HomeMy WebLinkAbout0125 STONEHEDGE DRIVE - Health 125 STONEHEDGE DRIVE
Barnstable
A = 317 - 063
Ju,p 09 1511:14p p.19
Commonwealth of Massachusetts
- Title 5 official Inspection Form ,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessmentsn
X
125 Stonehedge Drive
Property Address
Linda &John Stackhouse ', I
Owner Owner's Name x
information is
required for every Bamstabte MA 02630 6-8-15
page. Cityfrown 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 A. General Information
on thecomputer, D 1 \``���� .... I. so
n ��.ng out forms
use only the tab 1. Inspector
key to move your =�� JAM ES G '_
cursor-do not James D.Sears =J-. T^
use the return Name of Inspector
key. Capewide_Enterprises,LLC i'•, o�'Q�
Company Name %���1� .. T�iIF
153 Commercial Street ���iryin5 INSP,E�``����
�rfrnlm.�--
Company Address
Mash pee MA 02649
Cityrrown State Zip Code
508-477-8877 S 1623
Telephone Number License Number
r
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
I sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
0 Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
` .
6-8-15
A,spor's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
R report to the appropriate regional office of the DEP.The original should be sent to the system owner'
and copies sent to the buyer, if applicable, and the approving authority_
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�11
t5ns•3013 Tills 5 Olfidal Inspection Form:SubsuAaoe Sewage Disposal System-Page 1 of 17
Jun 09 1511:14p p.20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,
125 Stonehedge Drive
Property Address
Linda &John Stackhouse
Owner Owner's Name
information
required for every Barnstable MA _02630 6-8-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CM 15.304 exist_Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal.Tank D Box and pit.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined' (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old`or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
h
t5ins-W13 Title 5 miicial Inspection Fcr m:Subsurface sewage Disposai system-Page 2 of 17
Jun 091511:15p p.21
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
125 Stonehedge Drive
Property Address
Linda&John Stackhouse
Owner Owner's Name
information is Bamstable MA 02630 6-8 -15
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumpslalarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ms.3113 Title 5 Official Inspection Fam:Substsface Sewage Disposal System.Page 3 of 17
r
Jun 0915,11:15p p.22
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments ;
125 Stonehed a Drive
Property Address
Linda &John Stackhouse
Owner Owners Name
information is MA 4263Q 6-8-15
required for every Barnstable
page. Cityrrown 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.
❑ Ttre 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 farm.
3. Other.
D) System Failure Criteria Applicable to All Systems:
=s
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
ElStatic liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in assopM is less than 6" below invert or available volume is less
than Y day flow 0/7T
at5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Jun 09 1511:16p p.25
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
125 Stonehed a Drive
Property Address
Linda&John Stackhouse
Owner Owner's Name
information is Barnstable MA 02630 6-8-15
required for every
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
[] ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑, Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from 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 roust be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system faits. 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
.M ❑ ❑ 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
It 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•3N 3 -nue s omcial Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Jun 09 15-11:17p p.26
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
125 Stonehedge Drive
Property Address
Linda& John Stackhouse
Owner Owners Name
information is required For every Barnstable MA 02630 6-8-15
page. Cityrrown State Zip Code Dale of lnspedion
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ 0 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
i .
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Pegs 6 of f 7
i
Jun 0915,11:17p p.27
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s 125 Stonehed a Drive
Property Address
Linda&John Stackhouse
Owner Owners Name
information is Barnstable AAA . 02630 6-8-15
required for every Stale Zip Code Date of Inspection
page. Citylrown
D. System Information
Description:
The system is a 1000 Gal Tank D Box and pit
. F 0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
2013-75,000Gals
Water meter readings, if available(last 2 years usage(gpd)): 2014-81,000GaI's
Detail:
Sump pump? ❑ Yes ® No
Na
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•3113 We 5 Official Inspection Form'.Subsurface Sewage Disposal System.Page 7 of 17
Jun 09 15,11:17p p.28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
125 Stonehed a Drive
Property Address
Linda &John Stackhouse
Owner Owner's Name
information is required for every Barnstable MA 02630 6-8-15
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:
7/8114
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: ..
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"3/73 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 0 cf 17
Jun 0915,11:18p p.29
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Stonehedge Drive
Property Address
Linda&John Stackhouse
Owner Owners Name
information is required for every Barnstable MA 02630 6-8-15
page City/TDwn State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
1985 Permit#85-514. 6-2015 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
20"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet J
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4"PVC SCH 40
Septic Tank (locate on site plan):
8�
Depth below grade: feet
Material of construction:.
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1000 Gal.Precast H-10
Dimensions:
In
Sludge depth:
t5ins-3113. - Title S Official inspedian Farm:Subsurface Sewage Disposal System•Page 9 of t7
I
Jun 09 1511:18p p.30
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
125 Stonehedge Drive
Property Address
Linda &John Stackhouse
Owner Owner's Name
information is required for every Barnstable MA 02630 6-8-15
page_ City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness V
Distance from top of scum to top of outlet tee or baffle 12'
Distance from bottom of scum to bottom of outlet tee or baffle 17"
Now were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank at working level.Tank at 8"below grade_ Inlet tee,outiet baffle. No sign of leakage or over
loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from flop 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
r5ins-W13 Tide 5 Official Inspection Form:Subsurface Sexage Disposal System•Page 10 of 17
iJun09 15,11:19p p.31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments,
125 Stonehedge Drive
Property Address
Linda 8 John Stackhouse
Owner Owner's Name
information
required for every Barnstable MA 02630 6-8-15
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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 a Date r
Comments(condition of alarm and.float switches, etc.):
•Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Tlde 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Jun 09 15.11:19p p.32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments
125 Stonehedge Drive
Property Address
Linda &John Stackhouse
Owner Owner's Name
information is required for every Samstabie MA 02630 6-8-15
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cons.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box,.etc.):
D Box is 16'x16"-3W below grade w/one line out. Box is new 6-2015 w/cover at 6".
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.
(Sins•3113 Tith 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
f
Jun 09 1511:19p p.33
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
125 Stonehedge Drive
Property Address
Linda&John Stackhouse
Owner Owner's Name
information is Barnstable MA 02630 6-8-15
required for every
State Zip Code Date of Inspection
page. Ciij/ own
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.):
Leaching is a 4' precast pit. Pit at 58" below grade w/cover at 2'. Wet bottom, clean wall's. No
sign of over loading or high stain line
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•3113 Tifle.5Official Inspecticn Form:Subsurface Sewage Disposal System•Page 13 0117
I
Jun 09 15,11:20p p.34
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '
125 Stonehed a Drive
Property Address
Linda R John Stackhouse
Owner Owner's Name
informationeiced is every
Bamstatlle
required for eve MA 02634 6-8-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)~
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.);
tsins-3113 Title 5 oRfdal Inspection Force Subsurface Sewage Dispose'System•Page 14 cf 17
f .
Jun 09 15-11:20p p.35
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V a
125 Stonehedc�e Drive
Property Address
Linda&John_Stackhouse
Owner Owner's Name ^^�
information is Barnstabte MA 02630 6-8-15 _
required for every _-- .._. ...... -
page. City/Town state Zip Code Date of Inspection
D. System information (cost.)
Sketch Of Sewage Disposal System-Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand sketch in the area below
drawing attached separately
a
jj � I V
3U
►J.'�- ' J 1 � � j 1
s l I E
t
r0
i
t
f5ins-3113 TNe 5 Oftiool Inspemot Forth.Subsurfam Sewdge Disposal Sysienn-Ploge 15 of 17
Jun,09 1511:20p p.36
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
125 Stonehedge Drive
Property Address
Linda&John Stackhouse
Owner Owner's Name
information is garrtstable MA 02630 6-8-15 _
required for every
page. . Cltyrrown State Zip Code Date of Inspection
D. System Information (cons.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
14'+
i Estimated depth t high ground water: 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: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Beard 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
Auger Hole 14'no G W.. Bottom of pit at 10' below grade. Bottom of pit at 4' above Auger Hole.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
15ins 3112 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
Jun 091511:20p p.37
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Stonehedge Drive
Property Address
Linda&John Stackhouse
Owner Owner's Name
information a Barnstable MA 02630 6-8-15
required for every
page. City/Town state Zip Code gate 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
t y
45ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. 5 ;73 Fee /v y
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
TippliCatiott for Disposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair 06 Upgrade( ) Abandon( ) ❑Complete System DKIndividual Components
Location Address or Lot No. 13. 'DP, Owner's Name,Address,and Tel.No.
o14L)+Lt M S` *%-A6 3SC
Assessor's Map/Parcel (`7)06 3 ' PT)- f US
Installer's Name,Address,and Tel.No. 50$ -4-17 Designer's Name,Address,and Tel.No.
t—k c—f N/A
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) oe
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the'provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. 0
Sig ed Date �
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. /6 Date Issued
e
Fee /O C)
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
}PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for 33is-pOSal 6pstem Construction Permit
Application for a Permit to Construct O Repair 00 Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. r a-j STf D4 DP, Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel V] ea 3 �rp�, v
Installer's Name,Address,and Tel.No. 508-µ7'7-$St 7'j Designer's Name,Address,and Tel.No.
d#WG;WrD,(5 sum-PK(SISS Lk,4. NA
l'"
TI pe 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)
Date last inspected:
h.
Agreement:
k
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
n A �
Y Permit No. (�X IAS — // 3 Date Issued
�0- THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(A) Upgraded( )
Abandoned( )by ( /A F&CJ(7bj5 0JTEV_Pj J_CjSt L Q( .
at bQ k) a has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N %✓ dated
Installer (( � � � (,�.�. Designer
#bedrooms 1�j Approved desi n flow n gpd
The issuance of this permit shall not be construed as a guarantee that the system will funio; as r esigne .
Date I Inspector
-----------------------
--------------------------------------- -- ----------------------------------------------''-----------------------
., ?� . . . Feed
No. �--;
THE COMMONWEALTH OF MASSACHUSETTS
�( PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction -permit
Permission is hereby granted to Construct( ) Repair(4) Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal.System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must beJcomple d wit in three years of the date of this permit. — --
Date / I / Approved by
v
j OT NO. : 9 ADDRESS:_OWNERS NAME:
NAME: /? U
SEWAGE PERMIT NO. 5-1NEW:,�_REPAIR:
DATE ISSUED:- DATE INSTALLED; IO-q-85
INSTALLERS NAME: � �-
INSTALLATION OF:
WATER TABLE: FINAL INSPECTION BY:
DRAWING OF INSTALLATION ON REVERSE SIDE:
7l
Z5
LOT NO. q ADDRESS:
OWNERS NAME: _
SEWAGE PERMIT NO. : Q NEW: REPAIR:
DATE ISSUED: DATE INSTALLED:
INSTALLERS NAME: -- -etyxo s(An =Aden
INSTALLATION OF:
WATER TABLE: FINAL INSPECTION BY:
DRAWING OF INSTALLATION ON REVERSE SIDE :
�L '
G� 49, `
1251
�� � �
LOC'A-TION SWAGE PERMIT NO.
BUT y SToaF Aco(,C ®n, 8s - S c 9-
VILLAGE Ilse,
N Zl1(3c. 1 voL,L,I A� �
I N S T A LLER'S NAME s ADDRESS
F-P-4 rvt<<c n 74 v4 j.�Z
S U I L D E R OR OWNER
DATE PERMIT ISSUED 7 S'
DAT E COMPLIANCE ISSUED
` "N
No. �t _ .��...f 7 f Q ,l `9 ✓ Fps....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...............OF...... .. , 'fI��TA d� ...._.. :::...!.._........
Application is hereby made for a Permit to Construct (V�<r Repair ( ) an Individual Sewage Disposal
System at: .
9 �"®�
._O'er i c�/'sr �-.�------� =
- --•............................................. ........................................................
Location-Address / or Lot No.
Owner Address
W �tVc ..-- ---•-•-•................
.......... .........
Installer Address
d Type of Building Size Lot_��,r-.0-?-6---.-Sq. feet
U Dwelling—No. of ........ Expansion Attic ( ) Garbage Grinder ( )
s3------•-•---------- ..
a ,.
a Other—Type of Building ............................ No. of persons.............. ........... Showers ( ) — Cafeteria ( )
Q, Other fixtures -------------------------------- ---
W Design Flow.........................6._d� ........gallons per person per day. Total daily flow__._........._....._.�!;1P........gallons.
WSeptic Tank—Liquid capacity/_____gallons Length_4_6______ Width..4. .__ Diameter................ Depths_ .--_.
x Disposal Trench—No..................... Width.................... Total Length...........__........Total leaching area-____-_--.-_--.-----sq. ft.
3 Seepage Pit No------I------------- Diameter.?z._6_.___. Depth below inlet..--4........... Total leaching area."�.�.....sq. ft.
Z Other Distribution box (+,`� Dosing tank )
~' Percolation Test Results Performed by... _ .................�... ................................. Date......... _��®"g�_
a Test Pit No. 1___ -
Test per inch Depth of Test Pit../ ...... Depth to ground water........................
Test Pit No. 2.....?!.......minutes per inch Depth of Test Pit..%_1�f.4-_____-. Depth to ground water........................
a •---•------------------------------------•--•---•-•••-----•- -----------------------------------
•-----------------------
•---------
•-----------------------
O Description of Soil_./10,2)��l.....V'�.... moo 0'l''' _.._ ® _ _
.....................................................
W
'j U Nature of Repairs or Alterations—Answer when applicable._______________________________________________________________________________________________
---------•-------.----•---•----•---------•-••••--••-•••----------------••-••---------•---------------------------••••--•••-••••...........----•.
a Agreement:
The undersigned agrees to install the aforedescribed Individ rewge Disposal System in accordance with
the provisions of iIi TIE 5 of the State Sanitary The unde s' urther agrees not to place th sy tem in
operation until a Certificate of Compliance has be s u e lth.
-2/j(/
Signed ........... --- ....... -----•I•--••••-- - 1 j------
Date
Application Approved By---- -��............. =-"•'-•--------------•-------•--•------- ......... ..�`3....... 5.---
Date
Application Disapproved for the following reasons----------------•-•-----•---------------------------------------•----------------------------••------....._------
..--•---------••--------•--•-•.....................................•---•-----------..._..---------••••...-•••-----------•-•-----------•----•---•-------------------------------••---•-•---••--•...------
Date
PermitNo......................................................... Issued.......................................................
r •
,.
Fps
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
InJS?A�G ........................OF.......�... ' ? .....-----•------....-•-•-•----
Appliration fur Disposal Works Tunstrnrtinn Prrurit,
Application is hereby made for a Permit to Construct (f-r Repair ( ) an Individual Sewage Disposal
System at:
........_- ....--•-- --• ..... ----•-------....-••---.....-••••---...•••---...-•..................•---••.............•-•........
Location-Address or Lot No.
G`1jiyu.ti D .........T ...._..._...Y!��v.
---•-•---•--- ........
Owner - Address
........... 'G-- -...._.. -7�' i...rc" .......................•......... ........................................
Installer Address ?� 5�
Type of Building Size Lot4i- .,r_..O-................Sq. feet
U welling—No. of Bedrooms..____..__. Expansion Attic ( ) Garbage Grinder ( )
D --------------------------
Other—Type of Building ............................ No.No. of persons...............�---------- Showers ( ) — Cafeteria ( )
p-' Other fixtures .......... .....•-••••-•-•-•-•--•-••--•-•-•-••-•--•-•-•--•------•••-----•......----••--•------•••-•--
W. ,Design Flow....................... ..gallons per person pqr day. Total daily flow.....................�3.�__._....gallons.
moo, ^
r4 Septic Tank—Liquid capacity.,. ? ...gallons Length.A.4........ Width.-r. /q.--. Diameter................ Depth ._...
Disposal Trench_No...........:......... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No._..J------------- Diameter..�..ea_._... Depth below inlet.....'��............. Total leaching area.O....sq. ft.
Z Other Distribution box (✓S Dosing tank )
`~ Percolation Test Results. Performed by.._. 4G�'!"� __..•_...��.................. Date......... .'��.� 1�.......
aTest Pit No. L...............minutes per inch Depth of Test Pit..l'��`a _r�__. Depth to ground water________ ___________
Test Pit No. 2..... :......_minutes per inch Depth of Test Pit__/:�K!?____.__ Depth to ground water......................
------ --------------------- • ..._....... .........................................
O -Description of Soil.2`.1�Yi`�.---.S9 a ------5"D!!� -f' •� C.o�u .' .��
x -----------------------------------------
U -..................................................................................................................................................
W ----------- -•_.---- ----------------------------------------•---------------------------- ----------•-•------------------------------•-•------------------------------------------------•---
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
..............-..... ---------------------------------------------------------------------------------•••-•--•--•---•• ......--------------..------------------------------------------••••••-•---•-•--
Agreement:
The undersigned agrees to install the aforedescribed Individua age Disposal System in accordance with
the provisions of ITL% 5 of the State SanitaryWOhe unders' e further agrees not to place the Sys min
operation until a Certificate ol-Compliance has a `- -
Signed................................................. ................................... -------.-.-• .....:......----
Application Ap)owed ' _ +r - -,Y: '' i
- .,�` Date
Application Disapproved for the following reasons:-'=...F-......-•--•----•••--•--•••---•--••-•••-•-•-••••--•-•---•--------•------•-•--••-•••--•-•---•---•-------
...................................................•---------................-----------•-----------------•----•.........-•-•••--•------•----•-•---•--••-•••----••--•••...-----••-••--•---•---••-•......
Date
PermitNo--------------------------------------------------- --- Issued....................................................... _
Date
•, ^yam„«-,,,,,.^"..,�....,.� .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH\
OF....................................................................................
T rtifiratr of Tomplia v
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by------------------ J rr �.�s------------- -------------------- ------ ,'�,'�'
-..
Installer
at--------- i � nth 1. � -'---•••--••• ..... ••--•-••---•-•--•--••---........-•-•--•-••.........................
has been installed in accordance with the visions of TITLE j of The State Sanitary Cq� as de• ribed in the
applac tion for Iisposal Works Construction Permit No.__ _: a_A_ �.-_.. dated. -..__ . '' S.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FU�NCIION SAYISFACTORY.
DATE.... ... --•--......---•-•----•--•-----....... Inspector.....-- ..............U. .. . ......&.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH w
<7 O F.... :..: .............................................................. _.No. ��y' 5 FEE._.
Disposal Works Tnnstr ion rrmit
1 Permission is hereby granted............ a-- ---------------------------•------------------------------------------
to Construct ( �,or Repair ( ) an Individual Sewage Disposal System
atNo.:••--•••••-- ..........---- •....% ............................................ ...................•-- ... _.........
Street j
as shown on the application for Disposal Works Construction Permit No.._.. .:-�..... Dated.._.--:-.t.- 40-c.................
................................... - --- 4X� ---------------------------------------
Board of Health
DATE------.......Jtit , ---------=--------------------------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
_
- -
F....,, . .. . __.. .. .-._,: a ,:,. —. . ..,... .. .. ._... :._... ,: ,. :.,... .,.,.,,.. .;. ..... .-
l -
•r
_
b.,. , <,
PR FIL E
SYSTEM O
T N O 'TO 'S ALE
TOP FDN.
FINISH GRADE FINISH GRADE OVER
FINISH GRADE OVER bIST. -BOX �� � FINISH, GRADE OVER
;o 4� . 0
.,.,.o.,o SEPTIC TANK
•.e...0,.o LEACHING PIT 4'�
0
-Oro
.,
3 ::o Q..o: VARIES
3 OF
112
,
e. . � e A., ..4e. .... �...b..d....a, .o: ,'Do.o........ . . o..o..o.c.c .Q 12 : PRECAST CONC. OR
J ;•a o,• a 4: 4: WASHED PEA STONE n
�' '•' ��• BRICK 6 MORTAR
a OUTLET PIPE LEVEL q N :. „
J2 0, TO 12 BELOW GRADE
r.
FOR 2 FT. MIN. y
A.•
4
I O.R.a.v u b .t•. m, n d •• .., 0.'•a'• . .
R VC TEES
C. I. O P ::.� 4'..:,c5'� .�.:.•.:•.,o. :d•
r
�. e
. • BSMT. FLR. .•..,.. f, e '
I :. • ::a. .. GALLON. :a I• :•' e.
EL o . . n a. DI TRIBUTION BOX
„ o• ,�;� a
! ..-a;° a, •� INSTALL ON LEVEL BASE 3/4 TO ?-1/2
:.o:ro PRECAST CONCRETEPRECAST
'
WASHED
H l'0 REINFORCED CRUSHED
I CONCRETE
o p: STONE
. :.'.
Q • • .�, 4A• d•.X.... .¢..a.Gr,A•A .e.D O •.O..O,•. .•. .b• 4 •• ;
. Q,,�. .d. :o..� .. :4..o.. . 'O.. ;atr C►'.'G?i:0.....4.Y?•.R b..$.d I
I
H 10 REINF.
f
SEPTIC TANK Ia::. •••. . .. .. a.,.
INSTALL ON LEVEL BASE of o oa. ,o, •,o.o o.
, NOTE. EXCA VA TE TO EL EV. ��! OR _ a•' '"'
L OWER TO REMO VE A L L IMPER VIOUS _ • _ _._ ._ ...
MA TERIAL BENEA TH THE LEACHING AREA
REPLACE `EXCA VA TED MA TERIAL WITH 6 6
CL EAN. CLA Y FREE SAND �y
/w,
:.
too
� I
EFFECTIVE DIAMETER
i
d LEACHING PI T
,
GENERAL! NO TES
V BASE
N `LE LEVEL
,,�
: . INSTALL O
N SHOWN ARE .BASED ON S UM �' D
?. ALL ELEVATIO S O �#
2. ALL PIPES IN THE SYSTEM MUSTBE CAST IRO
OR SCHEDULE 'AO PV
C._
-- - T
RVA TIDN: .,:/�' w
: OBSE I
NOTIFIED
T BARD OF HE L TH:...MUST BE , .
3. HE O ,
CTION s C MP ETE PRIOR
WHEN,,CONSTf�U I O L
- - :TO BACKFIL L ING ,
PERGOLA TIDN RATE."
_
IN. IN. _M /
T .r ,..
_ 4. ANY `CHANGES IN HIS PLAN..MUST BE..APPROVED
, .,, WITNESSED B Y. _
T BOARD, F TH ' ND CAPE 6 ISLANDS
I D
�cpsr CanrC�rE � BY HE -BOA D 0 ,.,.HEAL A
P T„ LEACHING I
V Y NG CO.: . NC.
„ . : SURVEYING . I
A T ALS AND 'INSTALLATION SHALLBE IN. �-
s. BRO. OF HEAL TH
. „ . DESIGN : DA T
`,.,ca. �.a ca . , COMPLIANCE KI TH rHE STATE SA TARP _ A
DA TE.
— _ `_ _ ,� _
CODE TI TLE V _AND LOCAL APPLICABLE
f1; .t'?
,1?,�
04
s is
. RULES AND REGUL�I TIONS
M R
Z k
NUMBER OF BEDROOMS ,
_ o +v t
1 ROW. IS:'.FROM R CORD PLANS AND
6. NORTH AR E P �
_.
L -� � � GA GE DISPOSAL
� � <IS-NOT TO- BE USED FOR SOLAR PURPOSES
C
. v
.. . ,« A - _ DA L_Y-FLOW - GP
7. FLOOD HA D ZONE I D
B. WATER SUPPLY w� 4�� �,,�' _.
, SEPTIC TANK:. RED b. GAL
a o c
�^• _ . SEPTIC TANK: f�ROVIDEO GA
\ , c-
LEACHING C I C REQUIRED GPD
I ,
i
es
� � SIDE�ALL AREA 7 S.F.
i
? S. F. X G S.F.. � GPD. .
,
O�� C.�
BOTTOM AREA.. .. S.F.
r
Z- , l O _ 1Z LEGEND S. F.X G/S.F. GPD
- ,
LEACHING. PROVIDED GPO
-;►
I.._. . ca 5,`t .a •�•a \N
PROPOSED ELEVA TIDN.
y i rr
EXISTING CONTOUR
x
SINGLE `FAMILY 1-�ESZL7ElVCE
'h OBSERVA TIDN- PIT
000 SALLOW
PRECAST CONCRETE ✓ _.._._.
DIStRIBL TIDN BOX -
�. r, ,
_ T TAW
i'
PROPOSED':.... SE AGE DISPOSAL SYSTEM _
, L
-
.;,. . ,LEACHING PIT .._ d
..:. pia,' ^ • O ::. :. r-.f
;- -. PRE RED `FOP
0 o SEPTIC TANK
EL7MUND FL YNN
_ RP I ,t RESERVE PIT AREA ,�
.. �. a . LOT 9 . S TGNEHEDGE DPI VE.
J : r
»,
v�
D
B A S ABLE MASS .
PIPE INVERT ELEVA TIDN s
ANICKI
DA TE.
,G
l
' w
y
CAPE '6 ISLANDS SUR E ING INC.
I PLOT PLAN
. ''
, .
_ . SCALE AS NOTED
,
, P. 0. ..BOX 334
SCALE. ?
, ... _ ,
PLANNO. �.,� . f TEA TICKET MASSMAP EC PCL LO ,
.'
._