HomeMy WebLinkAbout0225 MIDPINE RD - Health .25`A4'pine Road ' ; ` ;''' ;Via:
Barnstable
A == 349.. 019
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
!% 225 Midpine Road
Property Address Nj
Virginia Potvin
Owner Owner's Name
information is
required for every Barnstable Ma 02601 3-9-20 __
page. City/Town State Zip Code Date of Inspection[ 5
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. d�pttllltnrrrq,����
`���•���-\N OF M,qS
Important:When
filling out forms A. Inspector Information
on the computer, =�r JAMES
use only the tab James D.Sears _S
key to move your Name of Inspector *'.•
O •
cursor-do not �.�i
Robert B4Our Co. INC
use the return Company Name �ryOi F 5 LN Sp�G���
key. y���u►rNnuntpl����
363 Whites Path
Company Address
South Yarmouth_ MA 02664
City/Town State Zip Code
MIN 508-477-8877 _ S 1623
Telephone Number License Number .
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails } ,
3-9-20
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.M6l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20
required for every —
page. Cityfrown 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: v
® 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:
The system is a 1000 Gal. Tank D Box andTit. ,
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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
r Subsurface Sewage Disposal System Form Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20
page.
required for every 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 [I. 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):
Further Evaluation is Required b
3) q Y 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,rsafety 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: -
P ,
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c
N .ti
Commonwealth of Massachusetts
Title 5 official Inspection Form
!?� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. � 225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20 _
required for every __..__-_ ___. — _
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 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.
c. Other:
t �
4) System Failure Criteria Applicable to All Systems: ,.
You must indicate"Yes" or"No"to each of the following for all inspections: '
t
Yes No r
Backup of sewage into facility or system component due to overloaded or11 '
® 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 <
• I • a
t5insp.doc•rev.7/26/2018 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 ," r
Commonwealth of Massachusetts
r;e Title 5 official Inspection Form
a)i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name A
information is Barnstable Ma 02601" 3-9-20
required for every City/Town State Zip Code Date of Inspection
page.
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 irl'aeAspagg is less than 6" below invert or available volume is less
than 1/2 day flow A-1—
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of'6 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
M ❑ ❑ 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
) or a
Area—IWPA mapped Zone II of a public water supply well
.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
t5insp.doc�rev.712612018 .
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20
required for every --- -
page. Citylrown 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 insSection 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
❑ 10 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?
t
® ❑ Were all system components, excluding the SAS, located on site?
i
® ❑ 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,
r dimensions, depth of liquid, depth of sludge and depth of scum?
' Was the facility owner(and occupants if different from owner) provided with
❑ I ® information on the proper maintenance of subsurface sewage disposal systems?
f 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.
El ® 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.ooc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
ITitle 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
225 Midpine Road
Property Address
------------
Vir inia Potvin
Owner Owner's Name 02601 3-9-20
information is Barnstable Ma —
required for every -==1 own State Zip Code Date of Inspection
page.
D. System Information
1. Residential Flow Conditions: 3
3 Number of bedrooms (actual):
Number of bedrooms (design): 330
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description:
1000 Gal. Tank D Box and pit.
t
t ,
f 1
Number of current residents:
❑ Yes ® No
Does residence have a garbage grinder?
Does residence have a water treatment unit? ,
❑ Yes ® No
If yes, discharges to: '
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information.in this report.)
❑ Yes ® No
Laundry system.inspected? ,
❑ Yes ® No
Seasonal use?
2018-100,000Gal
Water meter readings, if available (last 2 years usage (gpd)):. 2019-47,000 Gal's
Detail: f '
❑ Yes ® No
Sump pump?
L' Present
Last date of occupancy: Date
Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 18
t5insp.doc•rev.712 612 01 8
Commonwealth of Massachusetts
Title 5 official Inspection Form
F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable •Ma 02601 3-9-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
4
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 ElNo
f _
t
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):
t -
3. Pumping Records:
+ NA
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: a
t6insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- I' Subsurface Sewage Disposal System Form Not for Voluntary Assessments
225 Midpine Road
Property Address °
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma t 02601 3-9-20
required for every State Zip Code Date of Inspection
page CitylTown
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
'Single cesspool.
❑ Overflow cesspool
�F
❑ 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
r 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:
199
3- Permit # 92 -454-4-2018 New D Box.
®.
Were sewage odors detected when arriving at the site? El Yes No
5. Building Sewer(locate on site.plan):
A
2811
Depth below grade:
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.__ ---
•' — ._ _ . a .. •. ' s 4
1
Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
t5insp.doc•rev.7/26/2018y
r'
commonwealth of Massachusetts
5A Title 5 official Inspection Forhi
lip' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.% 225 Mid pine Road
Property Address ,
Virginia Potvin -
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20
required for every City/Town State 'Zip Code Date of Inspection
page.
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: , feet
Material of construction: -
®concrete ❑ metal ❑fiberglass ' ❑ polyethylene ❑ other(explain)
i
I ,.
I -
If tank is metal, list age: years i
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑
Yes ❑ No
t r 1000 Gal. Precast H-10
Dimensions:
_. 2"
Sludge depth:
28"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
.;—
811
Distance from top of scum to top of outlet tee o•r baffle
f 17„
Distance from bottom of scum to bottom of outlet tee or baffle
Asbuilt-Tape
How were dimensions determined? 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 18" below grade w/cover's at 8". In and outlet tees. No sign of
leakage or over loading . — -
A
Title 5 Official Inspection Form:Subsurface Sewage Disposal System page 10 of 18
t5insp.doc rev.7/26/2016 • I - '
Commonwealth of Massachusetts
Title 5 Official Inspection Foam
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.% 225 Midpine Road
u Property Address
o
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20
required for every
page. City(rown State , Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: .b F
❑ 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: 1
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
w
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/2 612 01 8 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
�- •� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
225 Mid pine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20
for eve required o ,
q every
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.): t `
*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 is16x16 -31 below grade w/one line out. Box is new 4-2018 w/cover at 4".
i
• L' . ,. a '� r .,. r - A. y
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
' f
Commonwealth of Massachusetts
Title 5 Official Inspection F® M
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
225 Mid pine Road
Property Address
Virginia Potvin
Owner Owner's Name 02601 3-9-20
information is Ma
required for every Barnstable state Zip Code Date of Inspection
page.9
e.
City/Town
' n co
D. System Information (cont.) ,
10. Pump Chamber(locate on site plan):
❑ Yes ❑ No*
Pumps in working order:
I El Yes ❑ No*
Alarms in working order:
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc):
1 •
* 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:
}• r
Type: ,.
1
® leaching pits - .number:
L ,
leaching chambers number:
❑ ' c number:
leaching galleries
leaching trenches number, length:
❑
leaching fields number, dimensions:`
number:
El overflow cesspool
-
❑ innovative/alternative system
Type/name of technology:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
t5insp.doc•rev.712612018
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
`l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.� 225 Midp ine Road
emu-
Property Address
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20
required for every --
page. City/Town State 'Zip Code Date of Inspection
D. System Information (cont.)
r
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 a 1000 Gal. Precast pit w/4' stone. Pit is piped into riser. Pit at 5' below grade w/cover
at 28". 20 water in pit
s
t ,
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 -
r ❑
Indication'of groundwater inflow ❑ Yes No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t
f ^
t5insp.doc-rev.7l26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18,
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
225 Midpine Road ;
Property Address
Virginia Potvin '
Owner Owner's Name 02601 3-9-20
information is Barnstable Ma
required for every City/Town State —it p Date of Inspection
Code
page.
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.):
3
i
f
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A
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 Of 18
t5insp.doc rev.7/26/2018
r ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Fit
_-
1, 225 Midpine Road _
Prooeriv Address
Owner Uwner's Name
information is Barnstable MA 02601
required for every --
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t q
1?Epp
/3 •A- o�
�----� - 3
t5lnadoc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pa;e 15 or 17
5 t a6ed Xed dH W 6 t 810Z 60 JdV
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,v 225 Mid pine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is Bal _ Ma 02601 3-9-20
rnstabe
required for every — State Zip Code Date of Inspection
page. Cityrrown
D. System Information (cont.)
14. Sketch Of Sewage Disposal System: r
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
. a ,
Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 18
t5insp.doc•rev.7/26/2018
f
i .
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
225 Midpine Road -
Property Address
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20
required for every CitylTown' State Zip Code Date of Inspection
page.
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
14'
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
8-24-92
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H.on Design plan 8-24-92 14' no G.K. Bottom of pit at 11' below grade. Bottom of pit at Tabove
T.H. Depth• _
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
. k
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 t
t5insp.doc•rev.712 612 01 8
Commonwealth of Massachusetts
-s ,F Title 5 Official Inspection Form
8 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
225 Mid pine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is Barnstable Ma 02601 3-9-20
arns
required for every State Zip Code Date of Inspection
page. City/Town
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of: t
® 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
/y- 3 NO
� w
y
- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
tsinsp.doc-rev.7/28/2018
No. �o v'077 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pptitation for disposal *pstem Construction permit
Application for a Permit to Construct( ) Repair X) Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. ;VZ15 &(U0j>1UG R®41) Owner's Name,Address,and Tel.No.
®
Assessor's Map/Parcel
POTW^1
3 Y / 0 21 w{` A
Installer's Name,Address,and Tel.No. 5021 L(77-a&-?7 Designer's Name,Address,and Tel.No.
f<W�tDcc r�Tawkf� N 1A
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) =NS7,` L
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 Certificate of
Compliance has been issued by this Board of Health.
Signed Date_ -3
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 9-01 '6 Date Issued 3
7.
No. o1 y� Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippliLatlon for ]Disposal 6pstem Construrtlon Permit
` A lication for a Permit to Construct Repair W Upgrade Abandon pp ( ) p pgr ( ) ( ) ❑Complete System Individual Componernts
Location Address or Lot No. e`1 J D IPLN G n 011J 41) Owner's Name,Address,and Tel.No.
`- [.rJ V t V Qr(?!tA Po"CwN
Assessor's Map/Parcel � 9 Q 2�"S' (�1 j' PROA RAMSTAAL45
Installer's Name,Address,and Tel.No. 50$—Y77-gg r Designer's Name,Address,and Tel.No.
C�PCG+uJtaL'� C�VT�'aJS�
15 C���l 3i t�i 9469' ���
Type of Building: /
Dwelling No.of Bedrooms AI A` Lot Size sq.ft. Garbage Grinder( )
• t
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures p
Design Flow(min.required) /V /+— gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
is Nature of Repairs or Alterations(Answer when applicable) VAh;-rA _ _ A_)jEj,► ) H j 0 O-BOX 4- k(5o5R
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
, Y Compliance has been issued.by this Board of H`ealth./� /` ,.•e
Signed,, �c�}l _ ,� !l� Date -3 fi
Application Approved by L .&—AA_- � Date 5 '2
Application Disapproved by Date
for the following reasons
Permit No. gol i►— 6 Date Issued 3— 2 7-f V
_.- - ---------------------•- --, - ------------- - - --- - --- -- -- -- - - - - -- - - -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by CAPC—Lt3lbr a >r jV j b&PA
at all AdIPP009' ACA-b PAW has been constructed in accordance -
with the provisions of Title 5 and the for Disposal System Construction Permit No.r?Or b/'6•� dated �� 2ry— �(5
Installer ytt�6C,Jt77 p X 1$-c:.) Designer NIA
#bedrooms !V 11— Approved design flow /(�/�— gpd
The issuance of this permit shall not be construed as a guarantee that the systeKZ'l function"-a"s�}designed.
Date ,�J�1� Inspector
----------------- I- -------------- - ------------- -- -- -�------------ ------------- -------------------------------
No. l 6 .' -- Fee
THE COMMONWEALTH OF MASSACHUS TS
PUBLIC HEALTH DIVISION-BARNSTABLE, MA ACHUSETTS
BIsposal *pstrm Construction Permit
Permission is hereby granted to Construct( ) Repair O Upgrade( ) Abandon( )
System located at 04(01 016 800(:b
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:Construction must be com leted within three years of the date of this permit'
!�
Date ✓ ! Approved by ,
i
4
Pd
Commonwealth of Massachusetts
Title 5 Official Inspection Form :1,>
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
225 Midp ine Road
Property Address
Virginia Potvin cc,
Owner Owner's Name
information is
required for every
Barnstable ✓ MA 02601 4.6-18 ;
page. CityfTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:out
When A. General Information /aq 3
filling out forms ���d�U1f���l��rlb�l��i
on the computer. `�s�'(�OF Mgss
use only the tab
Inspector:
key to move your 1. - m.� JAMES G
cursor-do not James D,Sears =�:
use the return Name of Inspector
key. Capewide Enterprises
Company Name
163 Commercial Street
Company Address
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 16.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4-9-18
pector's Signature Date
The,sy stem inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
lSns.doc•rev.6116 Title 5 Orfidel Inspection Form:Subsurface Sewage Disposal Syst of 17
I, a5ed xeJ dH £b:66 260Z 60 Jd/
Commonwealth of Massachusetts
UVVII;z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
225 Midpine Road
v
Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
page. Cityrrown State Zip Code Date of Inspedion
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 CUR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal. Tank- D Box and pit.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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):
15ins.doc•rev.6116 Title 5 Official Irmpection Farm:Subsurface Sewage Disposal System•Pago 2 of 17
Z a5ed xe� dH Eb4 l, 8 60Z 60 Jdy
Commonwealth of Massachusetts
Title 5 Official Inspection Form
so
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41
u�
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of 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):
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
15hs.doc-rev.6116 Title 5 ORdal Inspection Form:Subsurface Sewage Disposal System-Pape 3 of 17
6 a5ed xed dH £bi 6 6 8 60Z 60 Jd`d
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
.
page. CBylTown 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
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in is less than 6"below invert or available volume Js less
than %day flow P,T
t5ins.doc•rev.6116 Title 5 Ofrrcial Inspedon form:Subsurface Sewage Disposal System-Page 4 of 17
tr a5ed xed dH, CV:,1• 260E 60 JdV
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
226 Midpine Road
" . Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
page. City/Town Slate ZIP Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
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 forma
0 ® 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 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
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.
15ins.doc•rev.6116 Title S Oficial hnpeciw form:Subsurface Sewage Disposal System•Page 5 of 17
5 a5ed XeJ dH £bU 8 60Z 60 Jd'd
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
L
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
® ❑ 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): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins.doc rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
9 a5ed xeJ dH £bU 8 60Z 60 jdV
Commonwealth of Massachusetts
Title 5 Official Inspection Form
. Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
_ 226 Midpine Road
u Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
1000 Gal. Tank-D Bok and pit.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2016-281,000Gal
g y g (gp » 2017-128,000Gai's
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Comm erciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203), Gallons per day(gpd)
Basis of design flow (seats/personslsq.ft., etc,):
Grease trap present? ❑ 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:
15ins.doc•rev.6116 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
L a5ed xed dH t t 6 6 8 60Z 60 Jdf
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ri Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner owner's Name
Information is required for every Barnstable MA 02601 4-6-18
page, City/Town state Zip Code Date of Inspectlon
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
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 UA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.61..6 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
9 a6ed xed dH tIVU '81.0Z 60 JdV
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
fro Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Pctvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
page. CityfTown State Zip Code Date of inspection
D. System Information (cunt.)
Approximate age of all components, date installed (if known)and source of information:
1993 -Permit #92 -454.4-2018 New D Box.
Were sewage odors detected when arriving at the site? 4 ❑ Yes ® No
Building Sewer(locate on site plan):
"
Depth below grade: 28
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.
Septic Tank(locate on site plan):
18"
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
a
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth: 2"
t5ins.doc-rev.6116 Title 5 Official Inspection Form Subsurface Sewage Oisposal Sysiem•Page 9 of 17
6 abed xeJ dH t7tU 860Z ,60 JdV
Commonwealth of Massachusetts
Title 5 official Inspection Form
7Subsurface'Sewage Disposal System Form- Not for Voluntary Assessments
7 L 225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name"
informations required for every Barnstable MA 02601 4-6-18
page CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle na
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle na
Distance from bottom of scum to bottom of outlet tee or baffle na
How were dimensions determined? Asbuilt 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 and outlet cover at 18" below grade wftnlet cover at 8". In and outlet
tee's. No sign of leakage or over loading.
3
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.W16 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 10 of 17
o l, a5ed xeJ dH 17b:1.6 910Z 60 JdV
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-&18
page. CityrTown 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:
Material of construction:
❑ concrete ❑metal ❑ fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17
�� a5ed xed dH W 1,1, 8I.0Z 60 JdVd
Commonwealth of
Massachusetts
Title 5 Official Inspection Form
lit"
< Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Mo 225 Midpine Road
Property Address _
Virginia Potvin —
owner owners Name
information isre(juir Barnstable MA 02601 4-6-18
page-
for every 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 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"-31" below grade wlone line out. Box is new 4-2018 wlcover at 6".
t
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,):
r
r
t
* If pumps or alarms are not in working order, system is conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doa-rev.5116 Me 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 12 of 17
Z 6 abed xeJ dH 5b:i,6 2 60Z 60 add
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
11,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owners Name
information is required For every Barnstable MA 02601 4-6-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont,)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length.-
El leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativetalternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. Precast pit w/4'stone. Pit is piped into riser. Pit at 5'below grade w/cover
at 28". 40"water in pit.
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
Mns.dx•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v, 225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.).
15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Deposal System•Page 16 of 17
b 6 abed xed dH 9b:11, 81.0Z 60 add
c Commonwealth of Massachusetts
Title 5 official Inspection Form
r6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
reformation is required for every Barnstable MA 02601 4-6-18
page. Cityfrown State Zip Cade Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building, Check one of the boxes below.
® hand-sketch in the area below
❑ drawing attached separately
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t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 ei 17
5 t abed xed dH 9b:6 t 9 1,0Z 60 Jdf
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
5
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 14'
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: 6-24-92
Date
❑ Observed site(abutting propertylobservation 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 highground water elevation:
T,H.on Design plan 8-24-92 14' no G.W.. Bottom of pit at 11' below grade. Bottom of pit at S above
T H Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
LSins.doe•rev.6116 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page_16 of 17
`` g t abed xed dH W L L 8 60Z 60 Jd`d
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
225 Midpine Road
Property Address
Virginia Potvin
Owner Owner's Name
information is required for every Barnstable MA 02601 4-6-18
Page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® inspection Summary, A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
f
t5ins.doc•rev,6115 Title 5 01`56al Inspection Form:Subsulaoa Scwage Disposal System•Page 17 of 17
L 6 abed xed dH Lb:6 6 81.0Z 60 Jdtf
TOWN OF BARNSTABLE
LOCATIONQLcQ�v,B '(���� SEWAGE #
VILLAGE ac� V; ASSESSOR'S MAP & LOTg. pf y
\NSTALLER'S NAME 6� PHONE NO. 3• S- Oc�S c�1\ 1 -(,U ya
SEPTIC TANK CAPACITY I� (90 y y w l Kati S
LEACHING FACILITY:(type) tfctc-�_ (size) li U�i�qo,l(onS
NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATER
k
BUILDER OR OWNER ±014( I —Lj: is ,, 1-o�4y
DATE PERMIT ISSUED: �'�N "97,
DATE COMPLIANCE ISSUED: 7
VARIANCE GRANTED: Yes No �/
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Toustxu.rtiun Frrutit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
system
/ v7'a/ IV ID f/�r/� e G� �a�
............. - ... ...........-• ....= .........._._........... .. .�r._.�n.........__.-----...........................
D . LocatiY}t r �/ / or Lot No.
..... -/�' .•• [PJ /uJ 1-o!. -�.�./........................ ...........-............---•--............. ..............................................
WV. a ��(�(!Limner ...................... _.__[ '.1 `� Address
a .-
Installer Address A.252
� ry��
d Type of Building Size Lot. _.._,t_________________Sq. feet
Dwelling—No. of Bedrooms..... 3 ------Expansion Attic ( ) Garbage Grinder (Alo)
WOther—Type of Building GU No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures .......................................
W Design Flow................d......._.___..___._..gallons per ge-t•-sen per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacityAKa.gallons Length................ Width................ Diameter-_--_-__-__-_- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------_------------- Diameter.................... Depth below inlet.................... Total leaching area.........._.......sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I...A!P�-_-_minutes per inch Depth of Test Pit.................... Depth to ground water.........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
C4
0 Description of Soil...... - --------------- --------
----
---------- ..................
.-----------------
�ct.- ----------------------•-----------•--••--•---•----------•----------•-------------...-•--••----•-------------....------------.
U ---------------------------------------
--•------------------------------------------
----
-----------------------------------------------------------
•-------------
•--------
•••--------------•------------
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-- -----•••--------•---•---------------•-•--•-----•-•....._.._.......---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comp ' ce has been issued by the board of health.
Signed ...- .... F
...... ..... .... ....
Application Approved BY � ---------- - -- ----- ---------------------------------- ---- --------------------------
Application Disapproved for the following reasons: .....................................................................---- --- ................
-----------------------------------------------------------------------
...........
Permit No. .. Issued .... l ..--(.. e
Ll
wr
„THE COMMONWEALTH OF MASSACHUSETTS,
BOARD OF HEALTH
TOWN"OF BARNSTABLE
00
App ira#inn for R-4paiitt1 larks'Tonstrnrtinn ramit -
Application is hereby made for a Permit to Construct (x)/or Repair ( ) an Individual Sewage Disposal
System at
In/D .....
Location duss�/ J or Lot No.
......................... - •---^•_______........__•_.._.__... .......--------------
_. .
O ner Address
L �1 MILL -........
Installer Address
U Type of Building Size Lot_?. ;_5a.._Sq. feet
Dwelling—No. of Bedrooms........ 3
................................. Attic ( ) Garbage Grinder (rl/a)
a Other—Type T e of Building (��r_____ 11/p-I yp g __!�_: _�_.�t?-� No. of persons____________________________ Showers ( ) — Cafeteria ( )
11� Other fixtures �i�-----------------------------------------------------------•------------
----
W Design Flow.............. .....................gallons per p_Abl3 per day. Total daily flow..........:33_®.....................gallons.
WSeptic Tank—Liquid capacity�.0041__gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................-
Test Pit No. 1___�,.,Z_._minutes per inch Depth of Test Pit____________________ Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
.t
•------ ---- --------------•------- -----_---------------------------------------
--------
_---------_--
O Description of Soil -�'� �E !�..44 -----------•-----------------------------------------------------------------------------------------------------
..........
U ...........................-•-..............................------•-•----------------------------------•------------------•---..----•-------------------•----------------......--------••--------------
W
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
-----------------------------------------------------------•-----...------------------------...----•----------------------------------------------------------------•-•--------------------.....-•_-----
r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the,State Environmental Code—The undersigned further agrees not to place the
system in operation until,a•Certificate of Compliance-has been issued/bD the board of health.
..� tSigned -... l
� re
,may
- Application Approved By ........ ...1/'L -.---.... . ----------- !----------- _---------------- ----- ..... ..
7 narE /
Application Disapproved for the following rear n r- -- ---------- - -- ------------------------------------ --- ------------------------------------------
----------------------------------------------- ----- - -----------
-----------------------------------------
Dace I
-- l
Permit No. -- --�--- --- -------------- -- Issued -f -- ���--..-..----'---....--------
THE COMMONWEALTH OF MASSACHUSE77S
„r. „'
BOARD OF HEALTH
TOWN OF BARNSTABLE
TerttftczxtP of Complinure
THIS S TO CERTIFY, That the Individual Sewage Disposal System constructed ( X ) or Repaired ( )
by....--� D _.ISC OL�-
Installer
at l U.�.....3.�--/�./!� /�/N� , -U GTJ/Y /9 a 6116
----------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ............................................... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................... .. - Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE r
Nog. FEE.... ...
�i��raa��1 �rk� ��an��rnnr�uan �rutif
Permission is hereby granted......
..__ 2 �S �-...._....---•--•---------------------------------------------------------------------------------------•--.......
to Construct ( )0 or Repair ) an Individual Sewage Dispo al System
at NotI1T_!_' .../Yl/ :1��11,E.... '�? - •Um/1'1G2U
Street /
as shown on the application for Disposal Works Construction Permit No._ __ ,�______ 1 ated...... ._ 'i`" --------------
----------------------------------- --- -- .......................................................
/� Board of Health
DATE L_." _ .`.:..._ ---
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9/1/2021 ShowAsbuilt(1653x2338)
TOWN OF-BARNSTABLE
LOCATION LO SEWAGE
VILLAGE Co4nwnoi ASSESSOR'S MAP'& LOT . V .pi
\NSTALLER S NAME 4 P.HONE NO: Jill '-j.O
�SEPTIC:TANKCAPACITY i yUy` yal(pw5
CLEACHING FAC LITY.(type) i�ec+a.t-, Q'� ,�4-1-0 (sib) ►100,1gt(oi s
NO.:OF BEDROOMS .3 PRIVATE WELL O PUBLIC WATER.
BUILDER OR OWNER. P7a 15, gjJk , 63. 371-0g.9y
DATE PERMIT ISSUED-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No, 1/
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