HomeMy WebLinkAbout0060 SPYGLASS HILL ROAD - Health 60 Spyglass Hill Road
Barnstable P
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Commonwealth of Massachusetts 356� DD1
(P Title 5 Official Inspection Form
16 16 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rr I
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SPY9�
60 lass Hill Rd.
Property Address
FRANO,JOHN&NANCY e
Owner Owner's Name V
information is C uid MA 02630 2/03/21
umma
required for every q g-Wn. `
page. City/Tom 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:When
filling out forms A. Inspector.Information
on the computer,
use Y the tab Robert Paolini
only
key to move your Name of Inspector
cursor-do not Robert Paolini
use the return
key. Company Name
67 Tanbark Rd.
Company Address
Marstons Mills MA 02648
i Citylrown State Zip Code .
(508)280-9499 S14454
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title
5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
2/03/21
Inspecto s gnature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/2S/201S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
R�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
f
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is q
required for every Cumma uid MA 02630 2/03/21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well'`*.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
' than 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: .
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area- IWPA) or a mapped Zone II of a public water supply well
t&nsp.doo•rev.712V2016 Title 6 official lnepection Form:subsurface Sewage Disposal system•Page 5 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Forums
65-P- Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is umma uid MA 02630 2/03/21
required for every C q '
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no".for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
lie ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
4
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�? Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Spyglass Hill Rd.
u
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual):, 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: na
Does residence have a garbage grinder? ❑ Yes.® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ 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:
Sump pump? ❑ Yes ia No
Last date of occupancy: NA
Date
t5insp.doc•rev.7/2612018 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
cam, Commonwealth of Massachusetts
Title 5 official Inspection Form
I Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 '2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd).
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection?. ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. Cityffown State Zip Code Date of Inspection
D. System Information (cunt.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy ,
❑ Shared system (yes or no)(if yes,'attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
y 2,
Depth below grade:
feet
Material of construction:
❑ cast iron W 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight. No evidence of leakage.System vented through house vents.
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
_ I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade:
2'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 GI.
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
46"
2"
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
12"
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.):
Pump every two years.lnlet and outlet tees in place.No signs of leakage.
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
l
c Commonwealth of Massachusetts
ry Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is required for every Cummaq uid MA 02630 2/03/21
page. Cityfrown State Zip Code Date of Inspection
D. System Information(cont.)
8. Tight or Holding Tank(cont.)
i
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is level.Box has one outlet laterals with equal distribution.No signs of leakage.
u
�p
N
t5insp.doc-rev.7/26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ .Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 6 Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Me 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name .
information is Cumma uid MA 02630 2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.No signs of hydraulic failure.
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
CoE11Q1XonvveaEtft,of Massach
M 5 Official. Inspectioin-F m
Subsurface Sewage Disposal System Form-Not for Voluntary Assessment
sa-Spyglass Niil Rd.
Pr"Addeess
FRANO,JOHN&.N'ANCY
Owner _ _.:.. .. __. ..
Owner's Name:
informationAs
2/03121
Cumma uid MA 0263Q
requUed=for every q
page. Cityfrown State: Zip Code Data of.lnspeciion
D,:Systeml Information fcont
t4: Sketcb`Of Savage Oftposaf systerrr
Provide a view of the:sewage disposal system, tricludmg.ties to;at least two permanent reference
landmarks or.benchmarks; Locate:all wells within;100 feet. Locate where public wafer supply ente
the buiilding Check one of the boxes below:
0 hand-sketch in the area below
drawing attached separately
B :F � .
N
Z/3/ZU2a,4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information' (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15,
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: pate
® Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS"database-explain:
You must describe how you established the high ground water elevation:
Used USGS observation well data.Used technical bulletin 92-0001
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
' c Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
60 Spyglass Hill Rd.
Property Address
FRANO,JOHN&NANCY
Owner Owner's Name
information is Cumma uid MA 02630 2/03/21
required for every q
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
'i
N
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
i
SZ 2-) 3% E E,��°
COMMONWEALTII 01; MASSnC'I1i_JSE`I"IS FEB 10
2005
EXECUTIVE, OI',FICE OI- ENVIRONMENTALAFI' 1ZSq� = i = -���
Too bF bA NS f LPL t.
a DEPARTMENT OF ENVIRONMENTAL PROTECTION ALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE, DISI'OSAL SYSTEM FORM
I'ART A
CERTIFICATION
Property Address: .alb . . o
-A ,CE-L - SOW® � ®�
Owner's Name:
Owner's Address: _, ^ # Of
f r
Date of Inspection:
Name of Inspector: (please print) �'��/'\ry% C) LoLk \ ►,^'
Company Name: C.
Mailing Address:
Telephone Number: 35a-t,j :f 4
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal systcm 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'Fitle 5(310 CMR 15.000). The system: .
V Passes
Conditionallv Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: `CZAA Date: 9,1-?JO
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 Continents
****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
Title 5 Inspection Form 6/15/2000 page
Page 2 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYS'11'M INSI'LCTION FORM
PART A
CEIZT11"ICATION (continue(i)
Propert4Addrcss:j 1 1
Owner:
Date of clion: d J
Inspection Summary: Check A,I3,C,D or E/ALWAYS complete all of Section I)
A. System Passes:
V/.I have not found any information which indicates that any of the failure criteria described in
15.303 or in 310 CMK 15.304 exist. Any failure criteria not evaluated are indicated below, 310 CNtR
J
Comments:
i3. System Conditionnlly I'nsses:
One or more system components as described in the "Conditional Pass'section
repaired. The system, need to be replaced or
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 file
followingm statements. If"not determined"please
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 I lealth.
*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 pipes)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of'Board of Health):
broken pipes)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). 'file system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SVSTEi\'I INSPECTION FORM
PART A
CE101FiCA`i ION (contimc(l)
Property Address:
Owner: _
Date of ins clion: 'vZ`
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of l lcalth in order to determine if the system
is failing to protect public health, safety or the environment.
I. System will pass unless Board of Ilealth 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
2. Svstem will fail unless the Board of Ilealth (and Public Water Supplier, if any) deterniincs 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 systern has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fronl 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 coliforni
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 I I
OFFICIAL INSPECTION FORM —NOT FOR VOI_,UNTARY ASSESSMENTS
St1I3SUIZFACE SEWAGE DISPOSAL SYSTEM INSPECTION LC PION FORM
PART A
CERTIFICATION continued
Property Address:
Owner:
Date of Ins Ilion: a 17,
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no"to each of the following for all inspections:
Yes N9
_ ✓ 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
Vclogged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
I A cesspool
N 1 Liquid depth in cesspool is less than G"below invert or available volume is less than %day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipc(s).Number
/ of times pumped
•' V Any portion of the SAS, cesspool or privy is below Itigtr growrd water elevation.
�t1t 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 i 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. PThis s_vsfenl passe; if the well water analysis,
performed at a DEP certified laboratory, for colifornr bacteria and volatile organic compounds
indicates that the well is free frorn pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 pprn, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this for•nr.)
(Ye )The system fails. I have determined that one or more of the above failure criteria exist as
escribcd in 310 CMR 15.303, therefore the system fails. The systcrn owner should contact the Board of
Health to determine what will be necessary to cnrrect the failure.
E. Large Systems:
To be considered a large system the systcrn must serve a facility with a design floNV 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 file criteria above)
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
— i the system is located in a nitrogen sensitive area(interim Wellhead Protection Area— I WPA)or a mapped
Zone 11 of a public water supply well
If you have answered "yes"to any question in Section L- 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.
q
it
Page 5 of I 1
OFFICIAL INSPECTION FORM — NOT h;Olt VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGI,', DISPOSAL, SVSTI?M INSPECTION FORM
PAWl' B
CIIEC'KI.,IS'1' ,
Property Address: 00. 6�,
Owner: ,
Date of In ction:
Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
Y No
Pumping information was provided by the owner, occupant, or Board of Fiealth
V 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?
v — 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 ?
V _ 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 ?
A _
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yet no
�/ _ Existing information. For example, a plan at the Board of Health.
✓ _ Detennined 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)]
5
Page G of I I
OFFICIAL INSPECTION FORM —NO'F FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC"PION FORM
PART C
SYS'FEM INFORMATION
Property Address: �cc)
Owner:
Date of Ins, ction:
RESIDENTIALFLOW CONDITIONS
Number of bedrooms (design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x N of bedrooms): '330
Number of current residents: 3 --
Does residence have a garbage grinder(yes oro):
Is laundry on a separate sewage system (yes o n ): _ (if yes separate inspection required]
Laundry system inspected (yes or no):—
Seasonal use: (yes oro:—
Water meter readings. if available (last 2 years usage(gpd)): 03
Sump pump (yes or a:— - -------— )00 r
Last date of occupancy: 03" O L} (�I Cj( (I
COMMERCIAL/INDUSTRIAL
•Type ofestablishrnent:
Design flow(based on 310 CMR 15.203):
Basis of design flow(scats/persons/sgft,ctc.): l>hd
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:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: , pM n
Was system pumped as part of the ins ccti� ore)
P (yes or rro
If yes, volume pumped: gallons-- Flow was quantity pumped determined?
Reason for pumping: —
TYPE OF SYSTEM
ASeptic 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)
-Tight tank Attach a copy of the DEP approval
—Other(describe):
Approxim to a2 of{{ajl C94wilcrits, da c installed(if k-n}}ow^^nl and source of information:
OUN A/1A M (lJt h X�i�t
Were sewage odors detected when arriving at the site(yes or trr .
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM - NOT FOIt VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTI,',M INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: ft
'
Date of Ins ection: -11�- 1�k D '
BUILDING SEVER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(explain): _
Distance ffbm private water supply well or suctio'n line:_
Comments(on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: V (locate on site plan)
Depth below grade: _
Material of construction:_✓concrete_metal__fiberglass_ polyethylene
other(explain) _
If tank is foetal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate) n
Dimensions: ISO
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: _
Distance from bottom.of scum to bott&rrrof outlet tee or baffle: l.IR
How were dimensions determined:_ '
Comments(on pumping recommendationet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.leakage, etc.):
+ c
C -
GREASE TRAP:_(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:
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.):
7
Page 8 of'I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORNIATION(continual)
Property Address: GC) tL1i1
Owner:
Date of Ins ection: G
TIGII'F or MOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polycthvlenc__othcr(cxplain):
Dimensions: - ----
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alann in working order(yes or no):
Date of last pumping:
Commanto (condition of nlnrni nncl font awitchan, etc.):
DISTRIBUTION BOY: /(if present must be opcnc(l)(locate on site plan)
Depth of liquid level above outlet invert:
Continents (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.):
- .AivJ
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alanns in working order(yes or no):
Comments(note condition of purnp chamber, condition of pumps and appurtenances, etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SN'STEM INSPECTION FORM
PART C
SYSTEM INFORMATION (cowinucd)
Property Address: GOQQ 2CROtt
IY1t'�
Owner:
Date of Ins ection: a g S
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:_
Type
leaching pits. number:
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, lcvcfof ponding, clamp soil, condition of vegetation,
etc.): -
r .woo
- -
CESSPOOLS: (cesspoohnust 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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.),
PRIVY: (locate on site plan)
Materials of construction: _
Dimensions:
Depth of solids:_
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ,
' 9
Page 10 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSU
RFACE
RF'ACI✓ SEWAGE DISP
OSALOSAL SYST
EM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
n
Owner:
Date of Ir )ection.
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks or
benchmarks. Locate all was within ]00 feet. Locate where public water supply enters the building.
� o
J
a R-
D q q, 3
Page I I of
OFFICIAL INSPECTION DORM --- NOT FOR VOLUNTARY ASSESSNIF.NTS
StJBSURhACI: SEti'�'A(;I? UISI'C)SA1, til'ti'I'1�;M INtiI'I�;C'I'IUN hOltl\7
PAR.I. C
SYS'I'1?M INFORMATION (continue(l)
Property Address: roc)
Olr'ncr:
Date of 1nsl Ilion: 01 (15
SITE, EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check) all methods used to determine the high ground water eln-ation:
V 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 I-Iealth-explain:
Checked with local excavators, installers- (attach documentation) _
Accessed USGS database-explain: _
You must describe how you established the high ground water-elevation:
— — _ -- ✓ -
A_S O
--. --
-.. . ..
y r
II
_ .�4()TOWN OF-BARNSTABLE
LC"ATIGiV 4 SEWAGE # 0.1
�. ;
VILLAGE thi in 4 u+ ASSESSOR'S MAP & LO v�- -06'
INSTALLER'S NAME&PHONE NO. �0���-� , �Lt ai CD J:U C , t13LO S3 0
SEPTIC TANK CAPACITY AX210 0
r
LEACHING FACU n Y: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMUDATE: COMPLIANCE DATE:
Separation Disiance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 100 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�-�� �
-� _. -
��r �
-� '�
�--� �� �
--�, ��
..
t
08:48 , �.....w.�' 0�.2/2=
LOCATION + LE
SEWAGE 9�V93
VIUAGA CAW M ASSESSOR'S
INSTALLER'S NAME d'PHONE N0.
S8PT1C TANK CAPACITY �SG l" dEd el .�
X
LEACH NG FACUIW-.(type) (size)
NO.OF BEDROOMS
BUELDER OR OWNER
PERMIIDA7E--5'-l 2 COMPLIANCE DATE:
Sepamdon Distance Between the:
Maximum Adjusted Grouadwater Table and Bottom of Leaching Facility Feet
private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Fat
Edge of Wedand and Leaching Facility(If any wetlands exist
within 300 feet of faciUw-)-, Feet
Furnished by J
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Fufnished by
9 3
c �
No. r
Fee_rio_
i
THE COMMONWEALTH OF MASSACHUSETTS
f PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS L�
01ppYfcation for Mizpool *p6tem Conttruction permit C�6
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
L°�ati ,df ess r Lot O er's Name,Address an Tel.No.,./
1 % S°VrG 4.0 /A 4 �3y_ ���,,3 e$etj AeNly Pv� 7U Jossdo�t�rlr
L to n/��,v► I IV r-le, j,3 v h&
Installer's Name,Address,and Tel.No. "'7 3� �/ 13 igner's Name,Addr ss and Tel.No.
Gin �v /J,o�r w cJ o��jai' j,,ee",r "
le? Ills L. Hf�i&4A
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
I
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued this Health.
P Y
Signed Date ?
Application Approved by >3
Application Disapproved for the following reasons
- I
Permit No. ^' Date Issued
00
„`- No. ti`w— �.ti� Fee l�
M _ THE COMMONWEALTH OF MASSACHUSETTS
s„ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppYication for Mi.5pogar *pgtem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage.Disposal System at:
Lo, ati°�A d ss r Lot �� t O er's Name,Address an Tel N1o.
b r r°i In s s `l� ps��� rPAl�y ��ST �/jo�►6orOlo�
vA►mA l� I lap RAC 1 S• Q° Ali 119 Udbba L
Installer's Name,Address,and Tel.No. l_/3� G 3v De igner's Name,Add"ss and Tel.No.
l o I
C, r c C�, /,1�/7 w lc t
0.
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
s fl.
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
rDescription of Soil 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 Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued bi y this Ra Health.
Signed Date ?d�G
Application Approved by 3
Application Disapproved for the following reasons
Permit No. " Date Issued "
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC-HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
r
Certificate of Compliance
THIS IS TO PTIFY,that the On-site Sewage Disposal System installedj(i)or repaired/replaced( )on
by r`,Q for
as LZAAfgLZA2i 0A`721 Z has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. '" dated
Use of this system is conditioned on compliance with'the provisi s set forth below:
elf
/ iMiay
Fw >
w.�-���.rr�•a�r _./. :._- _...�.——-.�.�..�—:�a.. ®�va�r.�sve..r-a►a_�...�.r.w+.s..r.�rs�+ww.�..a—.:�r..cwi-�.wr-w .-.s_rr.�J.r/'w�e-;sla'.�m•a�sr..iYw.e..
No. IIJI -- s
------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
nigogal *p!6tem"Construction Permit
Permission is here granted to A
to cy,,nstrqct( repair( )an On-site Sewage System located at "
s—=—r, ca i, LEAt rumm5�i✓�
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date: /��` M Approved y
SEPTIC - PROFILE TEST - HO-LE LOGS
T.O.F. AT EL.
(NOT TO SCALE)
ACCESS COVER TO WITHIN 6* OF FlN. GRADE ENGINEE -- -------
ACCESS COVER (WATERTIGHT) TO
WITHIN 6" OF FIN. GRADE
('T5, 5 MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM
------ WITNESS:
RUN PIPE LEVEL L-e- l'jA-6 -N&'fo
(DR—) FOR FIRSI 2' DATE:
PROPOSED
GALLON SEPTIC PERC. RATE
TANK (H-�,- z-5
CLASS SOILS P#
0-C,
(1% SLOPE) ___6r" CRUSHED STONE OR MECHANICAL
DEPTH OF FLOW COMPACTION. (15.221 [2])
TEE SIZES: (3% SLOPE) (-5% SLOPE) p0j) L k- �-1 Cr Cr
INLET DEPTH =
OUTLET DEPTH LOCATION MAP
C,4,.r/2- rl mac' V"�5
LEACHING ASSESSORS AID MAI PARCEL 0
FOUNDATION----- SEPTIC TANK D' BOX
FACILITY L-O^-I . (o,4 FLOOD ZONE
/� 1 / G BUILDING ZONE:
SETBACKS: FRONT -
e7 1A -SIDE
A t-4&a-v-.,"
2- G REAR
/ �1 -' i 1 \ \ I'� -714 PLAN REFERENCE:
54 o'
T
L:
L3
�j t-T gE(2- C-- (_0,_1 A T Q,a-e-0 NOTES:
1 . DATUM IS
X,
V.)
2. MUNICIPAL WATER IS
SEP'IC DESIGN: .I r-
(GARBAGE DISPOSER IS
DESIGN FLOW BEDROOMS JLC�L GPD) "50 GPD 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
`� I ,� / _ 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO--H
I,-o T- 4- USE A GPD DESIGN FLOW 5. PIPE JOINTS TO BE MADE WATERTIGHT.
SEPTIC TANK:. GPD GALLONS 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
/ �� I I �� �� "`'
USE A Lf�.e-C-1 GALLON SEPTIC TANK ENVIRONMENTAL CODE TITLE V.
r C7-) 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
LEACHING:
V,
USED FOR LOT LINE STAKING,
-7/ SIDES: _LC4L -4 -- G,P D 8. PIPE FOR SEPTIC SYSTEM TO `NCH. 40-4" PVC.
BOTTOM:-__--- G P D 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
TOTAL: h 45 S.F. 25 G P D INSPECTION BY BOARD OF HFJ�LTH AND PERMISSION OBTAINED
/ ' �: o FROM BOARD OF HEALTH.
TF7
(2
0 '
0
167
SITE AND SEWAGE PLAN OF
IN THE TOWN OF:
BOARD OF HEALTH
MA PREPARED FOR:
6;)s APPROVED DATE
0 2-0 (-%p Feet
SCALE: DATE:
L 0 L
down cape engineering, inc.
CIVIL ENGINEERS '\�A Of 44 J ARNE H.
ARNE OJA A
LAND SURVEYORS H. CIVIL
PHONE 508--362--4541 ALA 3M2
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