HomeMy WebLinkAbout0108 PALOMINO DRIVE - Health 108 Palomino Drive
Barnstable P
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TOWN OF BARNSTABLE
LOCATION .612-1- SEWAGE# D913�--
VILLAGE ASSESSOR'S MAP&PARCEL Jq Z -
INSTALLER'SNAME&PHONE NO. 1, 6 r�-7 71
SEPTIC TANK CAPACITY ts5 c 1 P r t act JaW -6 ft(___
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER tj I L JU t /
PERMIT DATE: L{ -J4-1$ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -l- 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) 6=. Feet
FURNISHED BY-_ 2)OsvJ L o�c � /WevO-1yr
3(� r
yr b
d296' JZ'
No.. �ILJ /-5 b". Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftpfitation for 30isposai 6pstem Construction permit
Application for a Permit to Construct( ) Repairt/Upgrade( ) Abandon( ) ❑Complete System e Individual Components
Location Address or Lot No. 10$ QUpm I f)o 0•r, Owner's Name]Address,and Tel.No. y� l07
eJ"rj� M 1��7 )rn Ro•Qw 4135
Assessor's Map/Parcel�97/35 " 0'1437
Installer's Name,Address,and Tel.No.fib$-?'7/ 9359 Designer's Name,Address,and Tel.No. ✓`7�S1- 3�� 'y
&rkol oZ`I v <2on10r_X ^,X 0
D 9 A AAA o141cS
Type of Building: '
Dwelling No.of Bedrooms J Lot Size 1� _ sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) i 3a gpd Design flow provided ��� gpd
Plan Date Ahy. 160 a° >15 Number of sheets / /Rev�isiion Date
Title >i�J /GFC ��o Vz�-ee MA—
Size of Septic Tank P.�(iS4_ Type of S.A.S.g4�,Lo?7 st Adi o 4) ;ISX lay
Description of Soil 6u sax-e 1
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental C d not t ace the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date �/ /�
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. I �_ Date Issued 'Y— �p
Fee00,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4
Rpplicatlon for Misposal *pstrm Construction Permit '
Application for a Permit to Construct( ) Repairi(/�Upgrade( )r Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. /v D' f �Gm j�V;�r, Owner's Name,Address,and Tel.No.
C21'r `(' ti-liIburo P-o•✓3ox 435
Assessor'sMap/Parcelac/7��j k Yv»r?,p e� CuniZ,yW /}- 01�37
Installer's Name,Address,and Tel.No..jv$ T7/ - g3Sq Designer's Name,Address,and Tel.No. S k-
T r c C,bevn E, iil i�_5,�1 roc rr 3 r
Type of Buildings
Dwelling No.of Bedrooms .-7 Lot Size /A 6r4-f__ sq.ft. j Garbage Grinder( )
Other Type of Building No.of Persons 1 Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3n gpd Design flow provided 3y9 gpd
Plan Date A/0U. /6, 9O I 5-/ Number of sheets / Revision Date
Title F 4 5
Size of Septic Tank ° C Type of S.A.S. ,Q, :�('(ol� denIn'a Wn 64 trJVA n)
Description of Soil 6cr <,2.r r /ocn )
J-
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, the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date /.;L
Application Approved by Date /
Application Disapproved by Date
for the following reasons
Permit No. ly Z 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
/�—L'� h
( )
Abandoned( )by�f -'sz,�' =,n e_
at 1.05 100161)9"110(Aj�lue / ,nr,�<f� (�err -has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NZ &_13 -dated
Installer (ter�O�U� ( i•},c���1Gf 1�a� . -C-p� Designer Z11W ni LZt L10 PA-v-- inap-/I r7r Y�C
#bedrooms Approved design flow gpd
The issuance of this pe .it shall not be construed as a guarantee that the system will nctin as g d o .
R
Date Li Inspector
1
No. ��C!% Fee /G C
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Nsposal *pstem Construction jhrmit
Permission is hereby granted to Construct( ) Repair(ram), Upgrade( )/p� ��// Abandon( )
System located at a� Y 2& v T L/►y-) )rl U� I��ian l,?/a_Lex
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'
lcom le ed Jwithin three ears of the date of this ermit.
Date 1 0` �/ (p y Approved\�y 1 _
I
I
r7U Ofems.-t•li-_1?ii;;.ti7 it js l'F
_ �� .S,_e�:���CLL� 1 ✓l ly"—i1 Gf�y,ii• r � A'-790-b3r-
tJTi�lAl?I is me r Ce it^�.`1,_1tcf1 h_r i
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c i 'Let e Su Cs� fs ,� z� ca a-yve -y Z�,s�e subsitia�talt aces , 1
-tee deSig,, :'; i�clydj�,-=0_ 7r a, qed c-Im- geS such as laiara rei0caa0�?ct�� I,
t.
I cerff ; ab0—Ve irs �Fri' najUr c'ngs
pe� yih Z O'.ldi i%lG LaL�.O i Qr�L?-ct'r. �� .Ie<oca'i19�.�31�r�Fk 'GC3 lP e''-5§-
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CIVIL
Nc. 6.502
( 7 esigau'S J, i,ah� J b/ U/ =f Stan, Y
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•�4..R O apt s' 3T� i��i% zT'. �_� Y 3x���_x�l.. s �_ arLr.t� u
s v i a�A 3r t��— --
-•� -3i%.T 1�.a�Y fT i FR i.'1';`�ii� Ai 1:� 5' 7T E'ellL1Lle
,��.,.. �.___ i-1m�I.
16' --3)7
Town.of nS •lbI
Fly' Department of Regulatory.Ser-dees
Public�J[eaZth.�iv,szoxa gate l° llirz-,41
aNAM
200 Main Street,Hyannis MA 02601 y
rm
Na
. �r ` ; Date Scheduled r � Tune o� )Fee�°d, f/0 0 �
NO
Soil Suitah l ity AssesSmentfor > 'e!T e D�s�aosa1
Performed By: Witnessed By: ✓i�V Lv, I^^ n
LOCATION d ft-A & E. NERAL-TN. FORMA TIO f
7.oealion Address /O ri /oA �r owner's Name t� la e Wry
ar~' Address
Assessor's IvIap/Patel: f �( lEngincer's Name �0 N/M-• aft -
NEW CONSTRUCTION REPAIR Telephone# (So�
,, t
Land Use: 1 J ~d�Ebt Slopes(9b) 2 Surface Stones A'
Distances from: Open Water Body 7 ® ft )?oss[bla WetA'rea® eft Drinking Water Well � t
[� I
Drai'nago Wny —ft Property Line _ -b ft Other ft
SIM'TCJao(Street name,dimensions of let,exact locations of test holes&pert tests,locate wetlands-in proxirn[ty to holes)
4,
-Ij
Parent material(geologic) Depth to k3edr4c%
Depth-toOroundwater: StandingWaterinHole: �/k� Weeping from Pit fa
Estimated Seasonal High Groundwater
DJE ERMNA rfl ON FCC.SEASONAL L H[GH FATE ��'AM R.
Method Used:
Depth Observed standing in obs.hole: __—___ lu. Gepth,tos911 lz�ett!Cs:. In,
Depth to weeping from side of obs.hole. ln, GroundwaterAdjuetment
Index WeII# Rcading Date: Index Well lava[ _ _._ AJ, t terT � ..aCGuntlwnter I,eVel ,
PER.COLA TI.ON'rEST Dake�. TjIna 1
Observation
Hole Time;at.9"
DopthofPerc. , '•`?15 Tlmettt6"
Start Pro-soak Time @ �.z Titni(9"-0)
End Pro-soak
Rate Min./Iuch �
Site Suitability Assessment: Site Fassed 5itr Felled: Addldonal TesUng Needcd(YIN)
original: Public health Dlvisloa Observation Hold Data To Be Completed on Back----
h
***If percolation test is to be eozaducted mithilat 100' of wetland,you must Must xtotitfy the
Barnstable Conwvation Division at least one(1) week prior to beginning.
Qc15 EPTICIPF-R CFORM.D O C
DEEP OBSER'VAkTION GIOU LOG IffO7e#
Dcptli from Sail Horizon Soil Texture Shcl Color Soil•. Other
Surface(in.) (Utl)A) (Mnnsell) Mottling (Structure,Stones;Boulders,
o i'ten:;y,%'Gravcil
us 1 OM 3j.
to-Z� .L� - ID 6�8' ••
+,+P O SEIZtVA NONE(OlL7E LOG ' Hole ip �
Depth from Soil Horizon Soil Texture Soil Color "Soil Other
Surface(in.) (USDA) (Mnnsell) Mottling (Structure,Stones,Bouldets.
onsis m `Yo Grave
DEEP 013SER.'V'A.TYON ROLE LOG Role g.
Depthfrom Soil Horizon SoIlTexturo Sall Color Soil Other,
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Ccilslstnylc Gravel)
I DEEP OBSERVATION ROLE r,IJG )91018#
Depth from Soil Hatlzon Soil Texture Sall Color 5oll tither
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stouts;Boulders.
Co si ten 6 '
9
Flood Ynsuran_cerRate Mats:.
Above500 year t(oodboundary No— Yes
"Within 500'year boundary No X Yes
Within 100 year flood boundary No,1 Y6s _
Denth.ofT atnrall.y,Occurring-PerviougMearl-al
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the sail absorption syeteml y�i
If not,what is the depth of haturally occurring pervious material's
Cert%�cation �' .
Z certify that of >(date)Y hava passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training,expertise and experience described in�10 ClUM 15.017.
Signature
• Q:rs.�rTlc�r�lrcna�,n.;7oc -
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U.S.POSTAGE>>PITNEY 130WES
PO*F';Eyy'y�wti Town of Barnstable
Public Health Division —
BARNB "', 200 Main Street
7� O
601 P 02
rFO MP'�� Hyannis,MA 02601 - ZIP
1 $ 006.73'
0001383424 SEP. 22. 2015,
7014 1200 0001 0358 5838
L;
Cynthia Milburn �OLc �����
PO Box 439
Cummaquid,
.. .;<: nsi°�it- �r1-�,,.. y�.. i�rt�'� �ia.i•�v;r',Zi.1a-� �
N RETURN TO SENDER
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SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3. A. Signature 0 Agent
■ Print your name and address on the reverse X 0 Addressee
so that we can return the card to you. j
! ■ Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery
or on the front if space permits.
D. Is delivery address different from item 17 ❑Yes
1. Article Addressed to: ry I
If YES,enter delivery address below: ❑ No
Cynt:hia'* Milburn
i
PO B.o_'439
0immmap d. MA 3.O
it I'I�I'II'll111IIIIIl 6l�3l'7II'll lt Priority
pAu re
❑Adult Restricted Delivery El Registered MRestricted IIIIIII III ' I
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❑Certified WHO Delivery
9590 9403 0232 5146 5387 94 ❑Certified Mail Restricted Delivery ❑Return Receipt for
Merchandise
❑Collect on Delivery
j � ❑Collect on Delivery Restricted Delivery ❑Signature ConfinnationT"'
2. Article Number(rransfer from service labeQ ❑Insured Mail ❑Signature Confirmation
7 014�' *1 it 0- 'b b b], 0 3'5 S 583 8 /, Ins°red Mail Restricted De"very Restricted Delivery
( (over$500) i
Domestic Return Receipt i
PS Form 3811,April 2015 PSN 7530-02-000-9053 ^_ _
UNITED STATES POSTAL SERVICE411 . ..... .....
D`
• Sender: Please print your name, address,and ZIP` 11"phis boke;
1� afG�3rz.�s�61�y
Fri6,ho f!'�a� IJla,�sra.�
zDDdlara,�S � ,�.
FI'icr}i?jcl}}?F:fli�l ??}t?E }}7 i: ?J�li?lEi�?Eit?
COMPLETE •N COMPLETE THIS SECTIONON DELIVERY
■ Complete items.l,2,and 3.Also complete A Sign tGt .�H DE,
item"4'if,.Restricted Delivery is desired. X OJ ❑Age z
■ Print"your name.and address on the reverse ❑Addres ee,
so that we can return the card to you. B..,Recely d b�rinted,Name) 0L�a��f9
■ Attach this card to the back of the mailpiece, V r1N
or on the front if space permits. /y
1. Article Addressed to: D. Is delivery address different fromtite(Pj. ? ❑Yes
If YES,enter delivery address bel .A� ro0
F
ia Milburn
istine Tynan 3, service Type
ox 264 E3 Certified Maii® ❑Priority Mail Express-
South Dennis, MA 02660 ❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑Collect on Delivery
4. Restricted Ddilvery?(Extra Fee) ❑Yes
2. Article Number .- •
(Transfer from service tabeq E 7 14 i 12 0 0 0 0 0'1 F t13 5 8' S 9 6 8 �
PS Form 3811,July 2013 Domestic Return Receipt
p f,Y,II.VYI ,.
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rn Postage $
o S7, 0"
Certified Fee
t3 Retum Receipt Fee
Q (Endorsement Required)Restricted Delivery Fee0 (Endorsement Required)o �J3
1 U Total Postage&Fees . /
Cynthia Milburn (�
i %Christine Tynan
` PO Box 264
South Dennis, MA 02660
I'
Certified Mail Provides:
o A mailing receipt
a A unique identifier for your maitece '
a A record of delivery kept by the Postal Service for two years
important Rem/nders:
n Certified Mail may ONLY.be combined with First-Class Maile or Priority Mail®.
a Certified Mail is not available for any class of international mail.
a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
a For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt,(PS form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for.
a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is
required.
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery°
a If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT.Save this receipt and present it when making an inquiry:
PS Form 3800,August 2006(Reverse)PSN 7530-02.000-9047
IME Town of Barnstable
Barnstable
Regulatory Services Department P
+ iARNSTABLE, * D
9 � ' Public Health Division m
200 Main Street, Hyannis MA 02601 . 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7014 1200 0001 0358 5968
October 28, 2015
Cynthia Milburn
% Christine Tynan
PO Box 264 d
South Dennis, MA 02660
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 108 Palomino Drive,Barnstable,MA was last inspected
on 8/26/2015,by John Graci, Sr, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
o Leaching pit or cesspool with high liquid level,<12" below.inlet(per Town
Code 360-9.1).
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action. .
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean; R.S., CHO
Agent of the Board of Health
QASEPTIC�Letters Septic Inspection Failures or Future Evl\108 Palomino Dr Bam Sept 2015.doc
(CC)
M M ..
art
..
Ln
M Postage $
C3
Certified Fee
r� Postmark
0 Return Race
Fee Here
0 Required)(Endorsement Re w �✓
Restricted Delivery Fee
O (Endorsement Required) p
f1J Total Postage&Fees
r Cynthia Milburn
- �
PO Box 439
Cum are 'd 7
Certified Mail Provides:
o A mailing receipt
n A unique identifier for your mailpiece
n A record of delivery kept by the Postal Service for two years
Important Reminders:
o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mails.1
e Certified Mail is not available for any class of international mail. -
o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
a For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is
required.
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".-
n If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT.Save this receipt and present it when making an inquiry.'
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
f
Town of Barnstable Barnstable
.�. ; Regulatory Services Department Q P
Cft
�ff"� p
9� MAM
639. Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7014 1200 0001 0358 5838
September 22,2015
Cynthia Milburn
PO Box 439
Cummaquid, MA 02637
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 108 Palomino Drive,Barnstable, MA was last inspected
on 8/26/2015,by John,Graci, Sr, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Leaching pit or cesspool with high liquid level,<12" below inlet (per Town
Code 360-9.1).
You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE OARD OF HEALTH
CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\108 Palomino Dr Barn Sept 2015.doc
I
Parcel Detail Page 1 of 6
of stiff 7
x
r Sri` Gfii' t
Logged In As: Parcel Detail Monday,September 21 2015
Parcel Lookup
Parcel Info
Developer —
Parcel ID f297-039 ) Lot OT 87
Location 1108 PALOMINO DRIVE ( Pri Frontage 1148
Sec Road Frontage
village BARNSTABLE � Fire District BARNSTABLE ,r
Town sewer exists at this address I No Road Index 1203
Asbuilt Septic Scan: , Interactive
297039 1 Map
Owner Info
Owner MILBURN, CYNTHIA A I Co-Owner
Streets ,PO BOX 439 Street2
City CUMMAQUID ( State,MA zip F02637 I Country F
Land Info _
Acres ;1.01 � use Single Fam MDL-01 ( Zoning RF-1 Nghbd 10106
Topography!Above Street I. Road fPaved
Utilities 7S_eptic,Gas,PublicWater I Location
Construction Info
Building 1 of 1
Year 1980 Roof ;Gambrel ExtJWood Shinglew
Built struct Wall.
Living 2068 Roof!Asph/F I AC None
Area Cover` Type ;
2 WDK I
Style Int Drywall —""I Bed 3 Bedrooms ms 2D
Wall Rooms uAT 1 gD i
Model Residential Int Hardwood Bath1 Full-2 HalfI r�
Floor Rooms
1s 24`
Grade lAverage l Heat Elec Baseboard l Total ' "�— 1 s BMT ;
Type Rooms- i
stories 1 3/4 Stories _l Heat Electric _.tl Found- Poured Conc.
Fuel ation
Gross;479
Area
Permit History .
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=23725 9/21/2015
Town of Barnstable
snftrrsr.,s1.E, * `
b 9 ,�� Regulatory Services Department
tED MA't�
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 7/6/15
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑Any portion of the cesspool within a Zone 1 to a public well
❑Any.portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
Leaching pit or cesspool with high liquid level,.<12"below inlet(per Town Code
§360-9.1)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
r
' 0
Commonwealth of Massachusetts M� 7:/'/ ' D3.
9
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
i:.O
ll
108 PALOMINO DRIVE F t�j
Property Address
MILBURN CYNTHIA -
Owner Owner's Name 'Q1
information is 02 .0
required for every BARNSTABLE MA 630 08/26/2015
page. City/Town State Zip Code Date.of Inspection
Inspection results must be submitted on this form.'Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:Whenfill A. General Information
on the
out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not JOHN P GRACI SR
use the return Name of Inspector
key.
GRACI SEPTIC INSPECTIONS LLC,'
Company Name
Q PO BOX 2119 -
Company Address
r TEATICKET MA ' 02536
City/Town State,. Zip Code
508-641-6694 S1468
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 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Eval tion by the Local Approving Authority
. 08/26/2015
Inspector's Signature Date.
The system inspector sh II submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 0 days of completing this inspection. If the system is a shared system or
has a design flow of 10,0 0 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate r gional 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.
p vs
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 '
Commonwealth of Massachusetts
W Title 5 Official Inspection Form ;
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
108 PALOMINO DRIVE y
Property Address
MILBURN CYNTHIA
Owner Owner's Name
information is
required for every BARNSTABLE MA 02630 , 08/26/2015
page. City/Town State Zip Code Date of Inspection ,
B. Certification (cont.) x
Inspection Summary: Check•A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found'any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR'l5.304-exist. Any failure.criteria not evaluated are
indicated below.
Comments:, .
NA
13) 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 infiltrationO 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):
NA
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Insp ection `Form s
Subsurface Sewage Disposal System,Form - Not for Voluntary Assessments .
108 PALOMINO DRIVE "
�M -
Property Address
MILBURN CYNTHIA `
Owner Owner's Name ;t
information is gARNSTABLE MA' 02630• '08/26/2015
required for every
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 . 's, ❑ Y: ❑ N ❑ ND (Explain below):
distribution box-is leveled or replaced . ❑ Y ❑ N ❑ ND (Explain below):
NA
a
❑ 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):,' 4
❑ broken pipe(s) are replaced. . '`❑ Y ElN' ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N - ❑ ND (Explain below):
NA
C) Further Evaluation is°Required'by the Board of Health:
r
❑ 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' `
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of'17
Commonwealth of Massachusetts .
W Title 5 Official InspectionForm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments b
108 PALOMINO DRIVE
Property Address
MILBURN CYNTHIA
Owner Owner's Name
information is required for every BARNSTABLE MA _ 02630 08/26/2015
page. City/Town State Zip Code Date of Inspection
I 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: NA
A.
**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:
NA
D) System Failure Criteria Applicable to All Systems: `
R
You must indicate "Yes" or"No"-to each of the-following for all inspections:
es No
El ® Backup of sewage into facility'or system component due to overloaded or - .
clogged SAS or cesspool
El ® 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 town overloaded -
® or clogged SAS or cesspool
.Liquid depth in cesspool is less than 6" below invert or available volume is less <'
❑ ® than '/z day flow x
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection, Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
108 PALOMINO DRIVE
Property Address µ _
MILBURN CYNTHIA
Owner Owner's Name
information is required for every BARNSTABLE MA 02630 08/26/2015
-
page: City/Town State 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 private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or,less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow_ of 2000gpd-
10,000gpd:
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303i 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
El system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA),or a mapped Zone 11 of"a'public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the'large system has failed. The owner or operator of any large -
system considered,a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection `Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M J•'' 108 PALOMINO DRIVE
Address Property dd ess
,
Y
MILBURN CYNTHIA
Owner Owner's Name
information is required for every BARNSTABLE ' MA- 02630• 08/26/2015" -
page. Citylrown State Zip Code Date of Inspection
C. Checklist p
Check if the following have been done. You must indicate'"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal-flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this.inspection?
® ❑ Were as built plans,of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ 'Were the septic tank manholes.uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid; depth of sludge.and depth of scum?
El information
the facility owner(and occupants if different from owner) provided with
information on 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
El
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 bed rooms)°:.; 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r
§, 4y
Commonwealth of Massachusetts
W Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form= Not for Voluntary Assessments
,M 108 PALOMINO DRIVE
Property Address
MILBURN CYNTHIA ,
Owner Owner's Name a t
information is required for every BARNSTABLE MA 02630 08/26/2015 -
,
page. City/Town State Zip Code Date ofInspection
D. System Information
Description:
1000 GALLON SEPTIC TANK DISTRIBUTION BOX AND 1000 GALLON LEACH PIT
Number of current residents: 2
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? _ Z Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2` ears usage d TOWN
9 ( Y 9 (gP ))� .
Detail
• Sump pump? ❑ Yes ® No
5 Last date of occupancy: _. OCCUPIED.
Y Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203). NA
auons`per day(gpo) '
Basis of design flow (seats/persons/sq.ft etc.): NA
Grease trap present? ❑ Yes ❑ No
'Industrial waste holding tank-present?,- ❑ Yes ❑ No
Non-sanitary waste discharged to th'e Title 5 system? ❑ Yes ❑ No .
Water meter readings, if available: " NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 108 PALOMINO DRIVE
Property Address
MILBURN CYNTHIA
Owner Owner's Name
information is BARNSTABLE MA 02630' '08/26/2015
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information,(cont.)
Last date of occupancy/use. r NA
- Date
Other(describe below):
NA
General Information
Pumping Records:
Source of information:' NA
Was system pumped as part of the inspection? ❑. Yes Z No
If yes, volume pumped: NA
gallons
How was quantity pumped determined? NA
Reason for pumping: NA
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 operatorunder contract
❑ Tight tank. Attach a copy of the DEP approval.
Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
,M 108 PALOMINO DRIVE
Property Address
MILBURN CYNTHIA.
Owner Owner's Name
information is
required for every BARNSTABLE t •MA: 02630 08/26/2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information '(cont) .4 -
Approximate age of all components, date Installed (if known) and source of information:
1980
Were sewage odors detected when arriving at the site? ❑. Yes ® No
Building Sewer(locate on site plan): ,
Depth below grade:, 22 INCHES
P g feet
Material of construction:
E] cast iron ® 40,PVC ❑ other(explain):
Distance from private water supply well or suction line: GREATER THAN_10+'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
SYSTEM APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME
OF INSPECTION
Septic Tank (locate on site plan):; _
Depth below grade: 16INCHES
P g feet'.
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑'polyethylene. ❑ other(explain)
NA
If tank is metal, list age: NA
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) b ❑ Yes ❑ No
Dimensions: 1000 GALLON
Sludge depth: (8) EIGHT INCHES
r
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts _
F Inspection f rm W Tale 5 Official Ins- ect o o
. p
Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments
°M 108 PALOMINO DRIVE
Property Address
MILBURN CYNTHIA
Owner Owner's Name V
information is required for every BARNSTABLE MA 02630 08/26/2015
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.),, A
Distance from top of sludge to bottom of outlet tee or baffle (26)7WENTY SIX INCHES
Scum thickness (3) THREE INCHES
Distance from top of scum to top of outlet tee or.baffle
(6) SIX-INCHES ,
Distance from bottom ofsscum to bottom of'outlet tee or baffle NA
How were dimensions determined? MEASURED
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, "
liquid levels as related to outlet invert, evidence of leakage, etc.):
SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT
TIME OF INSPECTION. RECOMMEND.PUMPING EVERY TWO YEARS`
Grease Trap (locate on site plan):
Depth below grade: NA
• feet `
Material of construction:
El concrete ❑ metal ❑ fiberglass ❑ polyethylene - ❑ other(explain): -
NA -
Dimensions: - NA
Scum thickness NA
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
Date of last pumping: NA
Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
i
i
Commonwealth of Massachusetts '
L W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
108 PALOMINO DRIVE_
Property Address
MILBURN CYNTHIA
Owner Owner's Name
information is
required for every BARNSTABLE MA '02630 08/26/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont:)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
NA
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: . ' NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene -❑other(explain):
NA
Dimensions: NA
Capacity: NA
. gallons ,
NA
Design Flow: R
gallons per day
Alarm present: ❑ Yes ❑' No
Alarm level: NA Alarm in working-order; ❑ Yes ❑ No
Date of last pumping: . . NA'
Date
Comments(condition of alarm and float switches,etc.):
NA
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts .M
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M
108 PALOMINO DRIVE
Property Address
MILBURN CYNTHIA
Owner Owner's Name r
information is
required for every BARNSTABLE MA 02630 08/26/2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert BOTOM OF PIPE
k
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.):
DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND_ AND FUNCTIONING
PROPERLY AT TIME OF INSPECTION.°
Pump Chamber(locate on site plan):
Pumps in working.order: . ❑ Yes ❑ N'o*
Alarms in working order: ❑ Yes' ❑ No'
,Comments (note condition of,pump chamber, condition of pumps and,appurtenances, etc:):
NA
" If pumps or alarms are not in working order, system,is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
NA
t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
108 PALOMINO DRIVE
Property Address
MILBURN CYNTHIA
Owner Owner's Name
information is BARNSTABLE MA 02630 08/26/2015
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
Z. leaching pits - number:
❑ leaching chambers number.
❑ leaching galleries s number:
leaching trenches% number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system, -
Type/name of technology;
Comments (note condition of soil, signs of hydraulic failure, level of.ponding, damp soil, condition of
vegetation, etc.):
(1) 1000 GALLON LEACH PIT WAS FULL AT TIME OF INSPECTION
Cesspools (cesspool-must be pumped as part of inspection) (locate on site plan):
Number and configuration NA =
Depth —top of liquid to inlet invert NA
r Depth of solids layer NA
Depth of scum layer NA
Dimensions of cesspool NA
Materials of construction NA
Indication of groundwater inflow, .❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
F
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form = Not for Voluntary Assessments
108 PALOMINO DRIVE
Property Address
MILBURN CYNTHIA
Owner Owner's Name
information is gARNSTABLE MA 02630 08/26/2015
required for every
page. City/Town State Zip Code Date of.lnspection
D. System Information (cont.)
Comments (note condition of soil, signs of-hydraulic failure,'level of ponding, condition of,vegetation,
etc.):
NA
Privy (locate on site plan):
Materials of construction: NA
Dimensions NA
Depth of solids NA
Comments (note condition of soil, signs'of hydraulic failure level of ponding, condition of vegetation,.
etc.):
NA
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form y
Subsurface Sewage Disposal System Form- Not for.Voluntary Assessments
,M 108 PALOMINO DRIVE `
Property Address r
MILBURN CYNTHIA
Owner Owner's Name }°
information is required for every BARNSTABLE MA' - , 02630 08/26/2015.
,
page. City/Town State Zip Code Date of Inspection
D. System Information (cost) -
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
DWY� t v f
of I`
• ,�2- 35g
3 n3-42
h4 = 53
0to
4 .64 q4q
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:'Page 15 of 17
Commonwealth of Massachusetts -
W Title 5 Official Inspection' Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
108 PALOMINO DRIVE "
Property Address _
MILBURN CYNTHIA•
Owner Owner's Name
information is required for every BARNSTABLE MA 02630 08/26/2015
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water .
❑ Check cellar
❑ Shallow wells F
Estimated depth to high ground water, 12+ FEET
„ 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: -
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked.with local Board of Health -explain: ,
ASBUILT OBTAINED
❑ Checked with local excavators,installers- (attach documentation)
❑ Accessed'USGS database -explain:
You must describe how you established;the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
108 PALOMINO DRIVE .
Property Address
MILBURN CYNTHIA
Owner Owner's Name
information is required for every BARNSTABLE MA 02630 08/26/2015
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
w
`
i
TOWN OF BARNSTABLE
BOARD OF HEALTH,
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION w
Date 3 ` I Time: 'In Out
Owner C YN-f H (A .M 1 LR-AA 14 Tenant Vic)Mmu„ &"&):D1L-
Address ®� �l�q Address t08 , P14I-O nij1 )o D 41 yCC
CUY40A►emu ,I- . MA :02431 1 1/ wsT(481,6 , MA
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities f
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities , &tic v C
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing
18. Driveway Width 6 aA `D rTZ
19. Number of Tenants Observed PA
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms 3 Number of Vehicles Allowed
Number of Persons Allowed (max)
Person(s) Interviewed Otooe(L Inspector
If Public Building such as Store or Hotel/Motel specify here
I
COMMONWL;AI:L`.H: OF MASSACH:USETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
PARCEL
LOT
Map: 09 Lot:
Par: �39
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_108 Palomino Dr.
_Barnstable_ C
Owner's Name: O'Keefe_ APp 2
Owner's Address: —same TO 2�04
WN OF e
Date of Inspection:_4/16/04 NFALTdEgeLF•-
Name of Inspector: Dion C. Dugan
Company Name:_ 1543 Main St.
Mailing Address: Brewster,MA 02631
Telephone Number:_508-896-9390 t
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes q
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
•q 4
Inspector's Signature: Date: !G
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments: *Recommend: Maintenance,pumping 3—5 yrs.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
I'age 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_108 Palomino Dr.
_Barnstable_
" Owner's Name:_O'Keefe -
Date of Inspection: _4/16/04_
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_ 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:
B. System Conditionally Passes:
N/A One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health;will pass.
Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health): - .
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health): .
broken pipe(s),are replaced „
obstruction is removed
ND explain:. .�
tr
w
Page 3 or I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) -
Property Address:_1.08 Palomino Dr.
_Barnstable_ „
Owner's Name:_O'Keefe_
Date of Inspection:_4/16/04_
C. Further Evaluation is Required by the Board of Health:
N/A 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 15303(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
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 coliform
bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility 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:
Page 4 of
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_108 Palomino Dr. t
_Barnstable_
Owner's Name:_O'Keefe
Date of Inspection:_4/16/04_
f .
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
— _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool •
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). "
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. ,
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. -
- _X_ Any portion of a cesspool or privy is within a Zone I of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. -
_X_ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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 forma
_NO_(Yes/No)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: N/A
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_N/A_ the system is within 400 feet of a surface drinking water supply
_N/A_ the system is within 200 feet of a tributary to a surface drinking water supply
_N/A_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)ora'mapped
Zone 11 of a public water supply well
Ifyou 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.
i
Page 5 of 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_108 Palomino Dr.
_ Barnstable
Owner's Name:_O'Keefe_
Date of Inspection:_4/16/04—
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks
_X_ _ Has the system received normal flows in the previous two week period
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection
_X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up
_X_ _ Was the site inspected for signs of break out
_X_ _ Were all system components,excluding the SAS, located on site
_X_ _ 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
_X _ 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:
Yes no
_X_ _ Existing information. For example, a plan at the Board of Health.
_X_ _ 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(3)(b)]
Page 6 of I
r --
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM`:''`
PART C
SYSTEM INFORMATION
Property Address: 108 Palomino Dr.
Barnstable
Owner's Name: _O'Keefe_
Date of Inspection:_4/16/04_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3— Number of bedrooms(actual):-3_ r r
DESIGN flow based on 310 CMR 15.203 (for example: 1,10 gpd x#of bedrooms):_330e d"
Number of current residents:_2 ,
Does residence have a garbage grinder(yes or no): =
Is laundry on a separate sewage system es or no): no if yes separate inspection required]
x "
Laundry system inspected(yes or no):_no
Seasonal use: (yes or no):—no—
Water meter readings, if available(last 2 years usage(gpd)) 2002: 1 i 1,000 2003: 1 e7000
Sump pump(yes or no):_no_ fi
Last date of occupancy: OCCUPIED—OCCUPIED
e
COMMERCIAL/INDUSTRIAL: N/A
r
Type of establishment:—N/A �
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available: « ,. "
Last date of occupancy/use:
r s
OTHER dr • .
(describe):
GENERAL INFORMATION ,
Pumping Records
Source of information: /L
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons=-How was quantity pumped determined? .' " r4
Reason for pumping: '
TYPE OF SYSTEM
X_Septic tank,distribution box,soil absorption system,
_Single cesspool
_Overflow cesspool
_Privy
NO 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)
Tight tank _Attach a copy of the DEP approval
_Other(describe): -
Approximate age of all components,-date installed(if known)and source of information: }..
_Installed_10/8/1980 (24 yrs.old)^B.O.H. Records
y - _ Were sewage odors.detected when arriving at the site(yes or no): NO -
Page 7 of I I +
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_108 Palomino Dr.
_Barnstable_
Owner's Name:_O'Keefe
Date of Inspection:_4/16/04_
BUILDING SEWER(locate on site plan)
Depth below grade:_30"_
Materials of construction:_cast iron _X_40 PVC other(explain):
Distance from private water supply well or suction line:_N/A
Comments(on condition of joints,venting,evidence of leakage,etc.):
_Joints are tight,venting is through the roof,no signs of leakage.
SEPTIC TANK:—YES—locate on site plan)
Depth below grade:_18" outlet cover built up Win 5"
Material of construction:_X_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) a
Dimensions: 1000 Gallon_
Sludge depth:_7"_
Distance from top of sludge to bottom of outlet tee or battle: 23"
Scum thickness:_1"_
Distance from top of scum to top of outlet tee or baffle:_6"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined:_by tape and rod
Comments(on pumping recommendations, inlet and outlet tee or battle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Recommend tank be pumped next year.Tank and tees in good condition,no sign of leakage.
*Recommend: Maintenance pumping every 3—5 yrs.
GREASE TRAP: N/A locate on site plan),
Depth below grade:_
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: y
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
i
Y
Page 8 of
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_108 Palomino Dr.
_Barnstable_
Owner's Name:_O'Keeic_
Date of Inspection:_4/16/04_
TIGHT or HOLDING TANK:_N/A_(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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or.no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:_YES_(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 level with some signs of carry over and no signs of leakage
PUMP CHAMBER:_N/A—(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 108 Palomino Dr.
_Barnstable_
Owner's Name:_O'Keefe_
Date of Inspection:_4/16/04_
SOIL ABSORPTION SYSTEM (SAS):_YES_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: one 6'x 6'w/stone_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): it found w/45" liquid in it,no staining,no sign of failure.
CESSPOOLS: N/A_(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: a
Materials of construction:
Indication of groundwater inflow(yes or no) a .
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc):'.
*Recommend: Maintenance pumping every 3—5 yrs.
PRIVY:_N/A(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.):
0
}
Page 10 of I I ,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_108 Palomino Dr.
_Barnstable_ r
Owner's Name:_O'Keefe_
Date of Inspection:_4/16/04_ r .
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties,to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
IN
A R ;
G,9•RAG� Nis �4�° : ' , '
d A - S2C.
5 3, .
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Page 1 1 of 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_108 Palomino Dr.
_Barnstable_
Owner's Name:_O'Keefe_
Date of Inspection:_4/16/04
SITE EXAM
Slope
Surface water -
Check cellar
Shallow wells
Estimated depth to ground water 28 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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)
_X_Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
By U.S.G.S.Atlas H A—692.
Pry a
LOCATION SELVAGE PERIRIT N0.
VILLAGE
INSTA LLER'S NAME i ADDRESS
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® U 1 DER OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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DAt.E C0MPLIANC:E ISSUtE.O_ /
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No...........2... .. Fps... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................
V.........OF.....
Appliratiou for Mipasal Morkii Tontitrurtion Prrutit
Application is hereby made for a Permit to Construct (V)'or Repair an Individual Sewage Disposal
System at:
aan.q.....Dsuv.-E;........... .........sam,41,90LA6f------------------------------------------------------------------
Location-Address or Lot No.
PQk,,c---- e.c--a,,. .A---------------------------------------------- .................................................................................................
ner
Address
!E_7---------------------------- ....... 4W...r ........................
Install
Address
Type of Buildings Size Lot_: _; _ -_-_-Sq. feet
U
Dwelling�Ko. of Bedrooms._...._..... .Expansion Attic Garbage Grinder
Other—Type of Building .... -------------- No. of persons...._!A5!4------------ Showers Cafeteria
Otherfixtures --------------------------------------------------------------------------------------- -------------------------------------------------------------
Design Flow..... ..... ........gallons per person per day. Total daily flow......................33.0...........gallons.
1:4 Septic Tank—Liquid capacity.,?66.0.gallons Length................ Width................ Diameter__-----____--__- Depth....__.._.......
Disposal Trench—No..................... Width_................... Total Length.................... Total leaching area....................sq. ft.
> ...... ............ Depth below inlet........
Seepage Pit No --- ---0 L----- Diameter---- Total leaching area.___.R.O.Lsq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by..__ ................................ Date.......YJAJA.0..............
Test Pit No. ...minutes per inch Depth of Test Pit____--_-La----- Depth to ground water...............
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
.............................................................................................................................................................
0 Description of Soil----a......... .............. -------.-J.P---I------ ......... .......Mk.P.5�"V
-----------------------------------------------*---------------------------------*----------------------------------------------------------------------------------------------*--------------------
---------------------------------------------------------------------------------------------------------------------..................................................................................
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'TTL_ 5'of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been�u d b the boar 4 of health.
Sig ..... ....
Application Approved By.......... ......... ... . ...............
Date
Application Disapproved for the following reasons:..............................................................................................................
........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
µ _
No....- .1. . Fims....:�w.f ...
r THE COMMONWEALTH OF MASSACHUSETTS
g BOARD'' OF HEALTH
r ', ----..................OF..........f;�NR.KSJ.A.Vle...--------- ..................
r
Appliration for Uhq�vii al Works C�g�muurtinn rrntit
Application is hereby made for a Permit to Construct (V,<or Repair ( ) an Individual Sewage Disposal
System at
�..........=-............................_.........................._..---• --------
Location• No.
Tess or Lot o.
........:....L_ -_...Y..h. S'r..L�S ...................................... ......_.._..........---••---•-•
C�w er Address
,Wa ...............S,0.�... ...... 0�_ _�_ ...................................... ............ ._..,,.__---------------------------_________________-_-----__-------
Installer Address
3 7 a�
d ,Type of Building Size Lot..__Y...i................Sq. feet
Dwelling-�--No. of Bedrooms.._' . ...............Expansion Attic ( ) Garbage Grinder (
to.
p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ----------------------------...............................
Design ____...Flow S5................ .......gallons per person per day. Total daily flow.............• �_.Q..................gallons.
W ...IOd
WSeptic Tank V Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width_X---__-_____•_ Total Length.................... Total leaching area......... 'a
sq. fC
�p_j_
3 Seepage Pit No------------- Diameter.-...P........... Depth below inlet........6....__.. Total leaching area................ ft.
Z- Other Distribution box ( Dosing tknk ( )
Percolation Test Result, •a Performed by......-._ o: G__________________________________ Date.._.____.: �01 ..............
,•' r-
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.___t?.,.? .........
Gi. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .................. ......................•..........................................................................................................
Description of Soil-----Qo1J......L.040 --- =--•----------..a=.:F---- '",� �.r,�k.............
`�"13 Yr!��l SG•�/�
,..
W
UNature of Repairs or Alterations—Answer when applicable---------------------------------------_--_--_----________--___-_- _---___-_;____________.
------------------------------------------------------------------------------------•••............--•-•------•-----•----•-----••••-----•--•--•-- ....................................................
Agreement: "' 4
p The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T i`T L E
p ; • 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' d by the board of health.
Sign ------•-•--- ........� ...
� ,,11(
A licat on A roved B -^ `-- fi ti •-/ ��-- -----
Date
Application Disapproved for the following reasons____________________________________________________________________________________________ ___________________
--------------•--=--------•-----•----------•---------------••-------------------.........----------•--=-••-------•-••----•-••-••---•-•--••.................... ------ --------------------
' Date
• i'
hermitNo.....................................................---• Issued_........................................................
R` Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... 7--e-v>1........OF............ .....
(Intifiratr of (Sputpliatta
T. IS S TO RTI ghat the Individual Sewage Disposal System constructed ( 'Tor Repaired ( )
b
--------------• ........---•---- --••..................... .
nstall
•-'=----- �-------.+-
has been installed i accordance with the provisions of T j ftT State Sanitary Cade As ibed in the
application for Disposal Works Construction Permit No
--------- dated--...--....1...................................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............1� 8D Ins pector.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
j ......... OF............. ....:...�'�.'.....................--•-----•---............
(9;Z
No..........••.....--..... FEE................••......
I) n-
r _Permission i�et''be y granted � ------- -"'`` ----------------------•---•- -----------•---...-•-- --......-•------
to Construc _ ( ) rpRepair � d' id al Sewa y%=Iem
at No._•--`--. l ' ! �
Street P—/—A .
as shown on the application for Disposal Works.Construction Per t� o.__ _._ ..tAted..........................................
/........ � Board of Health
DATE-------- / -•-•......:..........I..-•-------......:
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
IOT S43
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SYSTEM DESIGN: SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES anti,
LEGENDMARKED WITH MAGNETIC TAPE OR e
GARBAGE DISPOSER IS NOT ALLOWED PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION, 1. DATUM IS NAVD 88
99— EXISTING CONTOUR ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GR40E O� a
X 99•7 EXIST. SPOT ELEV. EXISTING 3 BEDROOM DWELLING TOP FOUND. EL. 120.3' FILTER FABRIC OVER STONE 2 MUNICIPAL WATER IS EXISTING
vOce � 4 0
0
99 PROPOSED CONTOUR DESIGN FLOW: 3 BEDROOMS 0 110 GPD = 330 GPD MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 12O' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
V
NOTE. 2" MIN. WALL 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS
USE A 33O GPD DESIGN FLOW THICKNESS REQUIRED BLOCKS OR TO BE AASHO H-M
198.41 PROPOSED SPOT EL. 11$.07' 4"�SCH40 PVC MORTAR ALL PRECAST RISERS
TH1
R; E
PIPES LEVEL 1ST 2' COMPONENTS H-1 5. PIPE JOINTB TO BE MADE WATERTIGHT.SEPTIC TANK: 330 GPD (2) = 660 JTEE
cN4o Pvc 4' (TYP.) INVS EL. 116.30SIDESTEST HOLE ENDS SIDES 0 BE IN ACCORDANCE WITH**USE EXISTING 1000 GAL. SEPTIC TANK ° °°°°2% SLOPE OF GROUND ° ° ° ° 6 CONSTRUCTL N DETAILS T: EXISTING o 0 0 0SEPTIC TANK�� 116.67 * o ° ° ° ®®®® ®®® ®®®® —��®® >°°°°o°o° 310 CMR 15.Of10 (TITLE 5.) ouS/j°O
$" MIN. SUMP ;°00000000 ®®®®®®®®�®® ®®®®®0�1�®®® ;°oo°oo°000°o e QC s
°°°°°°°°°°°° 12" MIN. INT. DIM. ° ®®®®®®®® �� OO®®®®���®0® ° ° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
GAS BAFFLE a ' °°ba4+°o°- o°o°o°o° °°°°°°O° Br099
LEACHING: N ° ° ° ° BE USED FOR LOT LINE STAKING OR ANY OTHER
c� UTILITY POLE '°°°°°°°° ®®®�®®®®"�� ®®®®�®���®® �00000000 PURPOSE. m
�7" FIRE HYDRANT SIDES: 2 (25 + 12.83) 2 (_74) = 112 GPD - 116.57' 1 16.40' °°°°°°°° " ° ° ° °
° ° ° ° °°°°°°°°
L EL. 114.3 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
NOTE NOT ALL SYMBOLS MAY APPEAR IN DRAWING BOTTOM 25 X 12.83 (.74) = 237 GPD H-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. n+
3/4"-1•-1/2" DOUBLE WASHED STONE 4' MIN. (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
TOTAL: 472 S.F. 349 GPD 6" CRUSHED STONE OR MECHANICAL ALL AROUND PRECAST STRUCTURES WITHOUT INSPECTION BY BOARD OF HEALTH AND E Locus
OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00 X 12.83' PERMISSION OBTAINED FROM BOARD OF HEALTH.
USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
COMPACTION. (15.221 [21) C)
10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
*THE INSTALLER SHALL VERIFY THE WITH 4' STONE ALL AROUND DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCUS MAP
LOCATIONS OF ALL UTILITIES AND ALL LOCATION. OF ALL UNDERGROUND & OVERHEAD UTILITIES
BUILDING SEWER OUTLETS AND
ELEVATIONS PRIOR TO INSTALLING ANYRIOR TO COMMENCEMENT OF WORK.
11s.3' V.I.F.v.I.F. NOT TO SCALE
( 1 % SLOPE) ( 1 % SLOPE) GROUNDWATER EXPECTED
PORTION OF SEPTIC SYSTEM MA BELOW EL. 106' 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
LEACHING REMOVED 5' BENEATH AND AROUND THE PROPOSED ASSESSORS MAP 297 PARCEL 39
APPROVED DATE BOARD OF HEALTH FOUNDATION— EXIST. SEPTIC TANK 10' D' BOX 12' FACILITY LEACHING FACILITY.
12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
**INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT
1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE
WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE
CONDITIONS IF NOT SUITABLE
TEST HOLE LOGS
ENGINEER: CRAIG J. FERRARI, SE #13871
V WITNESS: DAVID W. STANTON RS
11 16 2015
Jo7 i W DATE: / /
w PERC. RATE _ < 2 MIN/INCH
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DWELLING 120" 110' 120" 110'
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120 NO GROUNDWATER ENCOUNTERED
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BENCHMARK: A 97
SITE PLAN
OR. POOL APRON PARCE 9 TITLE
20 0 NAVD88 x ''9 7. 0 AC
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#108 PALOMINO DRIVE
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DATE: NOV. 16, 2015
— Scale: 1"= 20'
0 10 20 30 40 50 FEET'
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DANlEt A .0� DANIELA. y o DANIEL�+ A. �, downcope.com
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CIVIL.. CIVIL fl o.40.ab0
A No.4098 1
No.46502 FFs , o/a y
�r o of o� civil engineers
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Fss/ S �N�,� v ��E� _, land surveyors
o L 939 Main Street ( Rte 6A)
DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675
LICE # 15-317
15-317