HomeMy WebLinkAbout1176 BUMPS RIVER ROAD - Health 1176 BUMPS RIVER RD., CENTERVILLE
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UPC 12534
HASTING9,.YN
TOWN OF BARNSTABLE
�y-74(p
LOCATION &,npr, Qiucr Rck SEWAGE# ZOZ I - 08e,
VILLAGE (2c.nA c ru:)1 c ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. ,(�€� C3 EXc aLtO�4,on - TY?- DG53
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 9 BOX O*J
NO.OF BEDROOMS
OWNER_Morris Kol ka-
PERMIT DATE: 3-7 Z'21 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
A)-
AV 3Z' s
132 yo,G.,
A3' yt �
83.38
AEI - Ye f A a
IN IJ3
F'r on+
No. !iC/[/� 60 Fee �s
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
9pplitation for Misposal bpstem Construction j9pr Yit
Application for a Permit to Construct( ) Repair()0 Upgrade( ) Abandon( ) ❑Complete System [9 Individual Components
Location Address or Lot No. 1�-}10 QUm?% P.ivtt 9 a. Owner's Name, `Address,and Tel.No. wi s KOACa
Assessor'sMap/Parcel r'^ 10� &M s &WIr �001c1 U-4cf6klf,
Installer's Name,Address,and Tel.No. ca0o. o n Inc. Designer's Name,Address,and Tel.No.
Z>'}y R,ooA-r. 1'S0 So.ndw'�4, So 8 4�� o(os 3 tJ A
Type of Building: UA
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) 651 o kk akion 64 Otw d-b(yk .i +t,, And PJ pn Q
-6N to,4 to 6-box io ltacknv QNLV t
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 Bo d of Health.
Signed X Date 311112.1
Application Approved by Date
Application Disapproved by Date
for the following reasons
3
Permit No. —Z) Date Issued LZ 2
i
No. (�-��t �u'+" Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L/ 55
PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Tipplitation for. Misposaf 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System DO Individual Components °
Location Address or Lot No. �1'}lo dUmPS P.wc� Q�', Owner's Name,Address,and Tel.No. �Iof f s
5 K a1 KC.
Assessor'sMap/Parcel � �'^' W4� &m(?S �,vrt' {CoGA tr,ei42tui11C,
Installer's Name,Address,and Tel.No. $f j c c c oc�l o n 1 n(. Designer's Name,Address,and Tel.No.
��y R o�+� 1So Sa�dW,c4, SC>Z • ��� • o(�S3 N A
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
t
Other Type of Building No.of Persons Showers,( ) Cafeteria,( )
Other Fixtures
Design Flow(min.required) A/(A gpd Design flow provided/ gpd
� r
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)y''Y15ka�kfl__ un of ()f.J cl-b0l, }te C\nt+ 0�6001'
�. -tong to c+�--bo< tb �?ndn,o,, nk)N I&
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.
, Signed/` LC'' Date ' 11 9'7 1
`v e / /
Application Approved by ,< Date / q f 2-
�-. /
Application Disapproved by Date
for the following reasons
Permit No. Date Issued 3 �? 2
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
1 THIS IS TO CERT,IF that the On-site,Sewage Disposal system Constructed( ) Repaired( X) Upgraded( )
Abandoned( )by 'i M'�: Ewa
'
r at 11I n� !R rA has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. W-060dated Vn,
Installer �u U' !t s tt; ',.- Designer
Al
/t� /
#bedrooms )r � h c- ,, nnk�, rj VIA Approved design flow 11A gpd
The issuance of this permit shalll,not be const/rued as a guarantee that the system will function as+hddesi�gned:
Date 5 T ,/ '� Inspector , t __
No, 2 1 bete Fee -7-s-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
MispoBal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( I!) Upgrade( ) Abandon
System located at Nomp.G Rita Rmei s
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 be completed within three years of the date of this permit.
Date Approved by
THE rqy
Town of Barnstable
pRNSTABM
b, Inspectional Services Department
rFD MP'�
Public Health Division
200 Main Street, Hyannis MA 02601
Off ice: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool
❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation
❑ A portion of the cesspool is located within a Zone 1 to a public well
❑ A portion of the cesspool is located within 50 feet of a private water supply well
with no acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
VO LI ER t'GUvs'Mar✓ Q D I!/�rr _FZ nC w, -ee Ofrio QI j1Q
Repair deadline: U f
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
1®g_ 0_4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
J
1176 Bumps River Rd
Property Address f
Kalka, Morrris
Owner Owner's Name
information is Centerville ✓ Ma 02632 3/3/2021
required for every
page. Citylrown State Zip Code Date of Inspection
t
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 5/41-1Is a.l(o
on the computer,
use only the tab Chad Hathaway
key to move your Name of Inspector
cursor-do not Hathaway Septic Inspections
use the return Company Name
key. '
P.O.Box
151
r� Company Address
Forestdale Ma 02644
Citylrown State Zip Code
torn 774 274 2581 12866
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ® Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector's Sig ure Date
The system inspector shZty7solf)completing
a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ I have not found any information which i 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:
This inspection is not a guaranteeand applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described components. This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
Information on care and do's and don'ts can be found at town health dept or mass.gov
f
2) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El El El ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Yf 1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary. (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below):
Dbox is wrotted out and dirt is showing through sides .
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion.of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence-
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
a
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows.in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
I
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: light part time
use
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding.tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
I'
t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Officia,l Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date'installed (if known)and source of information:
1979 age of house from town Data base
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: 25+
feet
Comments(on condition of joints, venting,evidence of leakage, etc.):
none
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
.J 1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1000 gal tank
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8'x5'
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle .
How were dimensions.determined? tape and 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.):
baffles in place. no major decay. no visable leaks. tank is at working level. PVC from outlet to Dbox
and Dbox to pit is schedule 10 recommend replacing with sched. 40 PVC and installing new PVC tee
with leg and gas baffle when Dbox is replaced
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
• rn Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is Centerville Ma 02632 3/3/2021
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1." Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.):
Dbox no good. Its rotted out and showing dirt through sides
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c� Commonwealth of Massachusetts
r= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i,
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owners Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
D. System. Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
6x6' pit with stone around. pit dry with stain line 30" below invert.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
• �� Title 5 Official Inspection Form
! Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is Centerville Ma 02632 3/3/2021
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
1000 57-) �Z'L
[410 -D-3va C"c41n�
4000
3b
y,
yv
v
e ��
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owner's Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 28
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
lot el. 39
You must describe how you established the high ground water elevation:
per town GIS mapping lot el. 39' in area of septic. low in area mill pond and river@ el 10' bottom of
SAS el. 30'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
@ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1176 Bumps River Rd
Property Address
Kalka, Morrris
Owner Owners Name
information is required for every Centerville Ma 02632 3/3/2021
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For, 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
I
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INVOICE
CHAD HATHAWAY
P.O Box 151 Forestdale Ma.02644
774 274 2581
HPSIONCAPE@YAHOO.COM
INVOICE# 3010
Massachusetts DEP septic Inspector DATE:3/3/21
Title 5 Inspections—Emergency Services —Risers— Sewer Camera Inspections—Up Grades
Pipe and D-Box Repairs-System locating-Well Sampling—Pump and Alarm repairs
TO:KALKA,MORRIS
1176 Bumps river rd Centerville
DESCRIPTION HOURS RATE AMOUNT
Septic inspection
TOTAL $325.00
All work is to be completed in a workmanship like manner according to standard industry practices.Any changes or deviation to above
specifications described above by consumer may result in added labor and or material costs.All payments are due upon completion of work..
Payments over 30 days Late will result in interest charges at the maximum legal amount by law. Authorizing Signature agrees to terms
described above. Authorized Signature: Date:
Printed Name Date:
Please make checks payable to Chad Hathaway
THANK YOU FOR YOUR BUSINESSI
..�.. ...... ...... .. .. ..... ..... ........ ...... .....
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C.oMhidhWealth o �lassachaasetts
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:
Subsurface Sewage Dtsposai system Form-Not for Voluntary Assessments
I., 1.176 Bumps Rlvec Rd
Property;Address. -
- KE14NE,THOMAS.M &;BETTY MN:
Owner owner s Name _ -
mfomatton+s>
requiredforevery Centerville M.a 02632 3/27J2013
::
page.'. .. Cltyrtown State Ztp Code Dafe;of Inspectron
6nspec!pn results must be submitted on'thts form Inspe�tta n forrris msy:not be altered in any
way Please see conngleteness checklist at the end a#tha fooin
Impo taut When A: �a�0; i� ij_�t'I�(?rI�1�t1��
filling:out.forrims, .
on tti':e computer
use only the tab 1 Inspector
key to move your
cursor do not I ',
Sean M Jones
use the return; Name of Inspector
key .:
Capewide Enterprises
Company Name
153.Commeraal.Sf, ,
Company Address
Mashpee, .__ ! Ma ..._:_.. 02649
City/Town State Zip;Cade
.
: 6Oa4tt ss 7 _ s! a�22
--- —
:. :...: Telephone Number License-Number i
..
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... :: ::: ::: .
!:certify tat l have personally: nspec#ed the sewage dispasa!system at:this address and#hat:the
�rfarmation reported below is:true, accurate antl complete as of the time:of#he-inspection She Inspection
was performed„based:,on my training„and experience In'the proper function and malrj,, nce!of on:site
sewage disposal systems l am a I�EP approved system inspector pursuant to Seaton '15 340 of
Title 5(310 CMR- Q00)t The sys#em
.. . ::
r 1
® Passes; ❑ Canditionaily Passes ❑ :;Falls
❑ tVeeds Fu6t6 6 I Eyaliaation by;the LocaE Appraumg Authority
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3J27
Inspector s Signature Date J2 t�'
01
.
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........ ... ...... :.: ....... ......... ...-...... ..:...
.. .. .:
The systern'Inspector shall submi#a copy of this Inspectlon report to the Ap roving'A tPt''* oartl
of Health or-DEP)within,30 day5of completing this Inspection If the syste" 'GIs a;sharl sy or
has a design flow of 1a,000 gpd;or greater, the,inspector one! the system o ner shall subrn t- he
repa(t to the appropriate reglortal office of the DE!?. The original should be- ent to thyst owner
and codes;sent b 'the buyer, if applicable, and;the approving authority
:.. :.: :' ...: '-
_..
_ .... .... .
...
_ ..... .._,.,
_ _ _
*`*This;report only.descn es cobditions at the:time of tnspeirtton and under the eenditians gf use
. .. .. .:.
at that time This 1R$P C. ... does no address hovii the systefn::Will p'erform;,n the fiuture under
the same q`r different dro' to as of else
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t5i, 11110 .:: :5 T1tIe S Of�c al inspec n iin SuUs6lace Sewar�e>D1s $ai System Pape 1 of 17
i
I
N Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. Cityrrown 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:
Z 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:
The dwelling located at 1176 Bumps River Rd Centerville is served by a Title V septic system
consisting of a 1000 gallon septic tank, distribution box and a precast leaching pit. The system was
found to be in proper working condition at the time of inspection.
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 Inspection Form: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
°M 1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is Centerville Ma 02632 3/27/2013
required for every
page. Citylrown 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):
❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ 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 pondirig 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 '/z day flow
t5ins•11/10 Title 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
1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.'� 1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
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): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
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 years usage (gpd)):
Detail:
2011 = 139,000 total 2012 = 128,000 total " includes irrigation system
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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•11/10 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
.'y 1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
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:
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•11h0 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
, 1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
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:
original 1979
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade: 10"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth:
6" I
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
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
3'
3"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom'of outlet tee or baffle
10"
How were dimensions determined? opened covers, took
measurements
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 does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. Water level was at bottomiof outlet invert, tank was not leaking and was structurally
sound. Outlet baffle intact.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: 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
_ z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. Citylrown 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 was video inspected and found to be in good condition.
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 Form: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
M 1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. CitylTown 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.):
Leach pit had 14"of available leaching at the time of inspection with a stain line only 1" higher.
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. Cityrrown 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
CommQnW&9th cif MVl
Title f �' M in ct'
u
Subsurface Sewa9, isposal System Form Not for Uo3.pntary Assessments:
117,6.Bumps River,Rdi
...
Property Address..
KEANE, T,HOMAS M &;:BETTY ANN
Owner Own — --
er shame
tnfornatton is Centerville - Ma 02632 3127i2013
required for every _ _ _
a e Ct £I owr State ZipCode Date,of inspection
Ind®r. e���n (cunt ) ,
Sketch Of Sewage Disposal System Pravrde av�ew of the sevcrage:d�sposal system, including ties to
at least two permanent referencelandrrilarksytarbenchmarks,Locate'aH wells within 100 feet Locate.
where publicwater supplyenters;the building Check one of the boxes below
® band sketch �n the area belovu
4
❑ drawing attached separately
......
.:
..
.. . ...
. . .
d
f f 2 �, _,./'
32�
....
t `
i
t5ins 11110: Tile b Official inspection Form,Subsurface!Sewage Dispasai System Page.f 5 of 17 .
Commonwealth of Massachusetts
i w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. Citylrown 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: 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: i
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
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-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 1176 Bumps River Rd.
Property Address
KEANE, THOMAS M & BETTY ANN
Owner Owner's Name
information is required for every Centerville Ma 02632 3/27/2013
page. City(rown State Zip Code Date of Inspection
E. Report Completeness Checklist
Z 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
' V
DATE----- 0-------
1 7
PROPERTY ADDRESS:117.6 Bumps River Road __
__Centervi 1 le LMaus.,_______
02632 -----------------
On the above date, I Inspected the septic system at the above address.
This .system consists of the following:
1 . 1 -1000 gallon- septic tank.
2. 1 -Distribution box.
3 . 1 -1000 gallon precast leach' n it.
Based on my Inspect�or�, ? certify the.following conditlons:
4 . This is a title five septic system. ( 78 Code )
5. The septic system is in proper working_ order
at the present time.
6. Waste water is 50" below the invert pipe of the
leaching pit.
SIGNATURE:,f _—/—JAL
N a m e:_,L L,-lWaInkf-c..,Lr-___---
Company: Jose,ph_PL Hacamber & Son, Inc .
ox
Address:__B 66__ ________
—_CentervilleL Ha__02632-0066
Phone:...508 775_3338_______
w
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
C6S. H P. MACOMBER & SON, INC.
Tanks•Cesspools•Leachflelds
Pumped L Installed
Town Sewer Connections
9 ox 66 Centervllle, MA 02632-0066775.3338 775•b412
I LOT
=�0 ��
5
np FL 2 Sty .
r` p�0pc,E�. •'
w
Eugene Rastonis
1176 Bumps River Road 4/4/00
Centerville,Mass .
02632
System consists of.
1 -1000 gallon septic tank.
1 -Distribution box.
1 -1000 gallon precast leaching pit.
Septic system is in proper working
order at the present time.
i 1
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11 j�, �im�},p� 3��V't�c' �� �'e.xv t i��
r
t COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COX
Secretar
ARGEO PAUL CELLUCCI DAVID B. STRUH
Governor Commission
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Prop"Addre":11 76 Bumps River Road NarneofOwner Eugene Rastonis
C e n t e r v i l l e,Mass. Address of Owner:
Data of Inspection: 4/4/0 0
Name of Inspector:(Please Print) jr)S mph P Ma comber J r.
1 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.
MaiilingAddress: Box 66 Cen ,Mass_ 02632
Telephone Number: b U 8—_/_/b—_33
CERTIFICATION STATEMENT
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 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 47
Inspectors Signature: ! Date:
If
The System Inspec shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)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 Department ofrfnvironrnental Protection. The original should'be.sent to->tts
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Pagel of11
V.�Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CUMFICATtON(oont4rued)
Propoirty Addye": 1176 Bumps River Road Centerville,Mass.
OwMr. Eugene Rastonis
Date of kupecdon: 4/4/0 0
pSPECTION SUMM"Y: Check A. B, C. of D:
A— SYSTEM)PASSES:
I have not found any information which Indicates that any of the failure conditions described In 310 CMR 16.503 exist. Any tallwe
criteria not evaluated are Indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
iC>y One or more system components sa described In the'Conditional►ass•seotlon need to be replaced or repaired. The system.upon
completion of the replacement or repair,as approved by the Board of Health,Will pus.
Indicate yes.no,or not determined(Y. N.or ND). Describe basis of detsrmbutlon 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 Cortmcate of
Compliance(attached)Indicating that the tank was Installed within twenty 120)years prior to the date of the Inspection: or
the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial Infiltration or exNoation, 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 statlo water level observed In the distribution box Is due to broken or obstructed Opals)
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
. The system required pumpirtg-mm than'lourdmes-e•yeardus to broken-or obstructed pipe(*). the cysts.. w*vorsw—
Inspection It(with approval of the Board of•Hesith):
broken pipe(s)are repiacid
obstruction Is removed
revised 9/2/98 Page 2ofIt
SUBSURFACE SEWAGE DISPOSAL SYSTEM iNspkc )ON FORM
PART A
CERTIFICATION (continued)
P►owtyAddresa: 1176 Bumps River Road Centerville,Mass.
Owrw: Eugene Rastonis
Dete of Inspection: 4/4/0 0
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WTTH 310 CMR 16.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH.YMI.PROIfCT THE PUBLIC HEALTKAND SAFETY ARID THE ENVVIRONMENT:
Cesspool or privy Is within 60 feet of surface water
Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh.
21 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 pub0c 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 soll absorption system and the SAS Is less than 100 feet but 60 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. Method used to determine distance (approxlmation not valid).
3) OTHER
AM
revised 9/2/98 Page 3ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A 1
CERTiRCATiON(condrued)
Pmp.nyAd&"&- 1176 Bumps River Road Centerville,Mass.
Own«: Eugene Rastonis
Daft of In*pec6m:4/4/0 0
D. SYSTEM FAILS:
You must-indicate either "Yes" or "No" to each of the following:
A)b 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
Backup of towage irrto 4aci8ty�w system oornponentdaatte an ovedooded ordegged-SA&orcaaspool. •'�-,=—
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 iq th distrVtion box above outlet Invent due to an overloaded or clogged SAS or cesspool.
ZLiquid depth In�hcesop"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,No due to clogged or obstructed pipe(*).
Number of times pumped_.
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
4Z 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 s surface drinking water supply
the system-Is-within 200 4otof♦-tributar"oaourtaoedrk +gwatM-su►ply• -- -
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area:IWPA)or a mapped Zone 11 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 inforpstion.
revised 9/2/98 Page 4of11
1
j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ProwtyAddreas: 1176 Bumps River Road Centerville,Mass.
Owner: Eugene Rastonis
Date of Inspec6on:4/4/0 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 aystom compoa&nt&MamisjAan pum4ed4apatJoast two-aweaka sad-tba-vystem hasbaeoqucaiwrgwsrasaf flow
4b rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this
inspection.
_ Z 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 she was inspected for signs of breakout.
_ All system components, ccluding 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
Of tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System orrthe 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)]
_ The facility owner.(and.M�panu If different frau mner).wer&prcurJded with Jaf=%atiomon the proper maiataa ,f
SubSurface Disposal Systems.
i
t
I
revised 9/2/98 Page 5of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEFa INSPECTION FORM
PART C
SYSTEM INFORMATION
ProportyAddress: 1176 Bumps River Road Centerville,Mass.
Owner: Eugene Rastonis
Date of kupection: 4/4/0 0
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Ild g.p.d./bedro m.
Number of bedrooms dd s�igp) Number of bedrooms(actual):
Total DESIGN flow_i �G'�C�
Number of current residents:
Garbage grinder(yes or no): A l
Laundry(separate system) e nos or :_: If yes, sepwatelnspection.required --.
Laundry system inspected yel or no)
Seasonal use(yes or no):
Water meter readings,if available(last two year's usage egg:!!
Sump Pump(yes or no):_Ay,
Last date of occupancy:
COMMERCIALAN DUSTRIAL
Type of establishment: VA
Design flow: 107 apd.( Based on 15.203)
Basis of design flow AM
Grease trap present: (yes or no) .1
Industrial Waste Holding Tank present: (yes or no)A_0
Non-sanitary waste discharged to the Title 5 system:(yes or no)/_0
Water meter readings,if available: -
Last date of occupancy:
OTHER:(Describe) !Q
Lest date of occupancy:
GENERAL INFORMATION
PUMPING REC RDS and source f information:
,T )0,f 9lj li9lao
System pumped as part of inspection: (yes or no)ff
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF YSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
d Privy
IVY Shared system(yes or no) (if yes, attach previous inspection records,if any)
�(//9 I/A Technology et .Attach copy of up to date operation and maintenance contract
" Tight Tank .&W Copy of DEP Approval
Other �''4
A OXIMATE AGE of all components, date installedlif known)-and source of4aformation: .- .414e 1�F117
Sewage odors detected when arriving at the site:(yes or no)
revised 9/2/98 Page 6or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddreu: 1176 Bumps River Road Centerville,Mass.
Owner: Eugene Rastonis
Date of 4upecti°n: 4/4/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade:/, ,//��
Material of construction:_cast Iron Z0 PVC00 other(explain)
Distance fror 4.private water supply well or suction line
Diameter '
Comments: (condition of Joints,venting,evidence atieakage,♦tc.)Joints
System is ven ed- tnrouqh the house vL-nt--
SEPTIC TANK: d
(locate on site plan) /
Depth below grade: (D
Material of construction:•J/oncrete,e2l metal,&FiberglessA//APolyethylenoo&other(explaln)
If tank Is Instal,list age_ 1s.age.confirmed by Certificate of Compliance (Yes/No)
ci ! i 2
Dimensions: !6 y1d"A��: / r2i)/"1
/�4
Sludge depth: r _
Distance from top of udge to bottom of outlet tee orfialfle•. 4.L
Scum thickness:7.
Distance from top of scum to top of outlet tee or baffle:' t�-t/
Distance from bottom of scum to bottom of outlet t s or baffle:MCA
How dimensions were determined: 1"
Comments:
(recommendation for pumping, condition of inlet and outlet toes or-baffles, depth of liquid level In relation to outlet invert, structuraFintogrity,
evidence of leakage,etc.) Pum _ Inlet
& outlet Tees are in p age- i Q ti 0 'c3Ptnt at i- a QIj17 o4 ; r,�rer♦-
'1 I'T�n i structurally sound and IsMs
no evi nce ot leakage-
GREASE TRAP: e
(locate on site plan)
Depth below grade: 4)4
Material of construction:AM concrete NAmetal.VlFiberglassNi9Polyethylenoaother(explain)
-4154
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet too or baffle: AIA
Distance from bottom of scum to bottom of outlet toe or baffle: !�/1
Date of last pumping:-A
Comments:
Irecommendation 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.)
Grease trap is not present -
revised 9/2/98 Page 7of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
F-,,wtyAd&.,,: 1176 Bumps River Road Centerville,Mass.
Own«: Eugene Rastonis
Diu of Insp.cton: 4/4/0 0
TIGHT OR HOLDING TANK:' (Tank must be pumped prior to, or at time of, Inspection)
(locate on site plan)
Depth below grade: U�
Material of cons truction:44 concrsteNAmet&WAFibergiass &j,Polyethylen@,Uother(explain)
A0 —— —
Dimensions: A
Capacity: 44 gallons
Design flow:gallons/day
Alarm present
Alarm level:_4)A Alarm i.n`nworking order:Yes.L'A No.t/R
Date of previous pumping:�L_
Comments:
(condition of Inlet tee, condition of alarm and float switches,etc.)
Tight or holding tanks are_mot p resont.
DISTRIBUTION BOX:2
(locate on site plan)
Depth of liquid level above outlet Invert:
Comments:
(note if level and distribution Is equal, evidence of solids carryover, evidence of leakage Into or out of box, etc.) — —
D No evidence of solids
carry over No evidence of aakaga ; ntn n,- ni,jt Gf the ox.
PUMP CHAMBER:ti '
(locate on site plan)
Pumps in working order:(Yes or No) 41W
Alarms In working order(Yes or No)�/Q
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
ump chamber ; ; nest =rAGAnj
revised 9/2/98 Page Ior11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued)
PropertyAddre,s: 1176 Bumps River Road Centerville,Mass.
Owner: Eugene Rastonis
Deft of lnspoc:4/4/0 0 /
SOIL ABSORPTION SYSTEM(SAS)..
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields, number, dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology: r it Ee ive ( 78 Code
Comments:
(note condition of soil, signs of h draulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loam sand to medium fine sand No sign signa gf hydraulic
ponding Soils are dry yege a ion is norma
Waste water i G f i ftU inches below the pipe.
CESSPOOLS: e.
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: AJA
Depth of scum layer: A/
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of Inspection)
Cesspools arp not nrPsPnt -
Comments:
(note condition of soil, signs of hydraulic failure,level of pending,condition of,vegetation, etc.)
Cesspools are not nrPGPnt
PRIVY:"t
(locate on site plan)
Materials of construction: Dimensions: iL%9
Depth of solids:1(/101-
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
_Privy is not DiFesent. - - -
revised 9/2/98 page 9orn
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART Cr 0.
SYSTEM INFORMATION(con*"eM
Property Ad&O": 1176 Bumps River .Road Centerville,Mass.
Ownw: Eugene Rastonis
Date of I;%W*c1km: 4/4/0 0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at Fast two permanent reference landmarks or benchmarks
locate all wells wlthln 100' (Locate where publlc water supply comes Into house)
\
i
revised 9/2/96 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C , F
SYSTEM INFORMATION(continued)
Property Addrasa: 1176 Bumps River Road Centerville,Mass.
Own«: Eugene Rastonis
Data of inspection: 4/4/0 0
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 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_/Obtained from Design Plans on record
r Observed Site(Abutting property observation hole, basemeot sump etc.)
_ZDstermined from local conditions
Checked with local Board of health
Checked FEMA Maps
_ZChecked pumping records
Y Checked 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 PagtIIofII
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TOWN OF Barnstable BOARD OF HEALTH +
SUIISURFACF SF.WAGF DISPOSAL SYSTEM INSPRCTION FORM - PART D •- CE(ITJFICATION
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-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 1176 Bumps River Road Centerville,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Eugene Rastonis
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Sen' Inc.
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508) 775 - 3338 FAX ( 508 1 790 - 1578
R
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 .
Check one:
L Systeui PASSED j
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh 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 octed 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 .
� 1
Inspector Signature Date �Iw
copy of this certification must be provided to the OWNER, the BUYER
:)n6
where applicable ) and the I30ARD OP HEALTH.
* It the inspection FAILED, the owner or•"'operator ahal1 upgrade system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 15 . 305 .
partd.doc