HomeMy WebLinkAbout0049 CAPTAIN LUMBERT LANE - Health 9 Captain Lumbert Lane
Centerville
A= 147-011-009
I
12-0
No. (/— J�1 Fee 7r.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zippfitation for Misposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair(P Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 4 q CAT—r- Owner's Name,Address,and Tel.No.
Cane j 11vA-N-4 R ANn 1(ArTj+11TRS
Assessor's Map/Parcel �41 I o it o o q y 9 C0 r-*j N D Z G 3 2
I taller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
0g�T B oar [e $c8 - `I1� 94'1l
�3 L_►l.,4& Tkq-} S_jTN yArrw,�uTH D 2 to 6 L1
Type of Building:
Dwelling No.of Bedrooms Ain Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A& 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) S NSTrtl 1 o o}j L� 'Fee-
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 ofpra4h.
Si Date 9 'z 2 Z O
Application Approved by Date 705-/
Application Disapproved by Date
for the following reasons
Permit No. D Date Issued
--------------
No. 7 7lo — 3z)( Fee 757.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zippficatiou for Disposal 6pstem Construction hermit
Application for a Permit to Construct( ) Repair()o Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
s
Location Address or Lot No. 4 C P F'f- Lomt e 4 (,At,( Owner's Name,Address,and Tel.No.
t CAfs ej , RANT3 KANITPS
Assessor's Map/Parcel 4 U I I C es ," -C X r*i N L v_0,,-4+L N. Ct,,&1'c v 411 k p? 4 3 2
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No..
CSc,tT Scm `il� �4,11
7?. l aE., s -F&-ri4 S-,)TN VArnAc 02G6Li �-
Type of Building:
Dwelling No.of Bedrooms ; Aj A Lot Size sq.ft. Garbage Grinder(!'•,)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) N f' gpd Design flow provided IL.11g- gpd
.f. E;
Plan Date Number of sheets Revision Date
Title
r
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs'or Alterations(Answer when applicable) _�r, P,I t '4 EJ ,SA N+T6k4 Tee
Date last inspected: '
Agreement: t
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ,
.fi
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 ealth.
Sign
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. ./, y >L ( t Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(2�-3 Upgraded( )
Abandoned( -),by
at �/ :L U 0;77_3 i -r L4M� has been constructed in accordance
with the provisions of Title 5 and`the�for Disposal System Construction Permit No.?C72d dated �C7
Installer Designer t
#bedrooms AM Approved design flow A;A- gpd
The issuance of this permit shall not be construed as a guarantee that the system will fumction as designed.
Date Inspector
-- ------------------.---
No. 20 20 1 �^
Fee
THE COMMONWEALTH OF MASSACHUSETTS t
o PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction permit
Permission is hereby granted to Construct( ) Repair(�0) Upgrade( ) Abandon( )
System located at � C.d1{t' 1,XWr5e Z"r L..A4 ,
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. /1
Provided:Construction must be completed within three years of the date of this permit!
Date �� ' �G Approved by
Commonwealth of Massachusetts
,i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, f
49 Captain Bellamy Lane ,
Property Address r•
Ca
Franca Saunders
Owner Owner's Name
require fo
d for
is every
Centerville
required for eve MA 02632 8-2-19 '
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.
OF'Mq
Important:When A. Inspector Information s�# /y �U
filling out forms p Q �`��� q�y';
on the computer, ��:' JAMES :R,'
use only the tab James D.Sears z:
key to move your Name of Inspector U:
cursor-do not
use the return Jim The Inspector Man
�� \�o ���
key. Company Name 11, eF •..,
P.O.Box 784 INS
StPE`�����`
Company Address
West Yarmouth MA 02673
City/Town State Zip Code
508-364-4398 S 1623
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
8-2-19
�spectorrs Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
ISInsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
r:
I
Commonwealth of Massachusetts
Title 5 Official Inspection ns ection Form
� W
Mio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is
required for every Centerville MA 02632 8-2-19
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:
The system is a 1000 Gal.Tank D Box and pit
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
S Commonwealth of Massachusetts
119 Title 5 Official Inspection Form
,o p
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�V 49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is Centerville
required for every MA 02632 8-2-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cone.):
❑ 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:
t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 8-2-19
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 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 8-2-19
page. City/Town 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 simoM is less than 6" below invert or available volume is less
than 1/2 day flow P:7—
❑ ® 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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
r
Commonwealth of Massachusetts
(P. Title 5 Official Inspection Form
JF Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is
required for every Centerville MA 02632 8-2-19
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?
® ❑ 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
c Commonwealth of Massachusetts
o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 8-2-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): NA Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
1000 Gal. Tank D Box and pit.
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 2017-0 Gal's
2018- 8,000 Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 8-2-19
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(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: 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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is Centerville MA 02632 8-2-19
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:
1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
2811
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.):
Pipeing is 4" PVC SCH -40.
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
e
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is
required for every Centerville MA 02632 8-2-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 18"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 Gal. Precast H-10
Sludge depth:
3"
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
1"
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
17"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and cover's at 18". In and outlet Tee's. No sign of leakage or over
loading.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
J
i
�a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
9 p Y rY
z 49 Captain Bellamy Lane
u
Property Address
Franca Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 8-2-19
page. City/Town 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
required for
is every
Centerville
required for eve MA 02632 8-2-19
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 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x 16"-2' Below Grade w/cover at 1'. Box is clean and solid w/one line out. No sign of
over loading or solid carry over.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
,A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
V�
Property Address
Franca Saunders
Owner Owner's Name
information is
required for every Centerville MA 02632 8-2-19
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:
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
,-P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is
required for every Centerville MA 02632 8-2-19
page. City/Town 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.):
Leaching is a 1000 Gal. precast pit. Pit at 3' below grade. Pit dry w/clean like new wail's. No sign of
over loading.
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
-
t�4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u,
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
required on is every Centerville
required for eve MA 02632 8-2-19
page. City/Town 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
io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is
required for every Centerville MA 02632 8-2-19
page. City/Town 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
0
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13-A
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information is
required for every Centerville MA 02632 8-2-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Or
Estimated depth to Igh ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H. 12' no G.W.. Bottom of Pit at 9' below Grade Bottom of pit at 3' above T H Depth
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
p Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Bellamy Lane
Property Address
Franca Saunders
Owner Owner's Name
information ati is
required for every Centerville MA 02632 8-2-19
page. City/Town 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
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i
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that l 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. 1 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
2-7-13
Inspector's Signature Date
The system inspector shall submit'a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title 5 Official IVioForm: surface ge isposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. CitylTown 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:
System is in good working order with no sign of failure.
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 rtace Sewage Disposal System-Page
e 2 of 17
I
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town 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:
I
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
❑ 2 Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h 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
m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
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.]
0 ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
0 ® 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
CG Ar , 49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
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?
0 ❑ 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
t5ins•1111110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official I nspection f orm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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:
Sump pump? . ❑ Yes ® No
Last date of occupancy: 2-2013
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1980's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"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.):
Good condition.
Septic Tank (locate on site plan):
18"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gal
Sludge depth:
12"
t5ins-11110 Title 5 Official Inspeddon 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
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
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
20"
Scum thickness
1"
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
15"
How were dimensions determined? 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.):
Tank is in good condition with baffles installed and no sign of leakage.
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 Forth:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4M , 49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condiiton with water at working level and no sign of back-up from pits.
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
l o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2-1000 gal
❑ 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.):
Both leach pits in good working order with no sign of failure. Pit E was empty with no visible stain
lines.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
�_j
v Q
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Q-6 7i'
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town 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: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
o design I If checked, datef de gn 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:
USGS and town maps show no groundwater at 20'.
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Captain Lumbert Ln
Property Address
John Donovan
Owner Owner's Name
information is required for every Centerville MA 02632 2-7-13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts Allm
Title 5 Official Inspection Form
R (Wj
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments lc�
�M 49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is required for g
Centerville MA 02636 August 19 2009
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.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick T. Sullivan
cursor-do not Name of Inspector
use the return
key. Ready Rooter, Inc.
Company Name
� PO Box 371 -17 Jan Sebastian Dr.
Company Address
Sandwich MA 02563
BdA" City/Town State Zip Code
508-888-2805 S112843
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
Z Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
w
w
/ August 20, 2009
n— Insbector's Signature Date
CIO N Tl4e system inspector shall submit a copy of this inspection report to the Approving Authority(Board
Uv. �• of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
hasea.,design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
ti•--
Cam. report,to the appropriate regional office of the DEP. The original should be sent to the system owner
C-iD andecopies 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.
49captainlumbertla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Dis osal System-Page 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is g
required for Centerville MA 02636 August 19 2009
every page. 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:
*High water usage readings in summer months due to irrigation.
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�Iacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the Xfthe following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years of or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial in ' ration or exfiltration or tank failure is imminent.
System will pass inspection/alth
ank is replaced with a complying septic tank as
approved by the Board of H
*A metal septic tank will pait is structurally sound, not leaking and if a Certificate
of Compliance indicating ths than 20 years old is available.
ND Explain:
1
❑ Observation of sewage backup or break out or high stati�water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, s tled or uneven distribution box. System will
pass inspection if(with approval of Board of Heal
❑ broken pipe(s) are replaced
❑ obstruction is removed
49captainlumbertla-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is Centerville MA 02636 August 19 2009
required for 9
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain: j
❑ The system required pumping more th 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with a roval of the Board of Health):
❑ broken pipe(s) are replac d
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board f Health in order to determine if
the system is failing to protect public health, safety or the I onment.
1. System will pass unless Board of Health deter nes in accordance with 310 CMR
15.303(1)(b)that the system is not functioning i a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of surface water
❑ Cesspool or privy is within 50 fee of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Boar of Health (and Public Water Supplier, if any)
determines that the system is fu tioning in a manner that protects the public health,
safety and environment:
❑ The system has a Sept' tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface ater supply or tributary to a surface water supply.
❑ The system has a s ptic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
49captainlumbertla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is g
required for Centerville MA 02636 August 19, 2009
every page. CitylTown 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 S 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 wate analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the pr sence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no ther failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6' below invert or available volume is less
than '/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.
49captainlumbertla-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is required for Centerville MA 02636 August 19,2009
every page. City/Town 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.
❑ M Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ Z 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" each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 f et of a surface drinking water supply
❑ ❑ the system is within 2 0 feet of a tributary to a surface drinking water supply
❑ the system is loca d in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or mapped Zone II of a public water supply well
If you have answered "yes"to any estion in Section E the system is considered a significant threat,
or answered "yes" in Section D a ove the large system has failed. The owner or operator of any large
system considered a significan hreat under Section E or failed under Section D shall upgrade the
system in accordance with 3 CMR 15.304. The system owner should contact the appropriate
regional office of the Depa ent.
49captainlumbertla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is g
required for Centerville MA 02636 August 19, 2009
every 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?
2 ❑ 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))
49captainlumbertla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is Centerville MA 02636 August 19, 2009
required for g
every page. City/Town 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 GPD
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 ears usage d 2007= 542 GPD"
g ( y g (gp )) 2008= 359 GPD`
Sump pump? ❑ Yes ® No
Last date of occupancy: May 2009
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 T' e 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
49captainlumberlla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is Centerville MA 02636 August 19 2009
required for 9 ,
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Owners records: Pumped 2004
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:
Septic tank, D-Box and Pit#1 installed 1983. #2 Leach Pit installed 03/15/91.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
49captainlumbertla-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is Centerville MA 02636 August 19, 2009
required for g
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 16"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:
8 X 4.5 X 4.5 1000 gallons
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness 1/2
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
14"
How were dimensions determined?
Tape measure and dip tube.
49captainiumbertla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Formo Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name MA 02636 August 19 2009
information is Centerville
ion
required-for State Zip Code Date of Inspect
every page. CitylTown
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.):
Inlet PVC tee and outlet concrete baffle in place. Liquid level at outlet invert. Risers bring covers
within 6" of grade.
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.):
Tight or Holding Tank(tank must be pumped at ti a of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ polyethylene ❑ other(explain
fiberlassj:
concrete ❑ metal ❑ g
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10
49captainiumbertla 03/08
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is g
required for Centerville MA 02636 Au ust 19, 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: /gallons
s
Design Flow:
per day
Alarm present: Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alayM and float switches, etc.):
*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.):
One inlet, two outlets with equal flow. No solids carryover. No sign of high water staining over outlet
inverts. No sign of leakage into or out of D-Box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
'W
49captainlumbertla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is g
required for Centerville MA 02636 August 19, 2009
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number: 2- 1000 gals ea
w/stone
❑ 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#1 empty with no sign of high water staining. Clean stone visible through side walls. Leach
i pit#2 located and inspected with camera; dry at time of inspection with high water staining 3.5' below
inlet invert. No sign of past hydraulic failure.
49captaintumbertla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is required for Centerville MA 02636 August 19, 2009
every page. Cityrrown 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 o soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
1
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of/hydrulicilure, level of ponding, condition of vegetation,
etc.):
49captainlumbertla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is Centerville MA 02636 August 19, 2009
required for 9
every page. Cityrrown State Zip Code Date of Inspection
t 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 whe I re public water supply enters the building.
r
I
E
'4 `_I 3 - `ate` O ,
O
t
b. +
49captainlumbertla•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Captain Lumbert Lane
Property Address
Jim Goddard
Owner Owner's Name
information is required for Centerville MA 02636 August 19, 2009
every page. City/Town 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: >5feet
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: 1991
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:
ma.water usgs.gov terraserver-usa.com
You must describe how you established the high ground water elevation:
No ground water found during#2 pit install in 1991. Hand auger 2' below base of#1 leach pit showed
no ground water intrusion after 1 hour. Accessed local ground water contour and topo mapping. No
high ground water in area of system.
49captaintumbertla-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
1
Ivo. & .. FimBA...30.oo.
..�_
I A � THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
ApptirFation for Disposal Works Tonstrnrtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair*X) an Individual Sewage Disposal
System at:
� 2 Captain Lumbert Lane Centerville
__ --•----•.............................•---•.......... ..._..... .... - •------
Location-Address or Lot No.
- Cokela'..•••-•---•-•-•....••---•••----•...................•-------•---
Owner Address
W J.P.Macomber Jr.
,.� ---••-----------------------•-------...-----•----------•----......--------....._----•-..._......._ .........----------------•----•-------•-•-•-•------.........._............_-------•--.............
Installer Address
QType of Building Size Lot----------------------------Sq. feet
DwellingX—No. of Bedrooms............ .............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------- ------------- -
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity--..........gallons Length--------------- Width-----------_--- Diameter.-------.------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter--------.----------. Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water..............--....--..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................---.
a ---------------------------------•------------------------•---......_...._.......--••-•----•.•-•------._....----------------------------•-----••..._....----
0 Description of Soil............... Sand:_8c-_GY'aVel_____.___..-___-, .
x
U ---•-------------------------------------------------------------------•---•------------•••-••--------------------------------------•--------------------------------•----------------------•-•---------
W ------------------------------------------------------------------------------------------------------------------------------------------------------•-------------•-------------------._...---•-------
VNature of Repairs or Alterations—Answer when applicable.-..............................................................................................
---------------------•-------------------........._.1-1JJO..�allon leach--•pit..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
j system in operation until a Certificate of CompliancWhas.,e, issued j) 7
rd of health.Signed -- - ----------------------------------------
Date---------------------------------
Application Approved BY .........
��.-..-I y--9
Application Disapproved for the following reasons- ---------------------------------------------------------------------------- -------------------------------------------------------
---------------------------------- ----- -------------------- -- --------- ---- ----------------- ---------- -------
Date
Permit No. �1...----e--�.-------------------------- Issued ............................
Dace
No...l./..:_..vl..... y; F $!..$._.30.00
U� THE COMMONWEALTH OF MASSACHUSETTS }
BOARD OF HEALTH
r TOWN OF-BARNSTABLE
.�ppliration for Roposal Works Towitru.rtinrt ran fit
Application is hereby made for a Permit to Construct ( ) or Repair�XX) an Individual Sewage Disposal
System at:
49 Captain Lumbert -ane Centerville f'
Location-Address } or Lot No.
- ••-C.QkP_I. ........................................................................ .......... ......................................................................................
Owner .............................................Address
J ....
w .P.Macomber Jr.
Installer Address
dType of Building Size Lot............................Sq. feet
V Dwelling.`r-,-No. of Bedrooms._'i__._..__.2----------------- -Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -------------------------------- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid-capacity........----gallons Length................ Width................ Diameter--.--.---------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter...................;-Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----_---------------------
-------------------------------------
-•--..... Date........................................
a
Test Pit No. 1................minutes per incht Depth of Test Pit.................... Depth to ground water------------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water<......................
O Description of Soil------------------------Ran?d..Rr_-C ra:1Le 1_..--------------------------------------------------
U --------------------------•------------••...------------------...._........•---------------••......-------•----
W
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
" ...-----•-----•-------------------------------•-=--•-----•-•-----------••--•--------------•---. -=-----------•----•---•----•-----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
�,- the provisions of.TITLE 5 of the State Environmental;Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the bo d of health.
%
Signed ... * / / �----- . ---------------------------� ....3/12/91
�� Date
Application Approved By ---------------* � -- ..--. <�------------------------------ .--,.>�---R-1.9...--r9/..----
Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------__..................................
---------------------------------------___---------------------------------------------------------------------------------------------------------------------------------------------------------------. ........................................
Date
PermitNo. -----....... -----ecf----------------------------- .Issued ............... .......................... --...
Daatete '
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �� f
TOWN OF BARNSTABLE 4` j
Cer#tft. ate of Tontlatiartce
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired )
by-----... -..P...Ma c omb e-r----Jr---------------------------------------------------------------------------------------------------------------------------........................................--------------
�j y� y� IIn�staller
-_- e - v +.tea 2«. ,.��d v.�t- 3.o r..: --------------------------------
at -------------�....Cfl.Z1.t.P- -�---�%?�1�'lr's'-?"-r---T>--•c'-----�R--- 1-". .�T.i..7..�-"---......-......--------------...------------...---------------------...-----
has been installed in accordance with the provisions of TITLE 5 o The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ........ .-... 9............... dated ................................................
THE ISSUANCE OF THIS-CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------- ........ /-. ... 1.................................... Inspector -... - L '/
THE-COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��_ 3"9 TOWN OF BARNSTABLE w
No... 1 FEs._ ... � 00..
Ehip ant Works Tono#rwtiort "parA t
Permission is hereby granted ,`-.:fib-P..,MaC�... - j.—
to Construct,( ) or Repair,W. an Individual Sewage Disposal System
at No.40--f—e)_1�'.:ai.n...Laimbl r— r�
...lan ...Cantexaz 1-11 t
----------------------------------------------••---------------......_.........
' Street Q Q
as shown on the application for Disposal Works Construction Permit Nol.Z-.4>_1...... Dated..........................................
..... ..:. ------------------------•----.....------............---•-
............
---_\ _..... Board of Health
DATE.. ..... -�----...: .`: ._
N
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
i
TOWN
F LIE
O
.00A'I"ION 7 9 C_�,P�G,,.r Ll-44lh bfl f ZPI SEWAGE #
ti LLAGE =eoferpt1le -ASSESSOR'S &LOT
NSTA,I,aI.EIVS NAME&PHONE NO.
;EPnC TANK C:APACTI'Y
,EAeCHYNG PACIIL ITY: (type)PI (size) ' C�
10.OF'EEDE.00MS_
IU DER CAR OVVNER—
't
'ERMITDATE:�. COMPUANCE DATE:
separation Distance Between the:
Aaximum Adjusted Groundwater Table to the,Bottom of Leaching Facility Eeet
�ivate dater Supply Well and Leaching Facility (if-any wells exist _
on site or within 200 feet of leaching facility)
Wge of Wetland mid L.eaciiing Facility(I£miy wetlands exist
within 300 feet of caching facility) Tees
'uraishcd by ,r '44wH_ /*e , "'. Up� Cloe 7-,c
a CL a
p G
d D
14
A -F- 3. 9-F- 3V"
14 59, 9_6_ 71
l
] TOWN OF BARNSTABLE
LOCATION �ij`[ a1�; �,�,,��,®� �„ SEWAGE#
VILLAGE_ 'C•n��'3 yi%\e, ASSESSOR'S MAP&PARCEL li?6.
INSTALLERS NAME&PHONE NO. J �, �M,o �,�r►
SEPTIC TANK CAPACITY OZ)�
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS ICA
OWNER
PERMIT DATE: 3 Ll Vn, COMPLIANCE DATE: a o�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. T 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
An j 3 )
a
A� tly �-