HomeMy WebLinkAbout0515 BAY LANE - Health 515 Bay Lane, Centerville
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UPC 12543
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No. d` � � Fee �/
THE COMMONWEALTH OF MASSACHUSETTS Entered in corn
'pater:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppliLation for MispoBal *pstem Const union VPrmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No. J l S " L.Cj-,R- Owner's Name,Address and Tel.No.
Assessor's Map/Parcel C_tp`"r ` -
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel..No.
S Cv \� Vrw-4� l\-3 0(c j,-uv'(\Nft
Type of Building: 1A,7t--��S
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) C&,. " e 1A C7 Q(-,�1L�% A-0 a U
9 Q M(
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.
d Date 112 7 /l of
Application Approved b Date
Application Disapproved by Date
for the following reasons r�
Permit No. ' �'c� o�� Date Issued (y
No. •O Fee V
THE COMMONWEALTH OF MASSACHUSETTS -m Entered in computer.
Yes
PUBLIC HEALTH DIVISION -TOWN.OF BARNSTABLE, MASSACHUSETTS
application for Misposal i&pstetn Construction Vermit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Z/ndividual Components U
Location Address or Lot No. S` S c n 2— Owner's Name,Address and Tel.No.
Assessor's Map/Parcel I Y-) 0 `�
l� � va V O 1\ �' 1 In
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
SC A C-4 v�R
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) C u UX A-o a U J
QDoX
- 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.
d Date �. 7 _/_1 ;L
Application Approved b Date �7 1
Application Disapproved by Date
for the following reasons
Permit No. �('? Date Issued 15�
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
y Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( VK Upgraded( )
Abandoned( )by
at C,--I l c���g,�IS(rV���� has been constructed in accordance �
with the provisions of Title 5 and the for Disposal System Construction Permit NaOD 19-ao b dated (Qj 4 J 2 )w
Installer C�j C�"(itJ�k4— Designer
#bedrooms h i A-- Approved design flow /A and
The issuance ofthis pe it shall not be construed as a guarantee that the system will fti—notibn as design d.
Date n 201 Inspector
i
---------------------------------------------------------------------------------------------------------------------------------------
No. C>f ^ �) 0 ( Fee (�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction i3ermit
Permission is hereby granted to Construct( ) Repair a/' Upgrade( ) Abandon( )
System located at S ( S ��. c,.�Q_ C-
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 Pe comple d within three years of the date of thi permit.
Date (� p� Approved
II
1
TOWN OF BARNSTABLE
LOCATION �� S" rY Lw\-e SEWAGE# ,DUI a - M1,
s
VILLAGE `ASSESSOR'S MAP&PARCEL J?7-0,�%
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Q-)<4S} LOG O
LEACHING FACILITY:(type) e�,L(,� �c (size)
NO. OF BEDROOMS Ap RbJC PRf ta(e-^,-t�
OWNER ^/ `-� 00 ®^I
PERMIT DATE: `p (2.-7 \2.. COMPLIANCE DATE: bs 1'l 2,
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 �S
300 feet of leaching facility) ✓V l.� Feet
FURNISHED BY
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Town of Barnstable Barn
BOARD OF HEALTH a14medoaft
'"M„STABM ' 200 Main Street, Hyannis MA 02601 I
2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.
Junichi Sawayanagi
CERTIFIED MAIL# 7011 0470 0001 4525 7178
June 11,2012 .
Mr&Mrs Herbert Vollmann
515 Bay Lane
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
• The septic system located at 515 Bay Lane, Centerville,MA was last inspected on 5/7/2012,by
James D. Sears, a certified septic inspector for the state of Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes" under
the guidelines of the 1995 TITLE 5(310 CMR 15.00).
You are ordered to replace the Distribution Box within two (2)years from the date
you receive this notification.
It is recommended that the septic tank and leaching pit be replaced with a heavy
duty (H-20) load bearing tank and pit due to its location beneath the driveway.
Another alternative would be to relocate the driveway.
PER ORDER OF BOARD OF HEALTH
o as McKean, R.S. CHO
Agent of the Board of Health
•
4
Q:\SEPTIC\L.etters Septic Inspection Failures or Future Eval\515 Bay Ln.,.doc
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rip-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
OwneHerb Vollmann
inform
nform Owner's-Name
information is required for every Centerville MA: 02633 5-7-12
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms OF
on the computer, `��`���5�.... Ss9�;0�
use only the tab 1. Inspector: 0
key-to move your p t) b5 ���;• JAMES
cursor-do not ___V•
James D. Sears ad�c
use the return ; SF —
key. Name of Inspector
Capewide Enterprises, LLC %�''••�' °
Company Name %��TFli'TIF��•'"0���
IL�I P Y INS?
153 Commercial St.
Company Address
Mashpee MA 02649
City/Town State Zip Cade
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CHAR 15.000).The system:
C5
❑ Passes ® Conditionally Passes ❑ Fail
eeds Further Evaluation by the Local Approving Authority t`
5-9-12
pector's Signature DateVA
a
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.
""This report only describes conditions at the timeof 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.
2)
t5ins•11110 Title 5 official in F •Subsurface Se wage i Qsposal System•Page 1 of 17
t
`f Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owners Name
information is required for every Centerville MA 02633 5-7-12
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Note: See aft page
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
' A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins.11/10 Title 5 Official Ins
pection Foam Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is Centerville MA 02633 5-7-12 required for every "
page. City/Town State Zip Code Date of Inspection
B.. Certification (cont.)
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):
Need to replace D Box
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
® Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11l10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,N any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
a ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
Part of leaching pit under stone driveway, Note: H- 10 Pit
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than Y2 day flow
t5ins•11/10 Title 5 Otfiaal Inspection Fonn:Subsurface Sewage Disposal stem•Pa
ge age4of17
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown 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 groundwater elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this 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 fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Tate 5 Official inspection Form:SubsuAace spedi Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. City/rown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): . 3 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•1 Ill o rife s Official�sPedion Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
ssystem is a 1000 Gal, Precast tank D Box and Pit H- 10
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2010�4,000GaI
g ( y g (gp ))' 2011 -72,000GaI
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commerciallindustrial 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•1100 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of,the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sew
age Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Jy< 515 Bay Ln
Property Address
Herb Vollmann
Owner owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
1980
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
4" PVC Pipe
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
F
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal Precast
1„
Sludge depth:.
t5ins-11l10 Tine 5 Official In
spection Form:Subsurface Sewage Disposal System•Page 9 of 17
r
Commonwealth of Massachusetts
Title 5 Official' Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is require for every Centerville MA 02633 5-7-12
d
page. Cityl-rown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
•
Distance from top of sludge to bottom of outlet tee or baffle 29°
Scum thickness 2„
Distance from top of scum to top of outlet tee or baffle 811
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape-Asbuilt
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 1" below grade w/inlet cover at 7", inlet baffle, outlet Tee, 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 top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11l10 We 5 Official Ins
pection Form:Subsurface Sewage Disposal System•Page 10 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title ,5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
` Depth of liquid level above outlet invert 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"x 21", 18" Below grade, Walls are gone , H-10, Need to Replace Box W/H 20,
D Box is located in stone driveway
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.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11110 Title 5 Official Ins
pection Form:Subsurface Sewage Disposal System•Page 12 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
y� 515 Bay Ln
Property Address
Herb Vollmann
Owner Owners Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is one 1000 Gal Precast Pit, Pit and cover at 16"below grade, 6"water, stain line at
18", No sign of over loading or carry over, wall's clean like new/ Note: Part of pit under stone
driveway
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
UV
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
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.):
t5ins•11/10 Tttie 5 Oftai In
spection Form:Subsurface Sewage Disposal System•page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
15 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°< 515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is
required for every Centerville MA 02633 5-7-12
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sevvage Disposal System•Page 15 of 17
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' Commonwealth of Massachusetts
a Title 5 official Inspection Form
F
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
° Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12+
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: 8-6-80
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H. on Design plan 8-6-80, No water at 12+ T.H. on plan bottom of pit at T-4"
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-wage 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary:A, B, C, D, or E checked
❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
❑' System Information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attach in
9 P Y p g attached separate file
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17'
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information �auuuum►►►►►,
filling out forms `\������1N OF�As
on the computer, o�� .• ••••..,.Syc���
use only the tab 1. Inspector: o�' •'•yG
key to move your :�: JAM ES '•N= --
cursor-do not = '
James D Sears
S :
use the return � -•-.—
ke Name of Inspector SEAR 4 0n
Capewide enterprises, LLC -•�•'FRTiF��o:•o�
Company Name ''�i, N SP�G
153 Commercial Street nuu111,0 `���
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5-9-12
blEpectors 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
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.
t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check .A,B,C,D or E/always complete all of Section D
A) System Passes:
❑:I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N_ ❑ ND(Explain below):
t5ins-11110 Idle 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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):
Need to replace D Box
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t5ins•11f10 Tihe 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
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 must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ E the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
F
1
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health_
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
system is a 1000 gal, Precast tank D Box and Pit H - 10
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 0 No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2012 -64,000GaI
g ( y g (gPd))' 2014 -72,000GaI
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping.Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box,.soil.absorption.system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
A
1980
Were sewage odors detected when arriving at the site? ❑ .Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑cast iron 0 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.): ,
4" PVC Pipe
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: yearn
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
. Dimensions:
1000 Gal Precast
1,.
Sludge depth:.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Jy< 515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
2"
Scum thickness
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape-Asbuilt
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 1' below grade w/inlet cover at 7", inlet baffle, outlet tee, 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 top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
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: El Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current;pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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"x 21", 18" Below.Grade, walls are Gone, H'- 10, need to replace box w/H 20 D
Box is located in stone drive way
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.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching p�Its 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 one 1000 Gal Precast Pit Pit and cover at 16"below grade 6"water, stain line at 18",
No sign of over loading or solid carry over, wall's clean like new
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is Centerville MA 02633 5-7-12
required for every
page. Cityfrown State Zip Code Date of.Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where:public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
I
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13
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Citylrown State Zip Code Date of Inspection.
D. System Information (cunt.)
Site.Exam:
s ❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12+'
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: 8-6-80
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H. on Design plan 8-6-80,no water at 12'+ T.H. on Plan bottom of pit at T-4"
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
't5ins-11/10 idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Bay Ln
Property Address
Herb Vollmann
Owner Owner's Name
information is required for every Centerville MA 02633 5-7-12
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
❑ System information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
{ TOWN OF BARNSTABLE p
LOCATION balk �a -P- SEWAGE #
VILLAGE G2.t,V I le- ASSESSOR'S MAP & LOT N I Sk
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY L® 0 O a�(o
LEACHING FACILITY: (type) LOOO ag p ii (size)
NO. OF BEDROOMS 4-
BUILDER O OWNE 4eF-6e►-r� O�1YV�0.1nr
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
Furnished by
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8/28/9 tea•
PROPI=RTY A1:1DRE SS: ��1�,�;P--.-, T ;=.-rie
PRE9®ED
6,< , SEP 4yct
On the a =< c I Inspectad the septic system at the above adr+�_
Th a syc w-,O ccinsists of the following: `: g
1 / - 1 -1000' gallon septic tai-,k . •._
2. . 1 -1000 gallon precast leaching pit
k
packed in stone .
631 -pistribution box.
ased on my InBoection, I certify the following conditions:
1 . This is a title five septic eysLem' (. 78, Code• ).
2. The septic system is _i_n yp •oper working
order at the present time .
,IGNATUR!- :
Name: J. P . Macomber Jr•.
' P�r'.acomber & S -I,lc .
Company:__ ,
Centerville Mass : 02632
k
Phone:___
-:::: FI i UTE A GU :���N, C,2 V's',.Fffl�.NrY
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�.;�. cox ��u Lc:I:C:viyilz, fvii> 02rr32-GOuG
W*-,n Commonweolth of Mossochusetts
Executive Office of Environmentol Moirs
Department of
tivironmental Protection
William F.Weld Trudy Cox*
Gawrnor gw,Wy
Argeo Paul Celluocl David B.Struhs
tL Gowaxx CorrurJwJorwr
• s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropertyAddrosa: 515 Bay Lane Centerville ,Mas!:; AddressofOwner. 44 Nobska Road
Date of Inapootlon: 8/2 8/9 6 (if different) Woods Hole,Mass.
Name of Inapootor. Joseph P. Macomber Jr . 02543
Company Name,Address and Telephone Number:
J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage dispooal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposcil systems. The system:
./Pasaes
l`...._. _. _.anon Fay the Loe:J Approving Authority
Inapoctoes SiYna.t Date: 1�j
The System Inspoctts .ubmit a copy of this inspoctioa report to the Approving Authority within,thirty(30)days of completing this
inspection. If the system is a eharod or has a deign flow of 10,000 gpd or grouter, the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to thL =;.t owi:er and copies sent to the buyer, if applicable and the approving authority,
INSPECTION SUMhLIRY:
Check A, B, C, or D:
A) SYS 1'Ehi
I hive 11:t i.ndicater th::t the system violates any of the failure criteria as derm,>d in 31,0 Cj,rR 15.303.
tU1j 1:::1',:.:. •;..._. ... :..: .. .:.__...,,: u'v u,dl,.ato;i txaow. '
D) SYST_—i' Cv fi•:'i.v.._ — . ;i;J i:J:
ict 0ao or 1::C: '::: .._ _. .:t :;sod to be replucu.i or mpa rod. The system, upon completion of the soplicau:ent os repair,Pns3es
Lacll D Ls of dates in„tion in all instances: If'bot d .:
:,lruC.urally unsound, shows substantial inflltiation or ezmtration,.or iiu,ii iaiiu:v).0
t t h nt
.____._....... ..... .. ....... .•., r...:� "":r:. .Ci: if the e:as lllp pt1C tank 1�G replaced j'A Ol'n�up tic "Vud
^se I'e^li ed with a aPPn+
Uy, the bl:,a d of health.
(revised 11!"3/95) I
One V °i ",:!:: "_ aeh bstts r�2103 6 FAX(617) 556-1049 9 Telephone (617)292.5SW
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddreaa: 515 Bay Lane Centerville ,Mass .
Owner: David Delorenzo
Date of Inspeotloa: 8/28/96
B)SYSTEM CONDITIONALLY PASSES (continued)
A& Sewage backup or breakout or huh static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
It The system required pumping more than four tim-'. u year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_0 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
ILQ Cesspool or privy is within 50 feet of a surface water
—4, Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
d�D The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
42D The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
a
. V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 515 Bay Lane Centerville ,Mass .
Owner. David Delorenzo
Date of Inspection: g/2 g/9 6
D) SYSTEM FAILS:
416_ I have determined that the system vioLxtes one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the.
failure.
A Q Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of emuent to the surface of'the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
10 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
,tcd:dir
Liquid depth in cesspool is less than 6"below invert or available volume is less than ll2 day flow.
0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(,).
Number of times pumped
A2D Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
�► Any portion of a 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.
/ifs Any portion of a cesspool or privy is within 50 feet of a private water supply well.
dZ 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
ooliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
/f1(� 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)
The owner or operator of any such system shall bring the system and facility into full complono•with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Anther information..
(revised.11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 515 Bay Lane Centerville ,Mass .
Owner. David Delorenzo ,
Date of Inspootion: 8/2 8/9 6 •
Check if the following have been done:
,Pumping information was requested of the owner, ocWa at, and Board of Health.
None of the system components have been pumped for at least two weeks aad the system has been receivingl
normal rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection,
_41L built plans have been obtained and examined. Note if they are not available with N/A
-Al facility or dwelling was inspected for signs of sewage back-up.
, The system does not receive non-sanitary or industrial waste flow
- The site was inspected for signs of breakout.
►sr
All system components, excluding the Soil Absorption System, have been located on the site.
,,, The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of bathes or
tool,mntorial of construction, &,zonsions, depth of liquid, depth of sludge, depth of scum.
„ The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non•i.ntrusive methods.
, The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddioea: 515 Bay Lane Centerville ,Mass .
owner David Delorenzo
Date of Inspeotiuu: 8/28/96
FLOW CONDITIONS
RESIDENTLAI.
Design Slow: 6 gallons jJc'n C y �i
Number of bedrooms: -�
Number of current resident:[�
Garbage grinder(yes or no):_d_)�
Laundry connected to system(yes or no):��"
Seasonal use(yes or no):_&D J l
Water meter readings, if available: `.
Last date of occupancy: 1
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_&�ons/day
Grease trap present: (yes or no)A�)
Industrial Waste Holding Tank present: (yes or no)A,&
Non-sanitary waste discharged to the Title 5 system: dyes or no)_
Water meter readings, if available: IV/;"-
Last date of occupancy:
OTHER: (Describe)
Last date of oocupnnry:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
-d'A
System pumped as part of inspection: (yes or no)/ld'
If yes, volume pumped: d�� aallorw
Reason for pumping: 4J19
TYPE OF§Y9TEM
Septic tauVdistribution box/soil absorption system
40 Single cc, pool
4A Overflow cesspool
�2 Privy
Shared system(yes or no) (if yes, attach previous inspc,c-tioa records, if any)
AW Other(explain)
ROXIMATE GE of all components, date in.:talled (if known) and source of information: 2 /I )
Sewage odors detected when arriving at the site: (yes or no) _
(revised 11/03/95) 6
LOCATION SEWAGE PERMIT No.
L A,
VILLAGE
I N S T A LLER'S NAME & ADDRESS
ct��T �Mlti� ik� /LUs �C
f U I L D E R OR OWMER
DATE PERMIT ISSUED
vy.
DATE COMPLIANCE ISSUED qhp/z/
�. dl)
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SUBSURFACE SEWAGE UISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued) t
Property Address: 515 Bay Lane Centerville,Mass .
Owner: David Delorenzo
Date of Inspection: 8/28/96
SEPTIC TANK: (1'/ylGt��Vj�G
(locate on site plan)
Depth below grade:u-
Material of construction: concrete —metal —FRP _ uliiw;expluin)
Dimensions: W 4y/
Sludge depth::;ahl�
Distance from top�fludge to bottom of outlet tee or
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._ :Q
Comments:
(recommendation for pumping, condition of inlet and Outlet tees or baffle depth of liquid level in relation to outlet invert, structural
trity, evidence of leakage, etc.) Pump tarik__ever2- _ years ;Inlet ou ,
it .
- b> --signp of leakage
Reeded at
--e-e-e nt time.
GREASE TRAP. A1041Pi
(locate on site pian)
Depth below grade—
material of constrorti6n-.4Woncrete metal FR? utner(explain)
Dimensions•
Scum thickness:
Distance from top ut scum to top of outlet tee or baffle: IPW
Distance from bottom Of 'CuM I" bor101P- pl OUllel We or
Comments:
(recommendation for pumping, condi—n, of inlet and outlet tres or baffles, depth of liquid level in relation to outlet invert, structural
integnt , evidence of leakage, eta
(revised s/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
t PART C
SYSTEM INFORMATION (continued)
fi
Property Address: 515 Bay Lane Centerville ,Mass .
Owner. David Delorenzo
Date of Inspection:8/28 96
TIGHT OR HOLDING TANY-
(locate on site plan)
Depth below grader
Material of constntctiow4dooncrete_metal_FRP_other(e=plain)
i
i 1
Dimensions: 1 A
Capacity: AIA gallons
DesAlarm flow.---�ons/day
Alarm level.
Comments:
(condition of inlet tee,condition of alarm and Aoat switches, etc.)
�r
F
h
DISTRIBUTION BOX:
(locate on site plan)
i{{
Depth of liquid level above outlet invert:_ E
Comments: 1
(note if level and distribution isequal, evidence of solids mover,evidence of leakage into or out of box,etc.)
D-Box has equal flow;No solids carry over;No leakage in or out
of the D Box. No repairs needed ?at the present time.
PUMP CHAMBER:Zd6j ec
(locate on site plan)
Pumps in working order:(yes or no) L4-
• Y
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
i,
f
'4
IE
j,
(revised 11/03/95) 7 �, .•;;i
A ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontlnued)
Property Addn5.x
Owner.
Date of Impaction:
SOIL ABSORPTION SYSTEM (SAS):,Z
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type: leaching pits,number:
leachin8 chambers,number
leaching galleries,number
leaching trenches,number,length: 0
leaching fields,number, '----long:
overflow cesspool, number:
Comments:(note condition of soil, signs of hydraulic failure, 1 ve f pon ,condi ' ve tatio etc.
Soils Medium sand to coarse sand; o sns o "iy�raunlic,—ra'rnzx
or bonding: All vegetation is normai. No repairs neede! at the
Present time -
CESSPOOLS:t )CI
(locate on site plan)
Number and configuration: Alh
Depth-top of liquid to inlet invert•
Depth of solids layer.
Depth of stern layer. �l _
Dimensions of cesspool:_ _
Materials of construction:
Indication of groundwater:
iWkw(cesspool must be pumped as part of inspection) AM
Com;nent�(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
1 d n t+7 44,Al Y 5
PRIVY:A&.16,
(locate on site plan)'
Material,of construction: A�./� Dimension:_ ?1�
Depth of solids: V,*
Comments:snota condition of&oil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95)• g
SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION •FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L_SPOSAL SYSTEM: j
include ties to at least two permanent references landmarks. or benchmark.
locate all wells within 100 ' Centerville. Osterviller Marstons Mills
Water Company
428-6691
DEPTH TO GROUNDWATER
depth to groundwater
mat2od o.f .determin4tion or approximation:
ter•u,_ ,
sY,91 �n' was installed. 121
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N
0,5
ELEV
C14—
GAB. SET
6p'
/Doo GA
LI-ON
5EPT'IC TANK
H 20 TOP
/ T j P F L Nl
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14 s I U
► i U BOX
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C L. SET 1-- � C ELEV
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-
N'/U.
B/ \� L/�1 V E
DISTANCE AS CERTIFIED
HFREBY,CERTIFY THAT THE BUILDING SITE PLAN
I ON THIS PLAN IS LOCATED ON THE -LOT S PLAN BOOK 28_ __
ID AS SHOWN HEREON & THAT IT . ---._. LOCUS:_-___—__.---..--. K 5 PG_ 65
RM TO THE ZONING BY LAWS OF THE BAY I_ANf, CENT'ERVI LLE MASS
";ONSTRUCTED DATE ., __._._... - ^. r • J cr
P;; - P
REF:
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tIWII Cape englneer'Iag PREPARED ! : ; — CF':Fth<LEJ EIP�OSE`� ---
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V
THE COMMONWEALTH OF MASSACHUSETTS
x n --DEPARTIV"T =OK--ENVIRONMENTAL %OTECTIC
BE IT KNOWN THAT
Jose h--P. Md comber, -r:
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection
June 8, 1995
Acting Director of the - 'ion of Water Pollution Con
z
a•fmnrn —nrrsr-•rrrnrmrnTenrsrnrrre+rrrrmvsrrervrrrarrnnrn mrnir na�nsnese, •r.e-.+•e•�•-rlm+t+�:..nr.r••�
TOWN OF Barnstable BOARD OF HEALTH !
SUBSURFACE SEWAGE DISPOSAL SYSUM INSPECTION FORM - PART D•- CERTIFICATION
�./ �•••L19-T':•:: �T.ItR•tT.TT1T1T.11i•R.'TSI T'itT.'Rl1f7lIT7•TS•fT`IITCR`t Z7TTlP"TtRRR71<♦t RTRRiRi�Tn.T9 .{7II7{TtfiT7'[fltTRf►R.F•JRI•I'T'R•1/w.1•�
-TYPE OR PRINT CLEARLY
PROPERTY INSPECTED
STREET ADDRESS 515 Bay Lane Centerville,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME T)avid nP1�orPn9,.n
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. MAcomber Jr.
0
COMPANY NAME J.P.Macomber & 'Son Inc.
COMPANY ADDRESS Box 66 Centerville,Mass . 02632
Street Torn or City State E1P
COMPANY TELEPHONE 75 - 3338 FAX t 508 1 790 1578
,.
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that th.e information reported '.is true, accurate, and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , =and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
XXXXXXXXXXXSysteui PASSED
The inspection which' I have conducted has not found any information
which indicates that the system ,,fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails to
protect the j)ublic health and the environment in accordance with Title
6 , 310 CMR 15 - 30.3, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
r ► ..
Inspector Signature Date $/29/96
.�% One copy of this c •ification must be provided to the OWNER, the BUYER .
(where applicable ) and the 130ARD OF HEALTH,
* if the inspection FAILED, this owner or"9 " erator shall u P upgrade ' the system,
within one year of the date of the inspection, unless allowed or requi.xed
otherwise as provided in 310 ChiR 15 . 305 . '
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Public Health Division (�
Town of Barnstable
P.O. Box 534
Hyannis, Massachusetts 02001
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JTHE COMMONWEALTH OF MASSACHUSETTS
BOARD I-I E T F ll 3
Apphratilan for Disposal Worko Tonstrurffi n 1hrmit
llx�#, Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:,
......... ro - -------------------------------------------------------------------------------------------------
Location-Address t No.
•----------- c..a�........"-_-LLft er tQ^.------- 17 7--- es�.c.�► d �l: r:lle.
W Owner Address
- ---------------------------
•--
Installer Address---•- '------------•----•----- ------------
� -
UType of Building Size Lot........:f ______________Sq. feet
Dwelling=No. of Bedrooms........X?...............................Expansion Attic ( ) Garbage'�Qrinder ()Id
aOther-Type of Building ....Vffnfto....... No. of persons____________________________ Showers ( ) — Cafeteria ( )
Other fixtures . -----------------•------------•----................
Total daily flow........J3Q.......................gallons.
WSeptic Tank T Liquid capacitylbOA_gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.________..�__._:__.Total leaching area....................sq. ft.
Seepage Pit No........I........... Diameter....&.3_...... Depth below inlet_.__.4jR_�......� tal area...s%0-r(....sq. ft.
Z Other Distribution box ( ) Dosin tank ( ) )6 V
aPercolation Test Results Performed by.___ ___ �l rI!l)-hPiZkDate...P�.-_lP_.........................................minutes
44 Test Pit No. 2................minutes per inch Depth of Test Pit............_....... Depth to ground water........................
a
Description of Soil 1� " °t -� _.5.-----�... _ - _ ........
v.
U --------------- -o�` 12- � - --_-_----------------•----------- - -
W
U Nature of Repairs or Alterations—Answer when applicable---------------------_....................................._...................................
----.._...-•-•••••-••-•-••---;---•----•--------•-••-•••-•-•----••••----•-•-•--••-••...................•-••-•---------••---•---------•-•-=---•--•-•----•••----•••••--•---•-•------•.......__.....__--•-•-
Agreement:
. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig ................. ----ll"_o.4 ----"_..
Date
Application Approved BY_
Date
Application Disapproved for the following reasons_______________ _____________________________________________________________••-•---•--.--....-----...----•-_--
.................•---•-----•------------...--•••---...--••---..._-•---•---...-•--._......-•---••••--------•---••....••••-•-••••----••-----••-•-----------••----•-•--••••-------•-•-••-•--•••--•----•----
Date
PermitNo......................................................... Issued_.......................................................
Date
IT No 1,:�
.......... ........... -.10...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE
......... OF. ..............................
Appliration for Utspaoal Workii Tonxitrurtion Vilmit
Application is hereby made for a Permit to Construct (K) or. Repair an Individual Sewage Disposal
System at:
r,(,IN 0-r 9
IL. ...........
!!�LA_Z.......... .............. .......................................................................................
Location.Tj5ress Lot N
,7.3 t L e........L".L T.%.mcr.j t 3 n.q.r . I.�.......... ............................ t,N...........
Owner Address
----------------------------- ----------------------------------------- --------------------------------------------------------------------------------------------------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.....__." _...............................Expansion Attic Garbage Grinder (Wo
Other—^ Type of Building ....RosaP4....... No. of persons............................ Showers Cafeteria
Otherfixtures ........................................................................................I.............................................................
Design Flow......L-6.............................gallons per person per day. Total daily flow........ Z-0.......................gallons.
9 Septic Tank-�Liquid*capacityl.Oia.O.gallons Length................ Width........_._..__. Diameter._.........._... Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. f t.
Z 00 g
Seepage Pit -No..--.-.I........... Diameter.... ....... Depth below inlet____J&........... ,�ta 34.1....sq. f t.
Z Other Distribution box Dosing tank ( -Percolation Test Results Performed by..... ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit........._._......._ Depth to ground water_....._.__.._.._...__...
Test Pit No. 2................minutes per inch Depth of 'Tpt Pit.................... Depth to ground water_.._.__......_......_...
P4 . ........ -----------------
.................................
ia* ------------
6-----_---- ...... - I_-
0 Description of Soil._... .... ...
U -----------------------7m.../A...... ----------------------------------------------------------
....................................................................................................... .......................................................
U Nature of Repairs or Alterations—Answer when applicable"' ..............................................................
.................................................................................................... ..................................................................................................
A:&eement:
The undersigned agrees to install the aforedescri.&d Individual Sewage Disposal System in accordance with
the provisions of TLITIE 5 of the State Sanitary Co&— The undersigned further agrees not to place the system in
i*I.'
operation until a Certificate of Compliance has been issued.by the board of health.
Si .... 'ki
. ... ................ ... ..... . ....
Date
ApplicationApproved By....... ... ................................... ........................................
Date
Application Disapproved for the following reasons:................ ...............................................................................................
..................................................................................................................................................................................................
Date
PermitNo................... .................................... Issued.......................................................
4, Date
THE COMMONWEALTH. OF MASSACHUSETTS
BOARD Z HEALTH
0 F........ .4/.#.*
..............................................
Trrtffiratr of Toutpliatta
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed or Repair4
by-- .................... ............................. ........�4i..... ----
Ins
a-
...................... y...........................................................
at........ .We 4w-
�W� rp
has been installed in accordance with provisions of 5 of The tate Sanitary Code as d,,cribed,4*n the
application for Disposal Works Construction Permit No.0.14�;_J............ dated......//....................................
THE ISSUANCE OF THIS. CERTIFICATE SHALL NOT BE,CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL' FUNCTION SATIS FA-C TORY.
DATE............................................ Inspector""-.._........ ............................* . T .....................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD... �e, ..... 0 `%� �..........L , r"HEALTH......OF..... . . �-.-
e
No................ ...... FELrd
Permission ip�ereby granted.............. ....•......
or Aair (F h In &SPO .'t---------- . ....... -----------------
A> ..... ......... .. ............ --------------------- ............
at N
to Construc 7. 1 LE
Street
�4./Zr� 7. ............................
as shown on the application for Disposal Works Construction Perm' o......... Pated...... ............................
............... . ...................
.........................
Board of Health
DATE.......... .......... .... . .... ........................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
' r
(( CATION SEWAGE PERMIT NO. ,
V,lLLAGE
oso
INSTA LLER'S NAME i ADDRESS
- 0- F—roh1l'o
ti
BUILDER OR OWNER
C IRp64Y
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ���/�/
_;
�� .�'
/$yam:_
`_ b
$ `A'� ` � -
COY I[i!1
G�
LOCATION -- � ,, SEWAGE PERMIT NO.
�j
v 4Y-LA,
VILLAGE f
INSTALLER'S NAJAF & ADDRESS
• u I t 01: R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUEO
I
A
y
Strebe Health
Commonwealth of Massachusetts
Date
Then personally appeared before me the above named Vincent E.
Strebe
and acknowledged the foregoing statement to be his free
act and deed.
Notary Public
My commission expir
es :
Page 5
off. 508-362-4541 COVE ISLANDLOWS
I fox 508-362-9880
down cape engineering, inc.
r
CIVIL ENGINEERS to
w
LAND SURVEYORS o
v
BEACH
939 main st. Yarmouth, ma 02675 1n
BAY LANE
LOCATION MAP (NO SCALE)
LEGEND
OAK
JIL
PINE
HOLLY
PROP. WORK LIMIT LINE
OF STAKED SILT FENCE
ti
OS �
.95
e � N
1D93 e p + 9 N
l
`s.10 �19. \r �`+ �r '.7a1 r f54.00
DECK ry
1 94\ ! 91 1 `r 46
+hj��7s a ROP. +z z
?998 `� +z3.4CD'N.
.16 1 23.36 LOT 8
\ \ 08
23,960 sgftt
I+2171 1 23.59
EXIXI T. AT y� 23.52 srsT.
I I � / EXISTING o 0 o a
DWELLING o
FF m 25.8' O R o>
LEACH
PIT r _
+2375
. I - (APPROX.LOCATION)
50,
scorn:PATIO
J"b ��/ M1 Z GAR.
P /
h
E
MARK — TOP OFETE BOUND
16.07
NOTES:
1. ELEVATIONS NGVD
2. FLOODZONE EL 11 AND C (HOUSE IS IN C)
3. ASSESSORS MAP 187 PARCEL 56
4. ZONING: RD-1 (30' FRONT, 10' SIDE)
5. ROOF RUN—OFF TO BE DIRECTED TO DRYWELLS
6. REF. ORDER OF CONDITIONS SE3-3780
(PIER, DECK, RESOURCE AREA APPROVALS) *f m 011 �
7. SEPTIC SYSTEM SHOWN AS PER AS—BUILT PLAN SHOWING PROPOSED ADDITION
(NOT CONFIRMED IN THE FIELD)
OF
jH OF 44
S 515 BA Y LANE
yGN IN THE TOWN OF:
ARNE
o. y (CENTER VILLE) BARNSTABLE
348 PREPARED FOR: HERB & PRISCILLA VOLLMAN
�q E S\ 3 �fa�
30 0 30 60 90
ARNE H. OJ PLS DATE
SCALE: 1" = 30, DATE: MARCH 18, 2004
00-246
REVISIONS BY -
-----------------
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L_ RmF I KIN- I 1 SASE l - ID•rw Trew N
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9 II �iCMb•'Mfg(!•O" -1 F?t31 .. 2°W4D INSOUTror' DfuWN Df� 4
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GJ E c o hl 0 F L 0 0 R P LA N SULESHEM
: y4"-110'{ 2o'F�I mnc °e
1 a 2
1
SECTION - SEWAGE
N
'
—SEPTIC TANK:- D"'BOX — — LEACH 'PIT ELEV MARSHGF'\P,��•• �^
TOP OF FDN S S"�`( 6�
- - -?�- - (MSL)x
"2"OF 1'8TO 1/2" /
WASHED STONE
2d
:,,a t 'a ,7 �. l�i
r ;
e r
_ �CB. 'S ET
r
IN-
OUT - IN - ,• YjO S t K 5rT
OUT» {x,3
x0 1 -
- ----I j
2 1,2p ^, li SEPTIC c't
- TANK 0 .,.;' C'O.O J / r-t o x'; .. \ i 1 \1Y` �•
----
------
ELEV. ELEV. ELEV. ? �.• \ , /
ELEV.
ELEV, ELEV.
OF 3/4" 11/2'
WASHED STONE 3O
4 ± -~ _ ON
BE•DRM � 44r+ ipEPT►GALAN
,
- S C T K
H TOP
TEST HOLE LOG , P' F•D}N(
R F l I F EFIA t `{I\ -vJAI_li. U a .. ., - _ `� --' CJ•(i' • "`Y I s L'•tom.
TEST BY \ T�t<+ =2Sr
[: WITNESS f
TEST DATE j3iu,N` Y;t; nF HF-,t-_T F+ DESIGN
--_._- BEDROOM HOUSE �1
T.H. # 1 T.H. # 2 -
v
.y_,<- .--- ELEV.�3,� (_'�/i<1'w NO - W '�7,
{-C�f�4v1 1 ` P f D eox
_ .,�,�-- .�_._ e_LEv. �c_ - DISPOSER � DISPOSER l �kl ' � .--
0 P RC RATE��C_—MIN/IN. -- — — 10 0
DP� AIL :J TH. l� � � -- ), {
FLOW RATE ��O (GAL./DAY) I
SEPTIC TANK ;_.3 0 (l.,`j
SAND K SIZE
y
r_ REO'D SEPTIC TAN �
42 C(�, ��" I .v LEACH FACILITY { ,\�\�
(3�.�\rEL �RA``EI ;SIDE WALL __:1 �� (2.,5) = _ G/D I i
c !BOTTOM J7, ( t ,O) s - i` G/D.
84"— ! �.8 -- I 0 I TOTAL = 4`57 G/� - �� _ \
- z2
F
� ---- is �,` � I
"A N C SAND
ON, E � DP 8.5D!A. PIT OF C.B-
J, J USE; __ _:.._._.._ —. x -- LEACHING _ — - I
I ) _DEL-E\z - ( I
n _. —`
J U .—CATER ENCOUNTERED � -- ---�-- .—.-�� __ .., •. C.B 5E 4 - ( C.
-- I I B SET_ .
PEPCOLATI ON T-EST RESUI_75S -3n IN 23, MIN - (LES5 THF,N '2MINJ/iNCH) 20` _
_ 4
NOTES t
20
UrILLS- 0IHEHWISE NOTED) _ _ _ __ _
EDGE 49 _ . _ 19.V- -
1. DATUM (MSL) + TAKEN FROM . _l�+/S'`.r- J (JC PAVEMENT
iENT R //-\Y
2.MUNICIPAL WATER------------15._----__-_-•,. _.`__-_-AVAILABLE 4_.J 1 f LANE
3. PIPE PITCHS't/a"PER FOOT, ^yr }t Q r(
4. DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO -.__- -__.____ _-_'_�44
74� .t�/"aM �y _� AS CERTIFIED
5. MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) Fl. � DISTANCE
6. PIPE JOINTS SHALL BE MADE WATFR TIGHT /4 H.
`7.CONSTRUCTION DETAILS TO BE ACCORDANCt WITH COMM.OF MASS. 1.7
Q PLAN
STATE ENVIRONMENTAL CODE TITLE 5 i'Y �� ' I HEREBY,CERTIFY THAT THE BUILDING SITE PLAN
SHOWN ON THIS PLAN IS LOCATED ON THE
�a�, C.+ C . < OUND°AS SHOWN HEREON &THAT IT_:�--_ LOCUS: LOT 8 PLAN f�C)OK 285 P(5 6
Cie r€3 { ice:
CONFORM TO THE ZONING BY LAWS OF THE
\:r
f ____ _ eAY L_A1� cEf�TERVILLF- �^�S.
TOWN OF -- -
REG.P I'd 1V1`!'L ENGINEER WHEN CONSTRUCTED, DATE BK P85 PC 6 J
I REF:
,
down cape engiaeeriag CHA\RLF_S e11POSE."�t`
f � PREPARED FOR:
CIVIL ENGINEERS
LAND SURVEYORS _-- _ - �.._. ._-
I ` BOARD OF HEALTH REG.LAND SURVEYOR tit 4 i
(EXISTING)
CONTOURS _ scaLE , 1 : --:3025 8C3
(PROPOSED)-0-0-0-0 APPROVED DATE MA Yarmouth&Orleans,MA c
€, +J 79
4
DATE �Q
r
� r
x