HomeMy WebLinkAbout0059 SHALLOW POND DRIVE - Health 59 Shallow Pond Drive
Barnstable
A = 234 080
t / h
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered incomputer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpplitatlon for Misposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair(&6"pgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. rl 5/4//o w ,,- DQ Owner's Name,Address,and Tel.No. flou y iq f 7 32
euz .tf-v vtrflt S'of // f
Assessor's Map/Parcel 3 — p$� ��v!:/ ?pC>vt V c� �
Insta er's Name,Address,and Tel. o. 3 y �J�iY Designer's Name,Address,and Tel.No.
� je�.�c�rt0 �ck�rrj
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) s'—°'9 r Zee, !.(,
Date last inspected: g'/ A
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 of to 1 e system in operation until a Certificate of
Compliance has been issued by this Board of Hea
Si e Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. /6 Date Issued 3 b
i _ . .4 ., e. •— ... —. x�r1^w.::,..��...fi".: • J"^"''+ t'......rk,yA.M^ . � r.,� '.t„Y+e,'� •.
i No /rG dL 1p > v f t :r 7
Fee
' THE COIVIMOKWEALTH OF MASSACHUSETTS Ent6.-d c'omputer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpplitation for Disposal *pstrm Construction permit
Application for a Permit to Construct( ) Repair(`0 Upgrade( ) Abandon( ) ❑Complete System Of. Individual Component
w,
Location Address oi•Lot No. .-�j Sk-110 w, 6.41 e)a Owner's Name,Address,and Tel.No. J%o-j 1 c f
i !
Assessor'sMap/Parcel Buz nfi 3"fle�C�' O � 5����UW A�Grr� �/
Installer's Name,Address,and Tel.I�Jo. YJ ?,C
( ¢ (f r/'JS' Designer's Name,Address,and Tel.No:
�w-V eL,, iD c
/''a t`l� S�� t•t, ri ryta u�y a� o a�d/ - '
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons rr Showers( ) Cafeteria( )
Other Fixtures r� !
Design Flow(min.required) 3 `} gpd Design flow provided gpd A
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) _�e g l C4, u
Date last inspected: T"/ 7 A ,
Agreement:
i. Theundersigned 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 .d-n`ot to place-tNe--system in operation until a Certificate of. '
Compliance has been issued by this Board of Heal h.
Signed .T- Date 0 7 V� _
Application Approved by Date ' .
Application Disapproved by Date
for the following reasons
1 ys
Permit No. C�rU tG !!p Date Issued i ,3 ` �0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Ste'` Certificate of Compliance
THIS IS TO CERTIF11Y,that the On-site Sewage Disposal system Constructed
n( ) Repaired( � Upgraded(. )
Abandoned( )by t� OJv M �j
at- n7 Li c. /f o W �.r I,74L Ceh i has been constructed in accordance-
with the provisions of Title 5 and the for Disposal System Construction Permit No?-'-_/i1"-C b dated
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit shal not be construed as a guarantee that the system wil f nctibn as design�ld.
� Date Inspector /(, �i �
r
No. c_p "o Y Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
5�a.- �csposaY �pstetn construction hermit
Permission is hereby granted to Construct( ) Repair(W11 Upgrade( ) Abandon( )
System located at �/' .�� G//G v g le-e!
i
[A 4
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.
Prbvided:Construction must be co pleted within three years of the date of this permit.
Date i`r I / Approved y
x?. 4
AsBuilt Page 1 of 1
.G / TOWN OF BARNSTABLE
LOCATION_'L6- Z.A S> 0. 0 Pt Q-9 SEWAGE #Q �o
PILLAGE CaUll_p_u tr ASSESSOR'S RAP & LOT4o
d•INSTALLER'S NAME Si PHONE NO. kilc'xc�'`( Op,�i "�7� L `
SSEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) i3O--;�bl
NO. OF BEDROOMS Z PRIVATE WELL R PUB�WATER
UILDER R OWNER N�CK�La►c�
DATE PERMIT ISSUED: r/t jyy =
DATE COMPLIANCE ISSUED: 6 9
VARIANCE GRANTED: Yes -No
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=234080&seq=1 8/26/201.6.
Commonwealth of Massachusetts a<3 / 090
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
tic .N 59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name Q}
information is /Ip �
required for every Cet�teville g�'/ ' QU/L Ma 02632 8/17/16
page. City/Town State Zip Code Date of Inspection
CT1
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
54* ��7
on the computer,
use only the tab 1. Inspector:.
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
/Q Company Name
8 Johns path
Company Address
S Yarmouth Ma 02664
City/Town State Zip Code
508-364-9587 S103522
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 Conditional) Passes Fails 1
❑ Needs Further Evaluation b -Local Approving Authority
8/22/16
In ector's Signature Date
The system inspector shall submit a co of this ins ection report to the Approving Authority Board
Y P copy p , •, p Pp 9 Y
of Health or DEP) within 30 days of completing thFis•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 a _ rovin authorit , 4"
****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 systemwill perform in the future under
the same or different conditions of use
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
e
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 59 Shallow Pond Dr
ej, Property Address
Douglas Gladding
Owner .t Owner's Name
information is ' Centerville Ma 02632 8/17/16
required for every
page. ,,,; City/Town State Zip Code Date of Inspection
.x
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every 63 Centerville Ma 022 8/17/16
page. Cityrrown 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 breakout 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):
System contains a 1,000 GI Septic,tank as well as a concrete distribution box and a 1,000 GI leach
pit. System is functioning properly at this time however the tank is leaking at the seem and needs to
be sealed.
❑ The system required pumping more than 4 times a year due to broken.or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑'Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,^M 59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
page. City/Town 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 cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary,Assessments
°M 59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma, 02632 8/17/16
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
El ® tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 1.5.303, 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. /
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form _
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
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 N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
E ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
N Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description.-
System contains a 1,000 GI Septic tank as well as a concrete distribution box and a 1,000 GI leach
pit. System is functioning properly at this time however the tank is leaking at the seem and needs to
be sealed.
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? ® Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
189 Gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: None provided
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑. Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 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
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:, 2
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.):
Tank is leaking
Septic Tank(locate on site plan):
Depth below grade:. 1.5feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is
required for every Centerville Ma 02632 8/17/16
page. City/Town 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
24"
Scum thickness 3
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Evidence of leaking
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas Gladding y.
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
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.):
Tank is leaking
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form y
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
page. City/Town 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 Level and at normal level
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ac^ 59 Shallow Pond Dr
M
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
page. Cityrrown 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:
❑ 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.):
Pit is dry and functioning properly
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas GIaddi n
9
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
page. City/Town 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.):
No ponding no break out
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.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
8/25/2016 Assessing As-Built Cards
F c-, %Sg TOWN OF BARNSTABLE
LOCATION t45 Z4� SNA A,, M (Lb SEWAGE# -a';M .
7��VILLAGE ' ,��� ASSESSOR'S MAP G LOTy`�0 -
ONI STALLER'S NAME Q PHONE NO. NkLQX Gz
(iSEPTIC TANK CAPACITY
LEACHING FACILITY:(type) O i7-- (size)
-
)NO.OF BEDROOMS _PRIVATE.WELL R PUBLICW
UILDER R OWNER
DATE PERMIT ISSUED: 7y
DATE COMPLIANCE ISSUED: 6 4 9
VARIANCE GRANTED: Yes No
a i
s
http://www.townofbarnstabl e.us/Assessi ng/H M di spl ay.asp?m appar=234080&seq=1 1/2
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16.
page. Cityrrown 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
I'p 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.
t5ins•3113 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
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is required for every Centerville Ma 02632 8/17/16
page. CitylTown 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: 10+ ft
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: 5/6/94
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:
Test hole data on plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Shallow Pond Dr
Property Address
Douglas Gladding
Owner Owner's Name
information is Centerville Ma 02632 8/17/16
required for every
page. Cityrrown 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
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Date: 2 L,:;Lz6
TOXIC AND HAZARDOUS.- MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: n k;tA „� wci
BUSINESS LOCATION:
MAILINGADDRESS: v Q Mail To:
TELEPHONE NUMBER: 5 �� �3 ��'" Board of Health
Town of Barnstable
CONTACTPERSON: P
EMERGENCY CONTACT TELEPHONE NUMBER: �v �-- �fa-�- �d Hyannis, M 02601
TYPEOFBUSINESS: 5 0 9 4;-
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES NO k
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. ry. I EED
Quantity Quantity I
Antifreeze(for gasoline or coolant systems) Drain cleaners i 2003
NEW USED Cesspool cleane�1
Automatic transmission fluid Disinfectants
_Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED p (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine _
Rustproofers Lye or caustic soda-z— '- F
L
Car wash detergents Jewelry cleaners _ _�-
Car waxes and polishes Leather dyes..
Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes> PCB's -�
Lacquer thinners ,�
Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor& furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
C �/ TOWN OF BARNSTABLE
LOCATION ' Zg (Z9) SEWAGE # & -o' z
p VILLAGE Q-/cA[C ASSESSOR'S MAP & LOT4 q0
Id",INSTALLER'S NAME & PHONE NO. Q .' VT' kZA
1
ASEPTIC TANK CAPACITY
do,
EACHING FACILITY:(type) lam. (size) a
NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER
OEDjR R.OWNER t-1
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: G 4
VARIANCE GRANTED: Yes No
i
�. �
��. � (`�
' ��I ' �
C[
S
No... .- �s..........�.o. .
THE COMMONWEALTH OF MASSACHUSETTS
? 5y �- BOAR® OF HEALTH
TOWN OF BARNSTABLE
Applirtttiutt for Uiupwial Wurlw Tugttitrurtiun reruti#
Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal
System at:
......................... ..�... .... ...--•---------. ---••--•••--•••--•--------•-------•---------•--•--••-......_...---....---------•--....._.....-•-•-
/VOV� /sV�A ._ /� or Lot No.
-•tom
••-•----- ..
s_ . .......................
-- - ------ -- --- ----
ow Address
... .. ...................
Installer Address
Type of Building Size Lot.. ...
_ ��.Sq. feet
,., Dwelling—No. of Bedrooms..... .............................._..E�pansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fix res ..--•---------------•---------
Design Flow...//0-A.M ------------gallons per person per day. Total daily flow......3,3 a........................gallons.
0� Septic Tank—Liquid capacrty4. . ..gallons Length,/ .�....---. Width.-S-6:.-... Diameter................ Depth... . ...
Disposal Trench--No. ...........14!4. Width.................... Total Length.................... Total leaching area. ........._.sq. ft.
Seepage Pit No...-.OAf, ...... Diameter.... C1.`....... Depth below inlet..... ........... Total leaching area.2 !�.�....sq. ft.
Z Other Distribution box (j ) Dosing tank ( )
Percolation Test Results Performed by..-- j..�L� � � ....................... Date.... 7 53
„-a Test Pit No. 141�.....minutes per inch Depth of Test Pit....l ._.._._.._. Depth to ground water.Jo
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil � `-. .! s?. �d_ s ._.. -- ----------------------------------•------------•------•----
...
x
a � Wr
w ...••.....-•---------------------------••--•••••••••---------......••--•••.........•••••-•........•----••-•---•-------------•-...--••••...............................................................
UNature 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 Compliance has beeO* .by ahe board of health.
Signed ............... .........I. . ................................. ..................................I......
ICI\ -- Dace
Approved B ^ �..�a�.:.... 9-
Application
PP Y ......... ��
Application Disapproved for the following rea.ronr: .............. ....... .................... .....................................................�..--................
....... .................... ....................................... . ...................................... ... . ................ . ................................... .......................................
Date
Permit No. ........... `.t.-/------- -- --- - Issued ...... . ..--
.............:.................................
Dace
r.+• •yrr. --^�-.�••-�..,^•^-•�,Ji-`.±i ti„ �r-�.+...�.�;-. �v .. a 7t►��ait--._-__�—�—�-� -. �; -- . -�
-(AQ :i
No......t--- ?., RB........... .r........
THE COMMONWEALTH OF MASSACHUSETTS
"P ? 5 3 BOARD OF HEALTH
TOWN OF BARNSTABLE -
Appliratiun fur, Diripusal Wnrkii Tonstrnrtinn rumit
Application is hereby made for a Permit to C 01ISta uct (A) or Repair ( ) an Individual Sewage Disposal
System at:
---------------------•----.......------....---------------------------..._......._._._... _..-•--•------••-•--•••-••------•-----•--•-•-•••••-•---•..._...••----•----------••.._....---------
f��w Location-Address , /
i(// ' __.........DI/VG I��----•------------------��. ��1/ 571
....�N- .r •r�— ....._.....
On ems"
►W.a %� .__....w
-- -- --- Addre�.. ...... =--.........
Installer Address
Type of Building Size Lot...4 )_Jr_� .Sq. feet
[-, Dwelling— No. of Bedrooms.____4�v----------------------------------Expansion Attic ( ) Garbage Grinder ( )
a ` Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d / Other fixtures . ....
W Design Flow.__J ...._._.gallons per person per day. Total daily flow-------3 .70
-
WSeptic Tank—Liquid capacityr_.�` Q,..gallons Length./d k........ Width__ . `... Diameter---------------- Depth_..J5.;71,.
x Disposal Trench-- No. ........... .A''7.. Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.___.D1. ..... Diameter----le.......... Depth below inlet.....1........... Total leaching area.74�61....sq. ft.
z Other Distribution box O Dosing tank ( )
aPercolation Test Results Performed j o,6 .............................
,.a Test Pit No. 1 2-----minutes per inch Depth of Test Pit--._ ......... Depth to ground water-.11.1%1:<--V1'�e.
LZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
................................ I---------------------
•.....................
•------------------
--------•...... --------
_.........
I.-----•--••----
D Description of Soil.................. Vd,�: 6. ........................
U .....-•------------•---------•--_.•..Z`��3:..iC0 9 . e5_....�t
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 Compliance has been i ,s e by;he board of health.
Signed ...... - -�_
g �-------------------------------------------------------------------- -------------- - ------------------------
Application Application Approved By ... -t --- --- .... _..... ----.........................................--------._... ...... ^.._...._.-.......cant
J �[�
Application Disapproved for the following reasons: ....................................................... .. .................... . .................................. .
...... ...............................................pp.................... . ... ... .............................. ......------................................... . ........... ............... . ......
Da[
PermitNo. ............./...`/.. :..?.. _.. �.-- ...... Issued . . -- ..._...._.................................. e......
Dare
____r._..•._...,._...�„o�._o��•_.�e�....�....�.._-.�®»��....-��.a...9�..,. ,®_._,._.�✓.��.r..�.a,.��.mimes®�®.��o®o®o,—,®-mmov.�-_,..�I'
[ THE COMMONWEALTH OF MASSACHUSETTS 1
BOARD OF HEALTH
TOWN OF BARNSTABLE
LLPrtifi. ate of (u��omytianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System co..-istructed or Repaired ( )
by ........................... ................... ................ ....................
Ins[allcr '
at ................/�.....0..�..........;)—I � �,�.D/ t_en1M .Q. ��A� ��.......... ..... ..........._.......... .has been installed in accordancewith the provisionsTITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ._...../�,_.--;,;c. .... dated _....................................:.__..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION OSATISFACTORY.
DATE......_..............� . `..(---..--.....L.`'f_._-...-...... .............-..__..-. Inspector ........... `*�,.....�� --........-----_---.:...------...-------
l
e- [ ( 0 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No...C.....'/-. FEE.....//In c'"`'----......
Disposal Works Tonstrudion f rrmit
Permission is hereby granted•-_------- — -------------•---------------------- ----------------------------•-------------•------•••-••---•---
to Construct (,/) or Repair ) an Individual Sewage Disposal System
at No............::....------.PJ� � ...
Street
as shown on the application for Disposal Works Construction Permit No.-.--9__)_-,)"Dated.... 3.:r/_�.._.•...
------- --- ------
DATE.. v Board of Health
-._-..��_.-:._..c1�/------------------------------•-- �/
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
SOIL 0G
N 0. 1 �� 0 1
S I T E PLAN
Q
i
` TOP OF FOUNDATION El. : 7LJ. o
�:: carry 7 I
8
Q �sE'Y/n 05,e MIN. 2% FINISHED b; RADE Q
DB e ;;0 W/7N/N /2 Q 9
v, IN EL 1
• �� .. _4 . .� _ /Z MIN. COVER �NS.rALL CONC- 1O I
IN IL
G-
! +- -- 2 COVER 1/8 3/8 WASHED STONE d '
IN E 1Gs84'
r • • ' '
L 018 '�Ii/ 6 ' SUMP IN El. o% .°.` o o aa• 3/4 1 1/2 WASHED STONE
4 LIQUID LEVEL I 1 ,1
/ v
I 'Lt-`-° °-�� `
°
o ° ' • ° •, DEPTH . ,° ° PE RC T ES T RESULTS '
PRECAST SEPTIC TANK WITH • : .' °° :, • 00 • ••° PRECAST LEACHING PITS NERC RACE : < ZM/r✓ f //✓e/f
• CAST IN PLACE INLET AND EL, `F. • . °° °o• " - aiy� �r,�r�. ,ram ��� ;-fln/ Y I
NO.. SIZE: WITNESSED BY
I OUTLET T 'S PER TITLE V _ 89�NSTf1.BL-�
BOARD OF HEALTH ,
SIZE : �SDd GALLONS s,Nc ` DIA zN� s- s= 90
6„ �,8. "7., OF STONE DATE : 7 3 `
I ( o LONG x W I D E x D E E P l Material
i us �� D I A ALL AROUND
EL. .� I i
PROFILE of PROPOSED SEWA- GE SYSTEM
I SYSTEM DESIGNED BY THE TOWN OF _ eiy:f 5,�_-4 1-7 REGULATIONS AND
T T TIT � .►� ..SAE LE V FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE 1/4 1 0
c1. I
iI N.S .
Le-�T/v/" 2,9
1 �
1 . All PIPES SHALL BE SCHEDULE 40 P.V.C . SEWER PIPE
)¢3, _�� �•F ( y� S �� �X► I i
I�5 i
2 All PIPES SNAIL BE SLOPED 1/4 PER FOOT 0 EXCEPT f R
E
i THE FIRST 2 FEET OUT OF THE 0 / 0 WHICH SHAII BE LEVEL
3. DESIGN FLOW BEDROOMS AT 110 GALDAY PIER BR GAL/ DAY
SEPTIC TANK SIZE -530 X/s it = Ly17 GAl t �
USE isoo GAL . Wl v�T GARBAGE DISPOSAL ! ��
-9r�D.,i qj I
I LEACHING SYSTEM : USE 1-iT
Gt/l 2 1-✓A_3f>E:r' ADD U/V,4),
EFFECTIVE AREA : SIDE Z27/f�%L S
2�- =
� 2X X X rt SCo P/T ANC
B 0 T T 0 M c-A- /,D - 28
TOTAL FLOW -
TOTAL REQ •O FLOWS X /oo/ 33o610 w/oyT GARBAGE DISPOSAL �/ �Ts '•Q✓t - _-,o !!I
49- 330 L zr
RESERVE FLOW � — GAL/ DAY IN RESERVE
REFERENCE PLANS
/V 7i oG' L-^/" J✓
I APPROVED BY :
BOARD F T 0 0 0 HEALTH
N
i
DATE
PROPERTY OWNER SITE AND SEWAGE FLAN
✓ AF�N` T/�bLE, AM, //C�"�/L A Lr L /n/G
l' tY t•_...
'a'�"` -
'LIAA! ' rtiR� BEDROOM SINGLE FAMILY DWELLING txsYC E.t!i LIURt'.A A4
NQ.33589 r` . h L 0 T : /vo, Z8 �,y,9zLow /o L
�Cn ,,e/✓E
0 A f E 41 y—AA
j
q �CICTER`
- I p �I ��� BOYLE ENGINEERING ASSOCIATES, INCORPORATED
I Box 595- 530 Thomas B. Landers Road W. Falmouth, MA 02514
7 f ��