HomeMy WebLinkAbout0996 BUMPS RIVER ROAD - Health 996 Bumps River Road, Centerville
A =
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UPC 12534
No.2_-9 R �,,, �
° MAiTINO� Y.N
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GI �9
99(, ` o n*S Ku e c rd Cw4',v 3 I fie,
Estate Of. Edward Sullivan ( Lee Sullivan
996 Bumps River Road
Centerville,Mass.
r0263/ .,
1 -1000 gallon septic tank.
2-2-1000 gallon precast leaching pits.
1 -Distribution box.
4 .Both pits were dry at time of inspection.
rr
DATE•_2/28_ 0---
l-
PROPERTY ADDRESS: 926_Bumps_River_Ro$d___
--Centg,L
__D2 fi l?------------------
On the above date, I Inspected the septic system at the above address.
This .system consists of the following;
1 . 1 -1500 gallon tank
2. 1 -Distribution box.
3. 2-1000 gallon precast leaching pits,
Based on my Inspection, I certify the.following conditions:
4 . This is a title five septic system. ( 78 Code )
5. The septic system is in proper working order
at the present time.
6. Both leaching pits were dry at time of inspection.
SIGNATURE-*Company; Jose.2h_P_ Naccmbor & Son, Inc .
Address Box 66
Centerville ` Ma__02632-0066
Phone:---508 775_3338_______
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P, MACOMBER & SON, INC,
Tanks•Cesspools•leachf lelds
Pumped L Installed
Town Sewer Connections
P.O. Box 6775•J33 Centerville,
MA 102632-0066
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-6600
TRUDY C
Sec-
ARGEO PAUL CELLUCCI DAVM B. STR
Governor Com.^;�
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CERTIACATION
Property Addre": 996 Bumps River Road Nam.of� . Estee Of Edward Sullivan
Address of Owner: ivan
DaUCenterville $ 02632 i c ro 9-.Berwick Mai
Nam of 4up•otton: �� /b0 Joseph P.Macomber Jr03 0�
Nart,.of hapector: (Please Pr{nt) p Cqj
I wn s DEP approved sy*Um InspecW pursuant to Section 16.340 of TW* (310 CMR 16.000)
compw-ry Nam.: J.P.Macomber & Son Inc.
M—T,+QAddr.sa: Rnx Fi(; CPni-excri 1-1 e., Mass . 02632
T"ph—Numb-: r5 nv°v---7r-7 5;3 3 o
CERTIFICATION STATEMENT
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 tnapectJon. The Inspection was performed based on my training and experience In the proper function snd
maintenance of on-site sewage disposal systems. The system:
.a
Passes
ConditJonally Passes
_ Needs Further Evaluation By the local Approving Authority
_ Fails I,�JJD,
Irupectors ?.h.II"./ubarJt
Data:The System Inspecto a copy of this Inspection report to the Approving Authority(board of Health or DEP)wW%ln thirty (30) days
compledng this Inspection. if the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspettor and the system owl
shall submit the report to the appropriate regional office of the Department of mv{ronmermW Protection. The odglnaJ should be sent to rw
system owner and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
'_ 6 2000
MAR
ToNN Of B*NSTJIBLE
r
v
revised 9/2/98 Page Iof11
C� Irintd on wow r.�e�
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
CERTIFICATION(continued)
ProprtyAckk—: 996 Bumps River Road Centerville,Mass.
°O'"""- E of state Of Edward Sullivan ( Lee Sullivan
2/28/00
INSPECTION SUMMARY: Check A, B, C, " D:
A. SYSTEM PASSES: �
I have not found any Information which indicates that any of the failure conditions described In 310 CMR 16.303 exist. Any fa+7we
criteria not evalusted.are Indicated below.
COMMENTS:
S. SYSTEM CONDITIONALLY PASSES:
.Ud One or more system components as described In the 'Condition&)Pass'section need to be replaced or repaired. The system,upon
completion of the replacement or repair,ss approved by the Board of Health, will pass.
Indicate yes, no, or not determined(Y, N, or NO). Describe basis of determination In all Instances. If'not determined',explain why not.
The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance(attached)Indicating that the tank was Installed within twenty(20)years prior to the data of the inspection; or
the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial Infiltration or exffhxation, or tank
failure is Imminent. The system will pass Inspection If the existing septic tank Is replaced with a complying septic tank as
approved by the Board of Health.
.�� Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed plpe(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 plpe(s)are replaced
obstruction Is removed
distribution box Is levelled or replaced
The system fequired pumphig-more than-fourtfinea-e yeardue to broken or vbstrncted plps(s). The system wiifpass--
Inspection If(with approval of the Board of Health):
broken pipe(s)are mplacid
obstruction Is removed
revised 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continuedl
Property Address: 996 Bumps River Road Centerville,Mass.
owner: Estate Of Edward Sullivan ( Lee Sullivan )
Date of Inspection: 2/2 8/0 0
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Aly 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 IN ACCORDANCE WfTH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH.WILL.PRQTECT THE PUBLIC HEALTH,AND SAFETY AND THE ENVBONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption System and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for collform 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. Method used to determine distance (approximation not valid).-
3) OTHER�Yll AV_
revised 9/2/98 Page 3orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (confirmed)
Property Address: 996 Bumps River Road Centerville,Mass.
owner: Estate Of Edward Sullivan ( Lee Sullivan )
Date of kupection: 2/2 8/0 0
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
_,Z2L I have determined that one or more of the following failure conditions exist as described 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.
Yes No i
Backup of-sewage into feciRtyror•aYete+n component due tto an overloaded ormbgged-Si0.S-orcesspod.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
/ cesspool.
41 Static liquid level in the distr' on bgx gbov�outlet invert due to an overloaded or clogged SAS or cesspool.
lin casspeeEis less than C6" below Liquid depth low invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped O,.
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.
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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
-coliform bacteria, volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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:
Yes No/
_!� the system is within 400 feet of a surface drinking water supply
the system ie-within 200 feet of.e-oibutery-too ourfaoo4gnk4,,V- ate+-supPly
the sY stem 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further infognation.
revised 9/2/98 Page 4or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B '
CHECKLIST
Property Address: 996 Bumps River Road Centerville,Mass.
Owner: Estate Of Edward Sullivan. ( Lee Sullivan )
Date of Inspection: 2/2 8/0 0
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system compomants kismai een prratpad►w.at-l"st two-%v*Ww awaltbe-aystem hasbaeoasceI;vW9 wratal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The 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.
_ All system components,1i ,Iuding 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 baffles
or tees, material of construction, dimensions,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. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C Is at issue,approximation of distance is unacceptable)
(15.302(3)(b)J
The facility owner(and.ocrupaats,if diffaraW lnfarmatioo cn.th&prnp&r maintaraa."f
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA
' PART C f '
SYSTEM INFORMATION
P► WtyAd&—: 996 Bumps River Road Centerville,Mass.
Owner. Estate Of Edward Sullivan. ( Lee Sullivan
Date of kupecti«u 2/2 8/0 0
FLOW CONDITIONS
RESIDENTIAL:
Design Aow:�_g•p.d./bedroom.
Number of bedrooms(de ign):_ Number of bedrooms(actual):_
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):�
Laundry(separate system) (yes or no If yes,asparatslupectlon.required
Laundry system Inspected 9 or no)
Seasonal use(yes or no)._4rs �'�
Water meter readings,If ava leble(last two year's usage(gpd):
Sump Pump(yes or no):1��4-
Last date of occupancy:
COMMERCU1LANDUSTRIAL;
Type of astabUshment:
Design flow: ( Based on 16.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present:(yes or no)-,&
Non-sanitary waste discharged to the Title 6 system:(yes or no)1
Water meter readings,If evallfb e:
Last date of occupancy:--XL/
OTHER:(Dsscribe) 'm
Last date of occupancy: 1
GENERAL INFORMATION
PUMPING RECORDS and s ur a of Information:
System pumped as part of in action:(yes or no)
If yes, volume pumped: gallons
Reason for pumping:
TYPE 0 SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
410 Privy
- 1117 Shared system(yes or no) (if yes, attach previous inspection records,If any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
46e Tight Tank _Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed{if known)-and source of4nforrt►ation:
Sewage odors detected when•arrlving at the site:(yes or no)
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:996 Bumps River Road Centerville,Mass.
Owner: Estate Of Edward Sullivan ( Lee Sullivan )
Diu of Inspection: 2/2 8/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade: i7
Material of go tructio _✓ast iro U40 PVC Zther(explain)
Distance troM private water supply well or suction line _
Diameter
Comments:(condition of Joints, venting,evidence of ilaakast,�Lc) —
Joints appear tight No evidence of loge
SEPTIC TANK:
(locate on site plan)
Depth below grade:!
Material of construction:Zcncr@t"-1Lm*t&W1Fiberglass4�2Polyethylene.(&other(explain)
If tank Is Enetal, list age&A Is.age.confwmed by Certificate of Compliance &/ (Yes/No)
Dimensions: ���iLcwrtb S//OlUic% 6-
Sludge dept�—
Distance from top of sludge to bottom of outlet tee orbaffle•.2;�!,Z —'
Scum thickness: T�,
Distance from top baffler
of scum to top of outlet tee or
Distance from bottom of scum to bottom of outlet tee r baffle:_2�
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, structuraHntegrity,
evidence of leakage,etc.) Pump septic tank every 2-3 years Inlet &
outlet tees are in place The 1 i aiii d 1 pvel at the nni-1 pt• i nvart-
no elziHejapsn of leakage.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: concrets•c�i metaW�Fiberglassy4 Polyethylenej�fother(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 41/t
Distance from bottom of scu m to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contlirwed)
Property Address: 996 Bumps River Road Centerville,Mass.
Ownw: Estate Of Edward Sullivan. ( Lee Sullivan )
Date of Inspection: 2/2 8/0 0
TIGHT OR HOLDING TANK:/ (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade: d/f
Material of construction:,I//tconcrete&Ametal,lLi FiberglassV�Polyethylene!/�other(explain)
Dimensions: Alh
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Ye3,!g NqA�*
Date of previous pumping: L4 _
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
T[Pub- nr Hn1 di ng T=nlrc ar@ not present.
DISTRIBUTION BOX:
(locate on site plan) /
Depth of liquid level above outlet invert: Alp
Comments:
(note if level and distribution is equal, evidenoe of solids carryover, evidence of leakage into or out of box, etc.) — - —
Distribution box has two laterals -No evidgncP of cnliac
carry over No Pvi apnrp of 1 eakaT ini-O Q-r—outr%f the hex.
PUMP CHAMBER:AZXV—
(locate on site plan) //
Pumps in working order:(Yes or No) N/¢
Alarms in working order(Yes or No)�i
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Pump chamber i c notpresent
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C I i
SYSTEM INFORMATION(continued)
PropertyAddrass: 996 Bumps River Road Centerville,Mass.
Own«: Estate Of Edward Sullivan ( Lee Sullivan )
Data of Inspection: 2/2 8/0 0 /
SOU.ABSORPTION SYSTEM(SAS)`y
(locate on site plan,if possible:excavation not required,location may be approximated by nondntrusive methods)
11 not located, explain:
Type. 1
leaching pits, number:_ O
leaching chambers,number:
leaching galleries,number:=
Isaching trenches,number,length:
lesching fields, number, dlmsnslons:
overflow cesspool,number:
Alternative system:
Name of Technology: Title Five 78 Code
Comments:
(note condition of soil, signs of hydraulic failure, level of pending, damp soil, condition of vegetation, etc.)
or �.5
house vent
CESSPOOLS: Ve—
(locate on site plan)
Number and configuration:
Depth top of Uquid to Inlet Invert:
Depth of solids layer: AJA
Depth of scum layer: AIA
Dimensions of cesspool: AIA
Materials of construction:
indication of groundwater:
inflow (cesspool must be pumped as part of Inspection)
Cesspools arp not Praccnf
Comments:
(note condition of soil, signs of hydrsuUc failura..level of pending,condition of.vegetation, etc.)
Cesspools are not prpcant
PRrvY:L4V__
(locate on site plan)
Mstsrjals of construe on: y� Dimensions:
Depth of soUds:
Comments:
(note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation;eta.)
Privy is not prPcpnt
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
• PART C 0 t
SYSTEM WFORMAT)ON(con*yjad)
PropenyAddre": 996 Bumps River Road Centerville,Mass.
Ownw: Estae Of Edward .Sullivan ( Lee Sullivan )
Dgu of Insp.ctbon: 2/2 8/0 0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmark•
locate all wells within 100' (Locate where public water supply comes Into house)
i0
O
S
i
revised 9/2/98 Page 10of11
99( 30"0!5 Kufr (d G( rv6 e'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C A 1#
SYSTEM INFORMATION(continued)
Property Address: 996 Bumps River Road Centerville,Mass.
Owner: Estate Of Edward Sullivan
Date of kupection: 2/2 8/0 ( Lee Sullivan
)
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater A6,/Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Site (Abutting property observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
f
Checked FEMA Maps
Checked pumping records
hacked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours Map.
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page 11of11
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1-
"OWN OF Barnstable WARD OF HEALTH
SOBSURFACR SEWAUF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
•••T.•t-T••. :•e—!..i/.�.�TT.1.1 fnl-.Tt.SI TR1f{9f TR'.►q'1:r�!.R�'11RT�il'R1�rT�IOV�/R�IA.�1t�7R7 A.R A
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 996 Bumps River Road Centerv(i3�lle,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Estate Of Edward Sullivan ( Lee Sullivan )
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph..P.Macomber Jr.
COMPANY NAME J.P.Macomber & Soif7 nc,
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City state LIP
COMPANY TELEPHONE ( 508 775 3338 FAX ( 508 ) 790 1578
n
A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete 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 .
• �t i Ilc{�I,
Check one :
Syste6 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 faiILIre
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 public health and the environment in accordance with Title
6 , 3.10 CMR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
61
Inspector Signature Date -I- ,/
ecopy of this certification must be provided to the OWNER, the BUYER
On
Where applicable ) and the BOARD OF HEALZ'It.
* If the inspection FAILED, the owner or operator shall upgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 . 305 .
partd .doc
l U it Ul' b AIC'N a I ski Lr-
LOCATION 504" SEWAGE `
VILLAGE �✓���iryl�l �. s ue - ASSESSOR'S MAP & LOT f g d
INSTALLER'S NAME& PHONE'NO.
SEPTIC TANK CAPACITY f 620
LEACHING FACILITY: (type) _ ���° � S (size) Aw
'4
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching facility (If any wetlands exist
within 300 fee of le ac ng cili y Feet
Furnished b
pw
®' _
® ' /' �-ol
I�A
1
J} '
DATE : 12/26/97
PROPERTY ADDRESS: 99 6--Bumps River Road
Centerville,Mass .
02632
On the above date, I Inspected the "ptic system at the -above aCdre86.
This system conslsts of the following:
1 . 1 -1500 gallon septic tank.
2 . 1 -Disttibution box
3 . 2-1000 gallon precast leaching pits, .
Based on my Inf�c�actlon, I certify the following condltlons:
4 . This is a title five septic system. (- 78 Code )
5 . The septic system is in proper working order
at the present time.
SIGNATURE :
Name : J . P . Macomber Jr.- r
-------,---------------
Company: J • P_Macoo)ber &_ Son _Inc
__Centervi l Le �Me99__02632
Phone : _5CZ_77_5_. 338_____-- i
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
(JOSEFRH P, MANMBER & SON, INC.
.• 7inkrCeupoolrl.eachlleida
Pump+d L Insullk
Town Sewer Connections
P.O. Box 60 ' Centerville, MA 02632.0066
7 7 5-3 3 3-8 7 7 5-b412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
3 C DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617-292.5500
N ILLIAM F WELD TRUD1 CORE
Governor SCcrCtan
ARGEO PAUL CELLUCCI DAVID B STRUFLS
Lt.Go%,cmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 996 Bumps River Road CentervilAj�ress of Owner:
Date of Inspection: 1 2/2 6/9 7 (If different)
Name of Inspector.:Joseph P_Macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J.P.Macomber & Son Inc_
Mailing Address: BOX 66 Centervillet MasG 09632
Telephone Number: 508-775—'I'I'I A
CERTIFICATION STATEMENT
I cenify 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date:
The System Inspector s all submit a copy of this inspection report to the Approving Authority within thirty (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 Depanment of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
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.
Indicate yes,_no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http://www.rnagnet.state.ma.us/aep
Printed on Recycled Paper
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 996 Bumps River Road Centerville,Mass.
Ov,ner: Edward Sullivan
Date of Inspection:2/2 6/9 7
B) SYSTEM CONDITIONALLY PASSES (continued)
L21D Sewage backup or breakout or high static water level observed in the distribution box is due to broken of oos:!_:-ec
pipe(s)or due to a broken. settled or uneven distribution box. The system will pass inspectwn if twits aporo�a, ^-
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets) The system —1; Dass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require funher evaluation by the Board of Health in order to determine if the system s fa,i,ng to protec-. :-r
public health. safety and the environment
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING 1,11 A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
A,0 Cesspool or privy is within 50 feet of a surface water
�2P 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 IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet to a sunace water s•.;pp•, o
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply -el;
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water svpD:, .e
The system has a septic tank and soil absorption system and the SAS 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 compo,nes nc:cates !ra:
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen ,s ee_a to o,
less than 5 ppm. Method used to determine distance t;r e' (approximation not valid)
3) OTHER
�Jl¢"
lr•v1�•d Os/]s/971 Pr.fl• 7 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 996 Bumps River Road Centerville,Mass.
Owner: Edward Sullivan
Date of Inspection:12/2 6/9 7
D) SYSTEM FAILS:
You must indicate ewer "Yes"or"No" as to each of the following:
VQ I have determined that the system violates one or more of the following failure criteria as defined in 310 CN1R 15.303. The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
-Z Backup of sewage into facility or system component due to an 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.
4/ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).
Number of times pumped_
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.
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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
You must indicate either "Yes"or"No"as to each of the following:
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:
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
N� 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 compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information
(rwiud 04/25/97) D.g• 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 996 Bumps River Road Centerville,Mass.
Owner: Edward Sullivan
Date of Inspection: 1 2/2 6/9 7
Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available wit"LA.,)
The 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.
r
,-/_ — All system components,.e luding 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
baffles or tees, material of construction, dimensions,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:
-/ The facility owner(and occupants, if djfferent from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
— Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) 115.302(3)(b))
(r—i—d 04/25/97) P.0• 4 01 10
/r
j
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properly Address:996 Bumps River Road Centerville,Mass.
Owner: Edward Sullivan
Date of Inspection: 12/26/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow. i .p.p./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):_
Laundry connected to system (yes or no):111)�,
Seasonal use (yes or no): 416'
water meter readings, if available (last two (2)year usage (gpd): !
Sump Pump(yes or no):fY�� jG'G '��J ag(J
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design Clow: / allons/day
Grease trap present: (yes or no)-,&/¢
industrial Waste Holding Tank present: (yes or no)d
Non-sanitary waste discharged to the Tale 5 system: (yes or no)
Water meter readings, if available. 141W
Last date of occupancy: A
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS d sorrc f information:
.ear s, %>`�,�., 12
System pumped as pan of inspection: (yes or no)
If yes, volume pumped: -- x/1 gallons
Reason for pumping
TYPE OF SYSTEM
�ASeptic tank/distribution box/soil absorption system
Single cesspool
�Q Overflow cesspool
W)/9 Privy
Shared system(yes or no) (if yes, anach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract(
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: ��//v -•
Sewage odors detected when arriving at the site: (yes or no)12
(—i..d 04/25/97) ➢.q. 5 of 10
SUBSURFACE SE»'AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 996 Bumps River Road Centerville,Mass.
0rner: Edward Sullivan
Date of inspection:12/26/97
BUILDING SEWER:
,Locate on site plan)
/f
Depth belo, grade
Material of construa,on cast iron 40 PVC _other (explain)
Distance from private wafer supply well or Bunion line
Diameter /'
Coin nts (condition of joins, ve trig, evidence of leakage. etc.)
z '� 'T
r c
SEPTIC TANK:Z'eVQ2)(9XW1�>u
!iou:e on srte plan)
I/
Depth below grade:,L
maier-al of construnion: /concrete _metal _Fiberglass _Polyethylene _other(explam)
if tank is metal, list age IL14 Is age confirmed by Cenlilcate of Compliance 1,4(Yes/No)
7 /
D:mens,ons� � � fj,,
Sludge depth.
D.stance from toff ssl^ud�ge to bonom of outlet tee or baffler
Scum thickness /YY7i�T'
Distance from top of scum to top of outlet tee or baffler
D.stance from bonom of scum to bond of outlet tee r baffle.r,
How dimensions were determined:
Comments
;recommendation for pumping, conditi of inlet and outlet tees or baffles, depth of liquid )eve m r.1 son to ou let inven. W c...a
magi ty, ev dent of leakage etc.)
�� .
GREASE TRAP:
;locate on site plan)
Depth below grade/1z-
•tisa:er�al of cons(ruction/Yr4 concrete4AmetaI+JFiberglass�Vi¢Polyethylenei<j other(explain)
Dimensions:
Scum thickness:—A,-�
Distance from top of scum to top of outlet tee or baffle:'&��
Distance from bonom o��f scum to bonom of outlet tee or baffle: IVA
D ry
ate of last pumping: ,r
Comments
irecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, sour. ra
,ntegnry, evidence of leakage, etc.)
/)54- 1 /' iJ7y
i
(nvu.d 0V75/971 D.y• 6 01 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 996 Bumps River Road Centerville,Mass.
Owner: Edward Sullivan
Date oflnspection:1 2/2 6/9 7
TIGHT OR HOLDING TANK:,//LtZank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:,U14
Material of con structionArconcrete/i$metal�V4Fiberglass///_//Pol yet hyleneel,�,Iidther(explain)
.fl
Dimensions: Il/�
Capacity:_ Rallons
Design flow: 4/24 -gallons/day
Alarm level:Al Alarm in working order, Yeses No
Date of previous pumping:
Comments.
(condition of inlet tee. condition of alarm and float swathes, etc.)
/ l nw 2/57 ZEET47/1
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(n to if ley I and distri tion is equal, evident of solids carryon, evid nce of leakage into or ut of box, e(c)
C� r i >
7'
PUMP CHA,ti1BER:.d-'A'- /9—
(locate on she plan)
Pumps in working order: (Yes or No)�/�
Alarms in .+orking order(Yes or No) Aze
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(r•vi••G 01/15/97) P�9. 7 of 10
tf
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 996 Bumps River Road Centerville,Mass.
Owner: Edward Sullivan
Date of Inspection:j 2/2 6/9 7 Q
SOIL ABSORPTION SYSTEM (SAS):z_/'.ei'y/� y�� feAll� /• T5
(locale on site plan, if possible; excavation not required, but map be approximated by non-intrusive methods)
If not determined to be present, explain:
Type 9
leaching pits, number:
leaching chambers, number: 0
leaching galleries, number: (_J
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, nufber:�
Alternative system:.U/7
Name of Technology:77i
Comments:
note condition of soil, signs of hydraulic failure, ``eve) of nding, condition q(vegetation, etc.)
14 7 YMOAuiz22 J.44 ITS s.'C ji' hYc/frrF,r� � i lirrF' 64 ✓J�i���;h� .
CESSPOOLS: 6,vt✓
(locate on site plan)
Number and configuration: A/f{-
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: /1J
Dimensions of cesspool: 1 -
materials of construnion: W14
Indication of groundwater: W'
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
ft
-- r
PRIVY: /U�-
(locate on site plan)
Materials of constructign: 4'W Dimensions:
Depth of W14
Comments:
(note condition of soil, signs pf hydraulic failure, level of ponding, condition of vegetation, etc.)
(rw1—d 011/25/97) ➢•g• 8 of 10
JI
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (commuedl
P.open) Addres9: 996 Bumps River Road Centerville,Mass.
O-ne': Edward Sullivan
Date of Inspection. 1 2/2 6/9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
c1uoe ties 10 at least rwo permanent references landmarks or benchmarks
locate all wells within 100 (Locate where public water supply comes into house)
99� g�rnPS River Rd Ccrrlc�v,lk!
D /
o
SUBSURFACE SEWAGE DISP . SYSTEM INSPECTION FORM
C
SYSTEM INFOI: ION (continued)
Property Address: 996 Bumps River Road Centerville,Mass.
Owner: Edward Sullivan
Date of Inspection: 12/26/97
Depth to Groundwater/Feet
Please indicate all the methods used to determine High Groundwa:Cr EIL,:a'ion:
_ Obtained from Design Plans on record
i
�oservat,on of Site (Abutting property, observation hole basemersrsimp etc.)
Determine it from local conditions
_Check with local Board of health
Cneck FEMA Maps
Check pumping records
neck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Ground• jitr Elevation. Must be completed)
Used Groundwater coe.ours Map.
Based on Gahrety & Miller Model
12/16/94
r
(r•vf.�.0 0//75/97) P•g• of 10
W )
I TOWN OF Barnstable BOARD OF HEALTII
SUI)SURFACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D.- CERTIFICATION
-TYPE OR PRINT UEARLY-
PROPERTY INSPECTED
STREET ADDRESS 996 Bumps River Road Centerville,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER's NAME Edward Sullivan
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & SoTf *Inc.
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or Clty State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1 790 - 1578
CERTIFICATION STATEMENT -
I certify that I have personally inspected the sewage disposal system at
this address and that the inrorination 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 ne:
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe 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 con rcted has found that the system fails to
protect the }public health and the environment in accordance with Title
5 , 310 CMR 15 .303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature Date 12/26/97
One copy of this certification must be provided to the OWNER, the BUYER
( Where applicable) and the BOARD OF H EAL711,
t If the inspection FAILED, the owner or ` perator shall upgrade the ayatem
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd .doc
1
w 9
t
- S
THE COMMONWEALTH OF M.A.SSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERT i i D TITLE S 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.
tM s, tv�s
Acting Dircctor of the f) i ion of Wilcr Pollution Control
� t�tif