HomeMy WebLinkAbout1293 BUMPS RIVER ROAD - Health 1293 Bumps River Road, Centerville
= 188 - 073
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No. 42101/3 ORA
ESSELTE
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' Commonwealth of Massachusetts
Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c / 1293 Bumps River rd
Property Address
Marjorie Boulanger
Owner Owner's Name /
information is Centerville ✓ Ma. 02632 8-5-20
required for every --- -
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information /at- 1,41 43
filling out forms
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Jim The Ins ector Man
use the return
--p- — -- _ - -
key. Company Name
P.O.Box 784 --------------- ---- —
r� Company Address
West Yarmouth Ma. 02673
City/Town State Zip Code
re(an 508-364-4398 _ S114430 _
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 OF*,q.
2. ❑ Conditionally Passes .ti
MICHAEL '.GN
_�: RS
3. ❑ Needs Further Evaluation by the Local Approving Authority - o. SEA ;
'* No.SI14430
4. ❑ Fails %%r'cFR F��� O�
IN
_- ------- 8-5-20 -- ._. ----- -
Inspector' Ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
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f
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1293 Bumps River rd
V
Property Address
Marjorie Boulanger
Owner Owner's Name
information is Centerville . Ma. 02632 8-5-20
required for every -- -- -- -
page. City/Town 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
i
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V � 1293 Bumps River rd
Property Address
Marjorie Boulanger
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20
required for every --- ------- ---- - - — --
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (corl
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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f
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Marjorie Boulanger_
Owner Owner's Name
information is Centerville Ma. 02632_ _ 8-5-20_
required for every ----.-------- - ----
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health and Public Water Supplier, if an
Y ( Pp � Y)
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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Ih I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1293 Bumps River rd _
Property Address
Marjorie Boulanger _ ._._._
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20
required for every ---- — —
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El ® 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 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
I
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply i
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
c41 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.............. ,. 1293 Bumps River rd
Property Address
Marjorie Boulanger
Owner Owner's Name
information is Centerville_ Ma. 02632 8-5-20
required for every - --- —
page. City/Town 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?
® El available
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1293 Bumps River rd
u Property Address
Marjorie Boulanger _
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 - Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to: --Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): 2018-114000ga12019-112000ga1
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: present
Date
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
t5insp.doc-rev.7/2 612 01 8 P 9 P Y 9
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
h !% 1293 Bumps River rd -
'�� Property Address
Marjorie Boulanger
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20
required for every -- - -- _--
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpa)
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: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: --
gallons
How was quantity pumped determined?
Reason for pumping: ---- ----
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
�,, 1293 Bumps River rd
.� Property Address
Marjorie Boulanger __ _
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20
required for every — -- — -
page. City/Town 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:
8-22-97 #97-450
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
2211 _
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
l5insp.doc-rev.7126/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 18
i
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ia Subsurface Sewage Disposal System Form Not for Voluntary Assessments
l;
Vic? ash 1293 Bumps River rd -
`J� Property Address
Marjorie Boulanger _ _ _ -
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20 —
required for every --- --
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
12"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1500
Dimensions:
4"
Sludge depth: — -
24"
Distance from top of sludge to bottom of outlet tee or baffle -- -
2"
Scum thickness -
Distance from top of scum to top of outlet tee or baffle 8 -
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge judge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 gal tank with in and out tees, both covers at 12" below grade
i
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I'o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c � 1293 Bumps River rd
�. Property Address
Marjorie Boulanger
Owner Owner's Name
information is Centerville Ma. 02632 8=5-20
required for every —
page. Cityrrown 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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1293 Bumps River rd
u� Property Address
Malorie Boulanger -
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20
required for every page.
City/Town 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 _-_--
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D box is 16x16 with 1 outletpipe, cover_is 28" below grade
I
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.......... . 1293 Bumps River rd _
u Property Address
Marjorie Boulanger
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20 _
required for every — -
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:
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: — — -
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
C�, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.J� 1293 Bumps River rd _... _
Property Address
Marjorie Boulanger
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20
required for every -- -- —
page. Cityfrown 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.):
SAS is 4 infultrators with 4' stone, clesn snd dry with no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert -�
Depth of solids layer
Depth of scum layer _
Dimensions of cesspool --
Materials of construction -
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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
1293 Bumps River rd _ --
`J Property Address
Marjorie Boulanger _ —
Owner Owner's Name
information is Centerville Ma_ 02632 8-5-20
required for every - -- -
page. CitylTown 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.):
l5insp.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
............c !% 1293 Bumps River rd _ _ -
u Property Address
Marjorie Boulanger_______.__.____
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20 _
required for every Y
page. Cit frown 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
Al - LI3 gi -31
A a - yl
3 _�! 3 —y?
g _56 y -SW
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3 o y
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
<-4�\ Commonwealth of Massachusetts
�� -- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
c !% 1293 Bumps River rd
Property Address
Marjorie Boulanger _
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20
required for every -- - —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated high depth to round water: 15,
p g g 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:
You must describe how you established the high ground water elevation:
SAS is up 15' from road
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
i
c Commonwealth of Massachusetts
-- . ,p Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1_293 Bumps River rd
Property Address
Marjorie Boulanger____
Owner Owner's Name
information is Centerville Ma. 02632 8-5-20
required for every --- - -- -- -- - -
page. Cltyrrown 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
q'
U
I1
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
I
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M „•''r 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
�I1. Inspector: � �✓
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433
Telephone Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
q4lllw--�
7/16/14
Inspect i na ur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. [I �
1293 Bumps River Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1293 Bumps River Rd
Property Address
Sullivan
Owners Name
Centerville MA 02632 7/16/14
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Pumping suggested every 3 yrs to prolong the life of the system
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ 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.
ND Explain:
n/a
❑ 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
❑ obstruction is removed
1293 Bumps River Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM yv 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
n/a
❑ 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
❑ obstruction is removed
ND Explain:
n/a
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
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.
1293 Bumps River Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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:
n/a
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
1293 Bumps River Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
1293 Bumps River Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
Cityrrown 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)]
1293 Bumps River Rd-03/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
Cityrrown State Zip Code Date of Inspection
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
Number of current residents: 0
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)):
Sump pump? ❑ Yes ® No
Last date of occupancy: Seasonal
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: n/a
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:
Last date of occupancy/use: Date
Other(describe): n/a
1293 Bumps River Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
City(Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Pumped every 2 yrs per owner
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):
Approximate age of all components, date installed (if known)and source of information:
1997 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
1293 Bumps River Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 12"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.):
Septic Tank(locate on site plan):
Depth below grade: 12"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:
1500g
Sludge depth: trace
Distance from top of sludge to bottom of outlet tee or baffle
>12" I'
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle
>2"
Distance from bottom of scum to bottom of outlet tee or baffle >2.1
How were dimensions determined? Measured
1293 Bumps River Rd•ON08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3 yrs to prolong the life of the system
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
n/a
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.):
n/a
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):
n/a
1293 Bumps River Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
1
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7116/14
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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.):
n/a
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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 in very good condition, 2' below grade
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
1293 Bumps River Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4 Infiltrators
❑ 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.):
Infiltrators were video inspected and are dry at this time, no indication of past backup
.1293 Bumps River Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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.):
n/a
1293 Bumps River Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M SV• 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
L 9� y
G =C) fl
a
� a
� sK
1293 Bumps River Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 1293 Bumps River Rd
Property Address
Sullivan
Owner's Name
Centerville MA 02632 7/16/14
CityrTown 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:
You must describe how you established the high ground water elevation:
per elevation of home
1293 Bumps River Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
�tHEJt, � Town of Barnstable
sniuvazne
Department of Health,Safety,and Environmental Services
�,
9� , Public Health Division
�Eo ' 367 Main Street,Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
Ms.Ann M. Clarke January 6, 1998
1293 Bumps River Rd.,
Centerville,MA 02632
ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 1293 Bumps River Road, Centerville was inspected on April
21, 1997 by Robert Bartolotti a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of 1995
TITLE 5 (310 CMR 15.00)due to the following:
• Backup of sewage into facility or system component due to an overloaded or clogged cesspool.
You are directed to hire a licensed professional engineer(PE)to design a system that will bring the septic
system in compliance with 310 CMR 15.00,The State Environmental Code,Title 5 within twenty-one
(21)days of your receipt of this letter.
You are also directed to hire a licensed septic system installer to install the system components within
forty-five(45)days of your receipt of this order.
You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into the buildings,onto the surface of the ground,or in
to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court of
competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean,R.S., C.H.O.
Agent of the Board of Health
PAR Real Estate System - General Property Incluir-y Help
Parcel Id' 188 073- Account No" 109046 Parent:
Location: 129:3 BUMPS RIVER RD CEN Neighborhood: 39AB Fire Dist: Co
Devel Lot: 7 Lot Size: 4::--"* Acres
Current Own : CLARKE, ANNE M State Class: 101
1293- BUMPS RIVER RD No. Bldgs: I Area: 1180
Year Added:
CENTERVILLE MA 26*_7:2
Deed Date: 010197 Reference: C57223
January 1st: CLARKE, RICHARD H& ANNE Deed MMDD: 0000 Deed Ref: C57223
Comments;
Vc-AlUes.* Land: 37000 Buildings." 65900 Extra Features:
Road System. 12193 1 n d " 194 (BUMPS RIVER ROAD ) Frntg: 119
Index.' ) Frntgg
Control Info." Last Auto Upd: 030897 Status: C Last TACS Update.' 030'_-:97
Land Reviewed By: Elate: 0000 E'ildgs Reviewed By: Date: 0000
Tax Title' Account: Taken' Account Status: Hold Status:
Cancel
1:--'ress XMT for more data
Next screen PAR Action
Owners Name
Road Index Road Name
Parcel Number 188 074
V
TOWN OF BARNSTABLE Oa"
LOCATION 9�3 � �vrrioQ ,P/lcl�?i �� SEWAGE #
VILLAGE 41Y2& ASSESSO 'S MAP & T
.T>VSPM-M,.S NAME&PHONE
SEPTIC TANK CAPACITY Co
LEACHING FACILrrY: (type) J,�(size) 60
NO.OF BEDROOMS
BUELDER OWNER '
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
ti
`� ;
No. ! _ /�® a;� — Fee
—
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ys
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
application for Mi!6po$al *pmem Conztrurtio.n Permit
Application for a Permit to Construct( )Repair(Io)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No/(; tx3"&M �//�/— Owner's Name,
Aldd�reess and Tel.No.
Assessor'sMap/Pazcel I� �2 o+ei72v'ri� ceiv�—�/ �/
Installer's Name,Address,and Tel.No. +� ice-1'� `( Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil 5_144 iQ
Nature of Repairs or Alterations(Answer when applicable) _T11 ST!'�// 5 ;?,04/`t,
/�- !fix 4� � s� co
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has be is B 5--"Q
Signed Date
Application Approved by Date `dam f
Application Disapproved for the following reasons
Permit No. q,7— Sa Date Issued g
��
No. — 7 � �..`41 j '' _ r Fee
THE COMMONWEALTH OF MASSACHUSETTS ' Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pphiation for nigaal *p!tem Con.5truction Vermit
Application for a Permit to Construct( )Repair(V510pgrade( )Abandon( ) ❑Complete System P Individual Components
Location Address or Lot No.,a '� I�r/ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel I ,/71 Z• 77'�s��l/I
Insta�err's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33d gallons per day. Calculated daily flow 3 q5� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. )�/A LTt,5T6f$
Description of Soil i4ll:o
Nature of Repairs or Alterations Answer when applicable) - �-sj / 4110
w Date last inspected:
Agreement: ?
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been-isstted-by4 ' B
I Signed Date
Application Approved by Date d� 'f ?
" Application Disapproved for the following reasons
Permit No. r r Date Issued
• —————————— «_fi————————————————-————— ——
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERvome
theO SwaggerDissp sal System Constructed Repaired Upgraded(
OAbandoned b at I a. -9j rA p5 i ov v' W p5Tf-eLh ehas been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 y ysv dated "2
Installer Designer
The issuance oAhi;petkutAaIrnoLrbe76nstrued as a guarantee that the syste ill function as designed.
Date / Inspector
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y
No. 9 2— 0S6 Fee b
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS r'
ligozal *pgtem Construction Vermit
Permission is hereby granted to Construct( Repair(i pgrade( )Abandon( )
System located at APF3 U INS N'
GAS-),e-YU t
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions. „
Provided:Construction must be completed within three years of the date of this permit.
Date: Approved bye .
f
NOTICE: This Fs to be used for the Rcj�, Failed
Septic Systems Only
CERTIFICATION OF SKETCII AND*APPLICATION FOR A DISPOSAL
IVOItKS CONSTRUCTION PERMIT' (WITTIOU'I'DESIGNED PLANS)
1, o�� � , hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at /��3 �y S Prue-4' meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE: g�
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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TOWN OF BARNSTABLE
LOCATION a�3 .«ac 6ZQ SEWAGE # 7" ^v
-VILLAGE a&t ASSESSOR'S MAP & LOT - O 7-3
INSTALLER'S NAME&PHONE
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ` (size) y S bKt
NQ.OF BEDROOMS
BUILDER OR OWNER
PI RMUDATE COMPLIANCE DATE:
S.e0aration Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
oa 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
Famished by
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BORTOLOTTI CONSTRUCTION,INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508-428-8926 FAX: 508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATTIO_N_n
Property Address: i 3 �- CF'
Date of Inspection: Inspector's Name:
ner's Name and Add-7 ss:
Off. 3�
CERTIFICATION STAT MENT•
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed 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 Ev uation By,the Local Aproving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(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 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 SUMMARYe
A)SYSTEM PASSES:
I have not found any information which!nd!c.aes that the system violatcs i ny of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system, upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes, nor,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,cracked, structurally unsound, shows substantial infiltration or
exfiltration, or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Broken pipe(s)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 pipe(s).
The system will pass 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 further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility_and thepresence of am__monia nitrogen and nitrate nitrogen is equal to or less
than 5 Will.
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7D) STEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
Th dbe contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
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.Fect 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:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 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:
The system is within 400 Feet of a surface drinking water supply
The system is within 200 Feet of a tributary to a surface drinking water supply
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area
(IWPA)or a mapped Zone II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
I-"Pumping information was requested of the owner,occupant,and Board of Health.
`None of the system components have been pumped for atleast 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 with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
i
v/The system does not receive non-sanitary or industrial waste flow.
- The site was inspected for signs of breakout.
✓All system components,excluding the Soil Absorption System, have been located on site.
✓The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected 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 or approximated by non-intrusive methods.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
�The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C _.
SYSTEM INFORMATION
FLOW CONDITIONS
RESII)ENTLAi.:
Design Flow: 93P gallons Number of Bedrooms: 3 Number of Current Residents:
Garbage Grinder: _ Laundry Connected To System: Seasonal Use:
Water Meter Readings, if a ilable:
Last Date of Occupancy:
C'OMMERCLALANDUST IAL:40
Type of Establishment:.
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL
INFORMATION
PUMPING RECORDS and source of information_: /W_ `
System Pumped as part of inspection-A)0 If yes, volume pumpe gallons
Reason for pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
/ aQ
Oth r(explain):aZ Cv
AP ROXIMATE AGE of all components,date installed(if known)and source of information:
Sewage odors detectifil when arriving a the site:
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:�Q_
Depth below grade: Material of Construction: concrete metal FRP Other
(explain)
Dimisions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
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.)
GREASE TRAP: .'p
Depth Below Grade: Mateiial of.Construction:. concrete metal FRP Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
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.)
TIGHT OR HOLDING,TANK: /L)b
Depth Below•Grade: Material of Construction:,_concrete_metal FRP_Other(explain).
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX::
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.)
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields, number, dimensions:
Overflow cesspool, number: / - (v 'DX 6',CJ
Comments: (note condition of soil, signs of hydraulic failur level of ponding,condition of ve etation,
etc.
IF
CESSPOOLS:
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction("X�ndication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, si ns of hydraulic fa' ire, level of ponding,condition of vegetation,
etc.
PRIVY:_
Materials of construction: _ Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
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SUBSURFACE SEWAGE DISPOSAL SYST'FM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
SU
DEPTH TO GROUNDWATER:
Depth to groundwater: /y Feet
Mepiod of Determination or Approxima 'on:
S ll
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TOWN OF BARNSTABLE
LOCATION SEWAGE # / 7" y6 b
r,
VII LAGE p f g- W ASSESSOR'S MAP & LOT -(5 7
INSTALLER'S NAME&PHONE NO. Icy _L
SEPTIC TANK CAPACITY `t�DO �S
c
LEACHING FACILITY: (type) !/Y► (size)
NO.OF BEDROOMS -J
BUILDER OR OWNER
PERMTTDATE: -eZZ�� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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