HomeMy WebLinkAbout1884 FALMOUTH ROAD/RTE 28 - Health 'l 1884 FALMOUTH RD/RT 28, CENTERVILLE'I
A= 189-030 -
No. 42101/3 ORA
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ESSEUE
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Commonwealth of Massachusetts
Title 5. Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owner's Name
information is /
required for every Centerville ✓ MA 02632 4/26/21
page. Citylrown- 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.
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A. Inspector Information S! 0- 1S33(o
Frank Nunes III
Name of Inspector t
saa ;
Company Name i
Box 841 r
Company Address
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East Falmouth MA 02536
Cityrrowh State Zip Code
508.272.6433 13010
Telephone Number rise Number
B. Certification
1 certify that:.I am a DEP approved system inspector i.n full compliance with Section 15.340 of Title 5 S
(310 CMR 15.000); Ihave 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
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3. ❑ Needs Further Evaluation by the Local Approving Authority
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4. ❑ Fails
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4/26/21
Inspecto a Date
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The system inspector shall submit a copy of this inspection report to the Approving Authority (Board l
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.
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Please note This report only describes conditions at the time of inspection and under the f
conditions of use`at that'time.This inspection does not address how the system will'perform
in the future under the same or;different conditions of use.
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Commonwealth of Massachusetts
F Title 5 Official
Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville MAI. 02632 4/26/21
page. Cityrrown State. Zip Code Date of Inspection
C.Inspection Summary.
Inspection-Summary: Complete.1, 2, 3, or,5 and all of 4 and 6. I
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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 notevaluated'are
indicated below.
Comments: 3
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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 at approved 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.
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❑ Y ❑ N ❑ ND(Explain below):
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Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not:for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection_Summary,(cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired:
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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 ❑ ND(Explain below): i
obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): I
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more:than 4 times a 1year due to broken or obstructed pipe(s). The
system will.pass inspection if(with approval of the.Board of Health): I
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Ej broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
obstruction is removed ❑ Y ❑ N ❑ ND(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
1.5.303(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
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/21
page. Citylrown State Zip'Code Date of Inspection.
C. Inspection Summary (cont.)
E 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:
El The system has aseptic tank and soil absorption system(SAS)and the SAS iswithin
100 feet of a surface water supply or-tributary to a surface water supply.
El 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.
El The system has aseptic tank and SAS:and the SAS is less than 100 feet but 50 feet or l
more from a private water supply well"".
Method used o determine distance.
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**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:
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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 o 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 In pection Form
Subsurface Sewage Disposal System Form-Not'for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville MX 02632 4/26/21
page. City[rown State Zip Code Date of Inspection
C. Inspection.Summary (cont.)
4) System Failure Criteria Applicable to,All Systems: (cont.)
Yes NoEl I
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® 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:
❑ 0 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.
❑ z 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.
El ® Any portion of a cesspool.or privy is less than 100 feet but greater than 50 feet
from a private water supply well with io acceptable water quality analysis, [This
system passes if;the well water analysis, performed at 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 bf 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. l have.determined that one or more of the above failure
criteria exist as described in 31.0 CMR 15.303; therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure:
5) Large Systems: To be considered a=large system the system must serve a facility with a
design flow of 1:0,000 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
❑ El system is within 200 feet,of a tributary to a-surface drinking watersupply
El ❑ the system is.located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone li of a public water supply well
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Commonwealth of Massachusetts
F Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owners Name
information is
required for every Centerville MA 02632 4/26121
page_ CityrFown State Zip.Code Date of Inspection
C. Inspection Summary (cont.)
Ifyou 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 C4 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.
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6. You must indicate"yes"or"no"for each of the following for aft inspections:
Yes No l
® ❑ 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?
ElHave large volumes of water been introduced to the system recently or as part of
this inspection?
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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?
z ❑ Was the site inspected for signs of break out?
Z ❑ Were all system components, excluding,the SAS, located on site?
E ❑ Were the septic tank.manholes uncovered, opened,and the interior of the tank
inspected for the conditioan 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 Soii;Absorption:System(SAS)on the site has
been determined based on`.
Z ❑ 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)1
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman.
Owner Owners Name
information is
required for every Centerville MA 02632 4/26/21
page. City/Town State Zip Code Date of Inspection
D.,System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203.;,(for example: 110 gpd x#of bedrooms): 330.
Description`
3 bedroom permit on file at BOH
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Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No !
Does residence have.a water treatment unit? ❑ Yes ® No
If yes,discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection El Yes U. No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ,0 No
Water meter readings, if available last 2 years.usage d 236 GPD
Detail:
Per water meter readings, irrigation at home
Sump pump? ❑ Yes ® No
Last date of occupancy:: occupied
Date
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Commonwealth of Massachusetts
F TiVe .5 QffidaV Inspection_:Form
'Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) i
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203); Gagons per day(gpd)
Basis of design flow(seats/persons/sq.ft„etc.)::
Grease trap present? ❑ Yes ❑ No f
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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
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Water meter readings, if available: i
Last date of occupancy/use: Date
Other.(describe below):
3. Pumping Records:
Source of information: No recent pumping per owner
Was system pumped as part of.the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was,quantity pumped determined?
Reason for pumping:
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Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owners Name
information is
required for every Centerville MA 02632 4/26/21
page. Cityrrown 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
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❑ 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;l/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:
There is no records.on when the leaching pits were installed,the septic tank is from 1995
Were sewage odors detected when.,arriving at the site? ❑ Yes, ❑. No
5. Building Sewer(locate.on site plan):
Depth below grade: feet
Material of construction:
E.cast iron ❑ 40 PVC ❑other(explain):
'
Distance from private water supply >10'well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
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Commonwealth of Massachusetts....
Title 5 Official Inspection. Form
Subsurface Sewage.Disposal`System Form-Not for Voluntary Assessments
�:rw)'_
1884 Falmouth Rd
Property Address
Forman
Owner Owners Name
information is +
required for every Centerville MA 02632 4/26/21
page. Cityrrown State Zip Code. Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
24" I
Depth below grade: feet
Material of construction:
Z concrete ❑ metal ❑fiberglass 0 polyethylene 0 other(explain)
H-10 septic appears to be structurally sound
If tank is metal; list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
6„
Sludge depth:
>12"
Distance from top of sludge to bottom of'outlet tee orbaffle
Scum thickness
1/2" II
Distance from top.of scum to top of outlet tee or baffle >2
>2,.
Distance from bottom of.scum to bottom of outlet tee or baffle
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity,
liquid levels as related to.outlet invert, evidence;of leakage,etc.):
Pumping suggested every 3yrs to prolong the life of the system
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owners Name
information is
required for every Centerville MA 02632 4/26/21
page. Cityfrown 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:
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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:
g
Material of construction;
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
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Capacity:
gallons
Design Flow: gallons per day
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Commonwealth of Massachusetts;
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary;Assessments j
k� 1884 Falmouth Rd j
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/21
page. Citylfown State Zip Code Date of Inspection
D. System Information (cunt.)
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? El Yes N
9. Distribution Box(if present must be opened) (locate on site plan):
011
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover; any
evidence of leakage into or out of box, etc.): {
H-10 D-box is 2' below grade, no adverse conditions observed, the d-box serves 2 pits, Pit"D" is.
presumed to be original from 1966 and pit"C"was in at a later date, the flow to pit"D is
restricted with a speed leveler so all flow goes to.pit"C"
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Commonwealth of Massachusetts i
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i
1884 Falmouth Rd
Property Address
Forman
Owner Owners Name
information is
required for every Centerville MA 02632 4/26/21
page. r.City/Town State Zip Code Date of Inspection €
D. System Information (cont.) I
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):
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If SAS not located, explain why:
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Type:
leaching pits number:
2
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❑ leaching.chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
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overflow cesspool number:
innovative/alternative system
Type/name of technology:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-.Not for Voluntary'Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville MA 02632 4126/21
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.):
Pit"C" is the primary pit,the efflunt level is 10" below the invert at this time, there is a stain line up to
the last row of weep holes but no indication of past hydraulic failure, top of the pit is 2' below grade,
pit"D"was video inspected, it is dry at this time ;it is presumed to be the original overflow pit from
1966, cover is to 12"of grade, flow to the pit is restricted by a speed leveler at the d-box
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
P
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.)
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Commonwealth of.Massachusetts l
Title 5 Official Inspection. Form I
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner
Owner's Name
information is
required for every Centerville MA 02632 4/26/21 I
page. £ityrrown State Zip Code Date of Jnspection.
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.):
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Commonwealth of Massachusetts
F Title 5 Officia.l Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1884 Falmouth Rd
lu,V-1
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville `MA 02632 4/26/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
14. Sketch Of Sewage Disposal System.
Provide a view of the sewage disposal system,including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the.boxes below:
® hand-sketch in the area below
E drawing attached separately {
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Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Notfor Voluntary Assessments
t
1884 Falmouth Rd
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville MA; 02632 4/26/21
page. Cityrrown. State Zip Code Date of inspection
D. System Information (coat.)
15. Site Exam
® Check Slope
Surface water i
Check cellar
❑ Shallow wells
>12
Estimated depth to high groundwater. feet i
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
Observed site(abutting property/observation-hole within 150 feet of SAS)
® Checked with local Board of Health explain:
4'seperation.;per 1995 compliance:
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Checked with local:excavators, installers (attach documentation) I
® Accessed USGS database explain:
TOPO mapping shows the site at54'msl:and nearby surface water at22'msl l
You must describe how you.established:the.high groundwater elevation:
See above
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Before filing this.Inspection Report, please see Report Completeness Checklist on next page.
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Commonwealth of Massachusetts`
0 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-NoYfor Voluntary Assessments
1884 Falmouth Rd
Property Address
Forman
Owner Owner's Name
information is
required for every Centerville MA 02632 4/26/21
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of.this form inclusive of
A. Inspector Information: Complete all fields in this section.
B. Certification: Signed &Dated and 1, 2,3, or 4;.checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6:(Checklist)completed
D. System.Information
For 8:Tight/Holding.Tank—Pumping contract attached
For 14: Sketch of.Sewage Disposal;System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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:;7 PARCEL
No.. ..•.. Fxs... ...30. 00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di-nVitiul Works (nnnitrnrtiun Fermi#
Application is hereby made for a Permit to Construct ( ) or Repair VX) an Individual Sewage Disposal
System at:
1884 Route 28 Centerville
............................•---•-•--........-----------•--••-------------------------------...... --•-------------------------------------•-----------------•---------•••-----•---------...---------
Location-Address or Lot No.
Saul Formon
......................_.......................................................................... -----------•------------------------....---------•---•----------------.........--------------••--.
Owne Address
W J. P.Macomber fir .
IustalIer Address
d
g Size Lot............................ype o Building Sq. feet
Dwellings No. of Bedrooms-..-.-_---_3
------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther Other—Type of Building ____________________________ No. of persons______________-__---------_. Showers ( ) — Cafeteria 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 ( )
aPercolation Test Results Performed bY-------------------------------------------------------------------------- Date--------------------------------------
Test Pit No. I________________minutes per inch Depth of Test Pit-------------------- Depth to ground water.....-.._____-_____.._..
rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit...._.-.-._____-._-- Depth to ground water........................
a ------------ --- ----------------------------------------------------------------------•----------.....-----------------•--------------.......-------...._.
ODescription of Soil-------------------------------------------------------------•-----------------------------------------------------------------........--------------------------------
VS.a cl.. G r a v e-1------------------------------------------------------------------------------------------------------------------------------••-------•------•----
W
------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.__0m i t c a v i n 3 c e s s p o o l . I n s t a 11
................................
1_-_1500---gallon...tapk.J-distribution box . Connect to existing 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
system in operation until a Certificate of Compliance has b en 'ssue by the ...................................a d of health.
Sign ... /o. - -��� M
- - 8/7/95
Dace
Application.Approved B �• - `
Date
Application Disapproved for the following reasons: .... - .........
..---
-... -
---- -------- ------------------------------------------------------------------------- --------------------------------------- ---
1. 00.7 <:..
Permit No. ..--, ------------- Issued __.... ''tee _..
Dare
ri
/,r, i ► �
No.. Fxs... ....30.00 .
THE,COMMONWEALTH OF MASSACHUSETTS
r
BOARD OF HEALTH
- TOWN OF•BARNSTABL,5/,-,-
,� lirttti a i ur.. i lit l Works TO-Mitrur_#'inn rami#
Application is herebyima' 'fbr a Permit t6 orjstruct ( ) or It piir �{ ) an Individual Sewage Disposal "r
System at: -
.............-__1884 Route 28 ..Centerville
-- -------\---•-•-----•-----•-----=------......._.._. 4
Location-Address or Lot No.
Saul Formon 4
......................-..........................................................................
W J.P.Maeomber dr. Address
••-•••••---•-••--••---•-•••-•-••-•----••--•-•••--•••-----•--•••----------------------•--____--•-•- ----------------
i' Installer Address
UType of Building 3 Size Lot............._..............Sq. feet
.., DwelIi No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons----------.----------------- Showers ( ) — Cafeteria ( )
dOther 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.
3 Seepage Pit No..................... Diameter.__-.--.._....__-_-- Depth below inlet................... Total leaching area___.....__________sq. ft.
Other Distribution box ( ) Dying tank (----)
--------------------------------------------------- Date........................................
Test Results Performed b .-_--_.-.-_._._. P g
a Test Pit \o. I________________minutes per inch Depth of Test Pit-----._-___..___. Depth to round water............_
f? Test Pit No. 2................minutes per inch Depth of Test Pit_--.....____-_______ Depth to ground water.........................
a' o-�----------------------------------------------------------------------------------•------
D Description of Soil.......................----•••••••••••-•----•--••-•••--•-••••-•-•-•---•--`" -----------447-------._...
v -Viand_._&..Gravel
VW --- -•------------------------------------------------------------------------------------------------------------ ----------- _________
Nature of Repairs or Alterations—Answer when applicable._Om i t Z v n g_ c d s s p o-o l •.___Instal l
----------------------
2--150� a11on•-_tank, l-distribution box. Connect to existing. 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
system in operation until a Certificate of Compliance has b en 'sued by the oa'd of health. K ` , ;
Signe ----- ..._. 8 f`/f 9 S
- ------------------------ -- --------------
� Dare ......e...,}
APPlicatiort'Approved BY ------------ -° - a ' - ----=--- ------------ � ��..----------------------�-------------------..4..--........ !..
Date
Application.Disapproved for the following reasons: ..... -- - ....... _....... ..... ....... - - ..-.....
-------------------_.......----------......--....--.......---------..........-------------....._ --.....---------- --------------------------------------- -------------------- ........................................
-------------- Date
h .._...�----------------
Permit No. Issued ! ✓... '' `"" ' -
Date
m.,-- -- ----.— --F-r— — ——_---ate:—_— -------- ——,._,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN'OF BARNSTABLE
C'ertifi ate of (ILlomyliane
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX�
by --------------J...P....Ma.e.omb.e.r.---Jr, ----------------------------------------------------------------------------- ----------------------------- ------------------------------------
InscJlrr
at .--..-._.....- 1884 Route 28 Centerville
has been installed in accordance with the provisions of TITLE of 1,4�_, 9_
Rronmental C de as described in
the application for Disposal Works Construction Permit No. idated . . _
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
DATE------- ..."-f ��..`�.. --- - Inspect rti- - - '
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
�, TOWN OF BARNSTABLE
FEE$...30.00...
J.�i��nntt1 nr�n �nnn#ri$r#uan rrnti�
J P Macomber Jr'
Permission is hereby granted_______-. __ _____________________ ___
to Construct 4 ) or Repair,,.,L-X an Individual Sewage Disposal System
18 Route 8 Centerville
atNo. _...--•--•- -- -_-------- -_--
Stree �/� ___
,-- G
as shown on the application for Disposal Works Construction Permi t ..____.__._xw•7 Dated. -�'/�_ -....--•-------
j
DATE-------�----!!--- ----------------` J4-------------------------------
Board of Health
FORM 36508 HOBBS&WARREN,INC..PUBLISHERS
•
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, J o s e p h P. M a c o m b e r J r , hereby certify that the application for disposal works
construction permit signed by me dated 8/7/9 5 , concerning the
property located at 1884 Route 28 Centerville meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED DATE: 8/7/9 5
LICE D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 2 5
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
TOWN OF BARNSTABLE
LOCATION/9$rV SEWAGE' r�Ae(3 7
VILLACE C'er1 r1rd ASSESSOR'S MAP & LOT f�'Cf�JO
INSTALLER'S NAME & PHONE NO.-`I -P, yr)peC)rn V(- c�(n -Djo
SEPTIC TANK CAPACITY
LEACHING FACILITY;(type)
NO. OF BEDROOMS__,3� PRIVATE WELL OR PUBLIC WATER
B171-7-?DER OD r1W'TFR -Y
DATE PERMIT ISSUED: r
DATE COMPLIANCE ISSUED:
r
1 .
1 \
1� 1
O J No
A
TOWN OF BARNSTABLE
LOCATION 1884 Falmouth Road SEWAGE #
VILLAGE Centerville
ASSESSOR'S MAP Cz LOT
Inspected by : Joseph P. Macomber & Son Inc .
Box 66 , Centerville
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 2-Cesspools (size) 6 X 8
NO. OF BEDROOMS --3- PRIVATE WELL O PUBLIC WATER
OWNER Saul Forman
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: (�
VARIANCE GRANTED: Yes No
!4
4/20/2021 ShowAsbuilt(1653X2338)
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TOWN OP:BARNSTABI E i
LOCIiIION,l $ a SEWA01E.dT�
Y1Lt_10E ( :ern. P.I\Ii��
.."-ASSESSORS MAP:& LOTIBEa3O
INSTALLER'S NAME& PHONE NO.`a-�IYY(3 (Jiiho(
h i
SEPTIC TANK CAPACITY :r o
LEACHING:FACILITY:(type) f[ j&Ap 4 (sLk�-� '
1
I:
NO.OF BED RooMS : . .PRIVATE WELL OR.PUBLIC WATER
BI�It.?)ER K)o nd�wrtiR -,7 llt�c.0 �th`y/J,E�'J-(
DATE PERMIT ISSUED: . .. .�--
DATE COLSPLIANC.E ISSUED;•_ = '' r' T
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Existing pit
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1500 Gallon tank.
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Omit caved in cesspool .
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1884 Route 28 Centerville
New Di Stsil)utistin bDUO
Existing pit
1500 Gallon tank.
Omit caved in cesspool .
1884 Route 28 Centerville