HomeMy WebLinkAbout872 CRAIGVILLE BEACH ROAD - Health 872A Craigville Beach Rd.
A= 226- 169
Centerville
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No.2453LOR
UPC 12534
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Commonwealth of Massachusetts
Title 5 Official Inspection Foem y
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments C4
C4
872 A&B Craigville Beach Road
Property Address
C. Beach Propertes LLC i rX'
Owner Owner's Name j
information is :a
required for every Centerville MA 02632 ! '
page. City/Town 11-15-18 Y
State Zip Code; Date of Inspection C-,.;+
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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.!
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Important:When O Vif
A. Inspector Information
filling out Forms p
on the computer, , �O , •yG+
use only the tab James D.Sears
key to move your Name of Inspector
cursor-do not
use the return Ca wide Enterprises
key. Company Name o
�`� 153 Commercial Street INSpEG��`���``\
Vllraa II Company Address �r� altiw',%
�� Mashpee MA 02649
58-4
Ci08-4 n77-8877 State
Zip Code
S1623
Telephone Number License Number
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B. Certification
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I certify that: I am a DEP approved system inspector in full complliiance 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:
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1. ® Passes
i2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
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�ctoesSiqnatuF��� 11-19-18
Date
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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 some or different conditions of use.
t5insp.doe-rev.7126J2018 Title 5 Official Inspection Form:Subsurface Sawa a Disposal 9 D System•Page 10l 18
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'�r\ Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
872 A&B Craigville Beach Road
Property Address
C, Beach Propertes LLC j
Owner Owners Name
Information is required for every Centerville MA 02632 i 11-15-18
page. Cityrrown Stale Zip Code Date of Inspection
C. Inspection Summary
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Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. j
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1) 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:
The system is a 1000 Gal.H-20 Tank D Box and two chamber's
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2) System Conditionally Passes:
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❑ 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 tanki(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):
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Commonwealth of Massachusetts
(p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F �
872 A&B Crai ville Beach Road
Property Address
C. Beach Pro ertes LLC
Owner Owner's Name
information is
required for every Centerville MA 02632 11-15-18
page. CltylTown State ZipCode
Date of Inspection
C. Inspection Summary (Cont.)
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2) System Conditionally Passes(corgi j
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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❑ 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):
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❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below):
❑ obstruction is removed ❑ Y ❑j N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
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❑ The system required pumping more than 4 times a year dueto broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken Pipe(s)are replaced ❑ Y ❑ IN ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
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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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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 I
872 A&S Craigville Beach Road
Property Address
C. Beach Propertes LLC I
Owner Owner's Name
Information is
required for every Centerville MA 02632 11-15-18
page. City/Town State Zip Code! Date of Inspection
C. Inspection Summary (cunt.)
❑ Cesspool or privy is within 50 feet of a surface watei
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❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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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 vtithin 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. I
❑ 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:
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This system passes if the well water analysis, performed at a DEP certifled 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:
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4) System Failure Criteria Applicable to All Systems: I
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
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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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
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;v 872 A&B Craigville Beach Road
r -
Property Address j
C. Beach Propertes LLC
Owner Owner's Name
information is required for every Centerville MA 02632 j 11-15-16
page. City/Town State Zip Code j Date of Inspection
C. Inspection Summary (coot.) j
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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 j
❑ ® Liquid depth in aems"OlLis 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 I's below high ground water elevation.
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❑ ® 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 withinia Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within W 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.
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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 C.4.
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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
872 A&B Craigville Beach Road j L -
Property Address
C. Beach Propertes LLC
Owner Owners Name
Information is
required for every Centerville MA 02632 j 11-15-18
page. Cltyfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered'yes"to any question in Section C.5 the s i ystem 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 1310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"y
es,, or"no"for each of the following for all inspections:
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Yes No
❑ ® Pumping information was provided by the of ner, 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 NIA)
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® ❑ Was the facility or dwelling inspected for signs of sewage back up?
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® ❑ Was the site inspected for signs of break out?
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® ❑ 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) 1310 CMR 15.302(5)]
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Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Sewage Disposal System Form •Not for Voluntary Assessments
872 A&B Craigville Beach Road
Property Address
C. Beach Prooertes LLC
Owner Owners Name
Information is
required for every Centerville MA 02632 i 11-15-18
page. City/Town State Zip Code, Date of Inspection
D. System Information
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1. Residential Flow Conditions:
Number of bedrooms desi n : 4
( g ) NA Number of;bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
1000 Gal. H-20 Tank D Box and Two Chamber's.
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Number of current residents: 0
Does residence have a garbage grinder?
❑ Yes ® No
Does residence have a water treatment unit? i ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? + ❑ Yes ® No
Seasonal use? I ❑ Yes ® No
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Water meter readings, if available last 2 ears usage i NA
( y 9 (gpd)):
Detall:
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Sump pump?
❑ Yes ® No
Last date of occupancy: NA
Date
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Title 5 Official inspection Form:Subsurface Sewage Disposal system Page r or 18
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Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A&B Craigville Beach Road
Property Address
C. Beach Propertes LLC
Owner Owner's Name
information is
required for every Centerville MA 02632' 11 15-18
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? El Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? El 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):
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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:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:r I
872 A&B Craigiville Beach Road
Property Address
C. Beach Propertes LLC
Owner Owner's Name
information is
required for every Centerville MA 02632 !, 11-15-18 page. City/Ttmn State Zip Code Date of In
D. System Information (cant.) Inspection
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4. Type of System:
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® Septic tank, distribution box,soil absorption system
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❑ 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.
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❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1990 Permit #90- 216.
Were sewage odors detected when arriving at the site? i
❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 22
feet
Material of construction: `
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❑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.
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Title 5 Official Inspection form;Subsurface Sewage Disposal System•Pape 9 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y
_872 A&B Crai Ville Beach Road
Property Address
C. Beach Propertes LLC
Owner Owners Name
information is
required for every Centerville MA 02632 11-15-18
page. City/Ttram State Zip Code Date of Inspection
D. System Information (cont,)
6. Septic Tank(locate on site plan):
1 1'
Depth below grade; I
i feet
Material of construction:
® concrete ❑ metal ❑fiberglass
❑,polyethylene ❑other(explain)
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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-20
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle ! 28"
Scum thickness 1 2"
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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 16"
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.):y
Tank at working level, Tank and covers at 1'below grade. Steel inlet cover- H-20 cement outlet
cover. In and outlet tee's. No sign in Tank of leakage or over load in .
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Commonwealth of Massachusetts
�. f Title 5 Official Inspection Form
9'1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
872 A&B Crai ville Beach Road
Property Address
C. Beach Propertes LLC i
Owner Owner's Name
information is
required for every Centerville MA 02632
page. City/Town 11-15-18
State Zip Code'' Date of Inspection
D. System Information (cont.)
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7. Grease Trap(locate on site plan):
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Depth below grade:
i feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass g 0 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 o�baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.);
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8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
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Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑'polyethylene ❑ other(explain):
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Dimensions:
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Capacity:
gallons
Design Flow:
gallons per day
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Commonwealth of Massachusetts
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for-Voluntary Al sessments
872 AM Crai ville Beach Road
Property Address
C. Beach Propertes LLC
Owner Owners Name
Information is
required for every Centerville MA 02632 11-15-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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8. Tight or Holding Tank(cant.) j
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.):
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'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
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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.): j
D Box is 16"x16"-2'below grade. Box is clean and solid w/one line out. No sign of over loading or
solid carry over.
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osal System-Page 12 of 18
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Commonwealth of Massachusetts
i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u�
872 A&B Craigvllle Beach Road
Property Address
C. Beach Propertes LLC
Owner Owner's Name
information is required for every Centerville MA 026321 11-15-18
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
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10. Pump Chamber(locate on site plan):
Pumps in working order: j ❑ Yes ❑ No"
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Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
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" 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:
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Type:
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❑ leaching pits numiber:
®
i 2 leaching chambers number
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
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❑ innovative/alternative system j
T e/name of technology;
ogY; i
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Commonwealth of Massachusetts
Title 5 Official Inspection F o rrn
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
z
872 A&B Craigville Beach Road
Property Address
C. Beach Propertes LLC
Owner Owners Name
information is
required forevery Centerville MA 02632 11-15-18
page. City/town State Zip Code Date of Inspection
D. System Information (cont,)
11. Soil Absorption System (SAS)(cont.)
Comments(note condtion of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two flow's. Ck D Box and camera out. No sign of'over loading or solid carry over. No
sign of holding water.Prob above and beside chambers-dry
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12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration j
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Depth—top of liquid to inlet invert
Depth of solids layer
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Depth of scum layer
Dimensions of cesspool
Materials of construction
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Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Commonwealth of Massachusetts j
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
872 A&B Cralgville Beach Road j
Property Address
C. Beach Propertes LLC j
Owner Owners Name
information is
required for every Centerville MA 02632 1.1-15-18
page. City/Town State Zip Code! Date of Inspection
D. System Information (cunt.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
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Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Fol m
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A&B Craigville Beach Road
Property Address
C. Beach Propertes LLC ,
Owner Owners Name
Information Is
required for every Centerville MA 02632 11-15-18
page. City/Town state Zip Code Date of Irlspeotion
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties tout 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
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151nsp.doC•rev.7/2812018 Title 5 0mclal Inspection Form:Subsurface sewage olsposd system•page 16 of 18
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
Property Address
i
Owner Owner's Name
Information is
required fnr every
page. City/Town state Zip Code i Date of Inspection
D. System Information (cont.) j
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: i
i
(hand-sketch in the area below
❑ drawing attached separately
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tBinap.00e•rev.71MZ01 a Title 3 0Mdel lnspecuon Form;Subaurface Sewage oiaposei system-Page 18 of 18
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Commonwealth of Massachusetts
i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
872 A&B Creigville Beach Road
Property Address
C. Beach Propertes LLC
Owner Owners Name
information is
required for every Centerville MA 02632 11-15-18
page. Chy/Town State Zip Code ; Date of Inspection
D. System Information (cont.)
15. Site Exam:
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❑ Check Slope
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❑ Surface water
❑ Check cellar
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❑ Shallow wells
!
Estimated depth to high ground water: 8
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: pate
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® Observed site(abutting property/observation hole within 150 feet of SAS)
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❑ Checked with local Board of Health-explain:
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❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
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You must describe how you established the high ground water elevation:
Auger T.H. 8'no G.W.. Bottom of chamber's at 45"below grade. Bottom of chamber's at 4'above
T.H. Depth.
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Before filing this Inspection Report, please see Report Completeness Checklist on next page,
t5insp.doc•rev.7/26/2018 Title 5 Officer Inspection Form:Subsurlace sewage Disposal system-Page iT or is
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A&B Craigville Beach Road
Property Address
C. Beach Propertes LLC {
Owner Owners Name
Information is j
required for every Centerville MA 92632 i 11-15-18
page. City/Town State Zip Code; Date of Inspection
E. Report Completeness Checklist i
i
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
i
Z 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
i
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached j
For 14: Sketch of Sewage Disposal System drawn on pg. 16or attached
For 15: Explanation of estimated depth to high groundwater included
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151nsp.doC-rev.7@6r201e TMe 5 Official Inspection Form:subsurface Sewage oisposet System•Page to of to
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CERTIFIED o RECEIPT
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Domeitic Mail Only
m For delivery information,visit our website at www.us;ps;xom=
o OFFICIAL
u Certified M15i1 Fee a
F�dfa SONISes&Fees(check box,add fee as appropriate) �1
❑Retum Recelpt(hardoopy) $
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a g PERKINS, CONSTANCE J & BURK, JOANNE
o 872B CRAIGVILLE BCH RD
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CENTERVILLE, MA 02632 (� /.
Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail label), for an electronic return receipt,see a retail
■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
•Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. USPS®-postmarked Certified Mail receipt to the
■A record of delivery(including the recipients retail associate. " ii
signature)that is retained by the Postal Service— Restricted delivery service,Which provides f ,
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent C 3
Impottant Reminders: Adult signature service,which Wquires the _3
•You may purchase Certified Mail service with signee to be at least 21 years of age(not
First-Class Mail®,First-Class Package Service®, available at retail). !
or Priority Mail®service. Adult signature restricted delivery service,which !!
■Certified Mail service is notavailable for requires the signee to be at least 21 years of age
international mail. and provides delivery to the addressee specified
■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent;
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the •To ensure that your Certified Mail receipt is
Insurance coverage automatically included with accepted as legal proof of mailing,it should beara7
certain Priority Mail items. LISPS postmark If you would like a postmark on r"l
■For an additional fee,and with a proper this Certified Mail receipt,please present your i
endorsement on the mailpiece,you may request Certified Mail item at a Post Office''for f-n
the following services: postmarking.If you don't need a postmark on this
Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion.
M of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.
electronic version.For a hardcopy return receipt, r
complete PS Form 3811,Domestic Return
Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
._s Form 3800,April 2015(Reverse)PSN 7530-02-000-9047
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3. A. lure
■ Print your name and address on the reverse 13 Agent
so that we can return the card to you, IL)Z,144O,Addressee.
e y Printed Name) C, Itf e
Attach this card to the Back of the mailpiecet
or on the front if space permits.
1 Article Addressed to: Q. is delivery address different from item 1 ❑Yes
)delivery address below: p No
PERKINS, CONSTANCE J &BURK,:JOANNE M�
872B CRAIGVILLE BCH'RD
GENTERVILLE, MA 02632'
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9590 9402 1934 6123 0978 76 Certified Mali@ Delivery
Mall Restricted Delivery 'L�tetum Receipt-for
❑Collect on Delivery 6 Merchandise
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PS Form 3811,July 2015.PSN 7530-02-000-9053 Domestic Return Receipt
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Postal Service
Town of Barnstable
Health Division
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200 Main Street
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Hyannis,MA 02601
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THE T°�
Town of Barnstable Barnstable
Regulatory Services Department ;edcaC"j
IARMAHM '
, "M Public Health Division
D"" • 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 .0001 4990 3653
June 26. 2017
PERKINS, CONSTANCE J &BURK, JOANNE M
872B CRAIGVILLE BCH RD
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 872 A & B Craigville Beach Road, Centerville was
inspected on 06/07/2017 by Shawn Mcelroy, certified Title V Septic Inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system"Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching facility with standing liquid level at or above the invert pipe (per
Town Code 360-20 h).
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
PomasOciea)n, R.S., CHO
Agent of the Board of Health
1
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\872 A&B Craigville Beach Road
Centerville.doc
Town of Barnstable
t6,39L.�,�� Regulatory Services Department
Public Health Division
200 Main Street,Hyannis MA-02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A McKean,CHO
Feb 6, 2007
Rev. 5111116
DEADLINES TO*REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000) _
'An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑Discharge or ponding of effluent to the surface of the ground w .
❑Pumping more than 4 times during the last year not due to clogged or obstructed
Pipe
❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (21 YEARDEA ILENF
q Single Cesspool
❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components,etc)
❑Leaching pit or cesspool with high liquid level, <12"below inlet (per Town Code
§360-9.1)
Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
F
Commonwealth of Massachusetts ,;,,
'
:a=1 Title' S official Inspection Form ;y
�.
l Subsurface Sewage Disposal System Form Not for Voluntary Assessments
872 A& B Craigville Beach Rd _ f9
Property Address
Joanne Burk
Owner Owner's Name
information is Centerville MA 02632 6-7-17
required for every
page. City/Town State Zip Code Date of Inspection 0
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 5161. Inspector: /
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification j
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 16.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
C f '
6-7-17
y
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
/0 US
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
r.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A& B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
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
P rY Y P
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
:a Title, 5 Official Inspection Form
! -'f�;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A& B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
page. City/Town State Zip Code Date of Inspection
B. Certification (coat.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
1a=1 Title 5 official Inspection For
If,., Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A & B Craigville Beach Rd
t J'
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
lal Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ag,
872 A& B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
f
A Subsurface Sewage Disposal System Form Not for Voluntary Assessments
-'„ 872 A & B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is Centerville MA 02632 6-7-17
required for 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?
® ❑ 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): 2 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A& B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA '02632 6-7-17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (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)):
• Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 6-2017
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
t;+l Title 5 Official Inspection Form
�r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A& B Craigville Beach Rd
t,_P Cb
t f
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
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•3113 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
872 A & B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
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:
1990
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
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: 1000 gal H-20
Sludge depth:
12"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
fps Title 5 Official Inspection Form
1, V l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a'
872 A & B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
page. City/Town 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A& B Craigville Beach Rd �
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17
Commonwealth of Massachusetts
=1 Title 5 Official Inspection Form
+r 11-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
872 A& B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is
required for every Centerville MA 02632 6-7-17
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 N/A
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.):
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_s;!„/ 872 A & B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-Flodiffusers
❑ 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.):
Flodifusser had water level above inlet invert at inspection.
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
RR Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A & B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
fp Title 5 Official Inspection Form
�f�;j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`u r�W. 872 A& B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
page. City/Town 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
r
i
fo
J
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
r f Title 5 Official Inspection Form" 4
1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
872 A& B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
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: 72"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:
Original design plans from neighbor property at 862-864 Craigville Beach Rd show groundwater was
encountered at 72".
4;
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
f Title '5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
872 A & B Craigville Beach Rd
Property Address
Joanne Burk
Owner Owner's Name
information is required for every Centerville MA 02632 6-7-17
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Map Page 1 of 1
Town of Barnstable Geographic Information System New search I Home I Help
Parcel Viewer Custom Map Abutters Map Size ® EN
Zoom Out j M j f M j jIn
JPG Map: 226 Parcel: 169 Prol e
P rty
'` , Location: 870 CRAIGVILLE BEACH ROAD Info
226158 "' Owner: PERKINS,CONSTANCE J&
qp ;l.
I 4 x'.
h 2Y8167
Q I12 Location Information
226188 — {!
gg Map&Parcel 22616914 l((
Location 872 CRAIGVILLE BEACH ROAD 33i
22E157 0 Acreage 0.i3 acres 1
R 11.4
3
f Current Owner �
7J Mailing Address PERKINS,CONSTANCE J&'
BURK,JOANNE M ,74
,:228188 a 872 CRAIGVILLE BCH RD .,
�, ae72 CENTERVILLE,MA 02632
22e1vo Appraised Value(FY 2012)
g904 Extra Features $7,000 "*
Out Buildings $0
Land $256,000
. Buildings $86,600
Total Appraised $349,600 N'
sv
2eis Reis
�8�4CKga Assessed Value(FY 2012)
915
Extra Features $7,000 4
j_9 Feet1CND Out Buildings $0
aa7a Land $256,000
�' Buildings $86,600 �
Set Scale J." = 39 I .Aerial Photos ,1 I MAP DISCLAIMER Total Assessed 3349,600 J
Copyright 2005-2010 Town_of Barnstable,MA All rights reserved.Send questions orcomments to GIS
BarnstableMA vi.2.4672[Production)
http:H66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=226169 11/20/2012
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r TOWN OF B®ARNSTABLE
LOCATION �'� Ccc,,yf A< �Cccl 9,-0 SEWAGE #
VILLAGE CeaA•r J°AV Y• ASSESSOR'S MAP & LOT �l d
INSTALLER'S NAME & PHONE NOC& %V\c
SEPTIC TANK CAPACITY 1 \
LEACHING FACILITY:(type)-2� Aow a,4-,k 5o+ize)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: zi
DATE COLIPLIANCE ISSUED: ,. I
VARIANCE GRANTED: Yes No
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cu, -
r, �s No. G ✓ � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s
application for MI8p08al 6pstem Construction permit
Application for a Permit to Construct( ) Repair) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ''l LA [t Owner's Name,Address,and Tel.No.
Assessor's 1Vlap4 li' � �1 P�aet Y; d�L 6'_1�idiC 2 d. CAP .; ..
Installer's Name,Address,and Tel.No. Designer's lame,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(min.required) gpd Design flow provided gpd
Plan Date F 01 �' 202-� Number of sheets Revision bate
Title
Size of Septic Tank 15-00 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) o -P
Date last inspected: ZO 1,9
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date [ A - 1 - Z o Z
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. ),)a 1 Date Issued
t
No. G� ' ✓ Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s
,,01-pplicatlon for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
. Location Address or Lot No: (:eA-%6 \t(� :" � Owner's Name,Address,and Tel.No. r "
Assessor's Map l
�►l Q ,, ,I(�P �- �j
ar t'✓I+(„� !c/u(' �, I L 6: Z3aK ?(.� !
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
24; .',T4_X L,449A
Type of Building: p
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
rS iP f Other Type of Building No.of Persons Showers( Cafeteria( )
s
a ' Other Fixtures
Design Flow(min.required) -tJ 'I gpd Design flow provided F �J;j�. gpd
Plan Date_ 1 a, " 2 t%2. -( Number of sheets Revision Date
� t
Title
r
Size of Septic Tank if.SCJ U' Type of S.A.S. = 'r],
Description of Soil
f
l � Pr.4•
Nature of Repairs or Alterations(Answer when applicable) rR\o yL,_� 14 °-j c? ���T7li Gjt,�-.rL�� ( at{
Date last inspected: ao 1IF t
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate`of
Compliance has been issued by this'Board of Health.
Signed Date ( p 7w
Application Approved by p Gi p � Q Date
Application bisapproved by `J Date
for the following reasons
Permit No. ,r�d 1 J r Date Issued
------------------------------------------------
�• THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE MASSACHUSETTS
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired Upgraded
( ) P (� Pam' ( )
Abandoned( )by i t,.u,W-J t>loe" :..
t
at Z 2 Gr2d1 Yt t,���ti, �--� Pyk,�has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2d 3 !� dated ( J� { 2--,-, 2-
Installer t C, Designer
#bedrooms od A- Approved design flow , _A1/4- �' gpd
The issuance of this permit shall not be construed as a guarantee that the system w otion asn.e g ied.
Date / / Inspector
---- -- - -------- - - --• ------ - -- - -------- -------------------
No. 0) .. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
isposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( Al Upgrade( ) Abandon( )
System.located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit,, /
Date Approved by