDER OR OWNER"_1'T 5j'A14.4—
PERMTTDATE: 3 . In - l 7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge.of.Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
O
J ..
;
O zZ
o 'a5 ..2
C '9�
R
No. s / Fee op
3/ 3:3 4•' ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplicatiou for Mi5po0ar *p5tem Con5truction Permit
Application for a Permit to Construct( V/Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Loc on Address o Lot No. L Q /,� ] / IAIE Owner's Name,Address and Tel.No. y5 �1!!� //V� !N2
to
Assessor's Map/Parcel 35 6 //6 e uAla-MOUE
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�r7 D1 ��1/i/D — CCU GU LL S r �} OC 7 7 -0735-
Type of Building:
Dwelling No.of Bedrooms Lot Size 37• 601 S sq.ft. Garbage Grinder(i✓q
Other Type of Building 4t)00 Q-FA-& �e_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 35-3 gallons per day. Calculated daily flow d gallons.
Plan Date 3 —/'W— 2? Number of sheets Revision Date
Title %Q3 Ml-PPiuE RI),, �Ue #7/f &)/J/Z)
Size of Septic Tank Type of S.A.S.
Description of Soil .t5 pie �L�o✓
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b s Board Tealth.
Signed -— Date
Application Approved by Date
Application Disapprove for the following reasons ell—
Permit No. 27 —/ 3 1 Date Issued
No. J R - Fee l 3 �
- z 1 ( :=THE COMMONWEALTH OF MASSACHUSETTS ` tered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pprtcatton for Migogar *p.5tem Conmructton Vermit
Application for a Permit to Construct( W Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Y Location Ad
dress o Lot NO. (� / 7 i Owner's Name,Address and Tel.No. 3415 IW IO PIAIE /�2
go ,
VE
Assessors Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
JD Dt MA16 -- -bECU GuG[G 2 �9 ssDC 7 7.5-Q735
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 37. 6d sq.ft. Garbage Grinder(I✓L)
Other Type of Building OtTd�✓LGL No. of Persons Showers( Cafeteria( )
Other Fixtures
Design Flow 5 3 gallons per day. Calculated daily flow gallons.
Plan Date 3 '/i — 117 Number of sheets I Revision Date ~�--
Title /43 M /DP/A/J:- RI). GUm/Y!/g bUIZ)
Size of Septic Tank /! (ry Type of S.A.S.
Description of Soil /15 IOC to 19^4
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: '
Agreement: `
t
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions`of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b • is Board of Health.
Signed Date
Application Approved by 2 Date _f
Application Disapprove for*tlhittelotll�owing reasons
Permit No. 7 -1-( Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ✓) Repaired ( ) Upgraded( )
Abandoned( )by -. U4�: 1)/(o/AAJU k=Co
at 4 /9 3 M/ n&I N9 Z)a. j�U Mfi l,4,00 b has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.9 7/&/dated Ate,
Installer�_T0 E 17/ C/#4 ND — D£C U Designer
The issuance of this permit shall not be c nstrued as a guarantee that the sysrilijunction as designed.
Date Inspector
17)
No. -------------------------
=1 )
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwigoar 6potem Congtructton Vertntt
Permission is hereby granted to Construct( V/ Repair( )Upgrade( )Abandon( )
Systemlocatedat /Q3 fYII610/AJ,F— D/2_ CUMMg6j11D
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this perm
Date: Approved by
TEST HOLE LOG
DATE: :9 • / /99�0
����• SOIL EVALUATOR.
WITNESS:
'y PERC RATE:.
y �3
1
4 Y�
_ •
3��zZ y 3
� C/ $.9.vD� �•/iS/�c .SgiYD
,b •, io ye G/g /a Y z 7�5�
I \ F llVe JrAtiw C'Z S�w.cl/
/a 7 Lo
A
o .. �-'�-''� � . . o !•t/A7ElZ. ��clGOv_.cJ.�EJ.�E.p__.__ -_.:
lAj
Loa DESIGN DATA
�• , Z,n 1� DAILY FLOW: (3)BDRMS.z 110 GPD= 33o GPD
/ SEPTIC TANIC: .33a GPD z=%- 660 GPD
7� \ USE: /So a GALLON PRECAST SEPTIC TANK
LEACHING FACILITY:
USE: :
p CAPACITY:
I _ SIDEWALL:
' �i '�(p• TOTAL:-.-------- 3- --
�r :,h�. 3ti�^ . ;$ro a zik" s'r •,`; �" 9:`i
t
NOTES: a
1. ALL PIPE TO BE 4"DIA.SCH 40 PVC.
2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION
BOX.
3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN
6"OF FINISH GRADE
4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A
GARBAGE DISPOSAL.
5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED
ON A 6"LAYER OF STONE
6. INSTALL GAS BAFFLE IN OUTLET TEE. PLAYER OF SIB•PEASTONE OVER
LP-I In.
WASAED STONE ALL
AROUND
TOP OF FOUND. i
@ EL. �j6,Ooo Io• II• 8
yyam,.oy 7
Y y800
��•75 Y�So a
SEPTIC SYSTEM PROFILE
SITE SEWAGE PLAN GENERAL NOTES
FOR 1. CONTRACPOR TO BE RESPONSIBLE FOR THE LOCATION
OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR
TO ANY EXCAVATION OR CONSTRUMON.
L SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WPrH
PREPARED FOR 310 CMR 13.oo:TTPLE v,
3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE
.5/�i�- /�.I>/.c.J.C�•- --h�C.. DETERMINATION.
t, �.._ 4. ALL DISTURBED AREAS TO LOAM AND SEEDED.. ' }} r
DATE: "� _"/�/_'31 7 SCALE: x
L ;r
S. CO TO PROVIDE 24 HOUR N
t Iq ONS. OF M
DANIEL B. gCSG ti
,� N BRAMAIj r -ray 'rtm t 5 `s �`
S y'�t-0"�, c`}•�i> s M �; y zu i z, ;ir W�,}#ay.: `• :1 f
F }�' '� .,,F•' in
ON
_..e3•..rn��.�Co-t� F-.. . !��•f• r�� y.':�1 '►1�I ��.���^ �?�TS��. E
-T
` WELLER & ASSOCIATES `
T cr.. ' 4 d ✓M.
1645 FALMOUTH ROAD CENTERVII.LE,MA. 02632
TEL: (98)7754735 FAX: (50).7754754 ;z x F y�r�q s�
,, APPROVED BY: