HomeMy WebLinkAbout0134 HILLSIDE DRIVE - Health 1134 Hillside Drive
193-054 Centerville
'PC 12543 '
i'o. 53LOFZ
-- p�Sl•CG'�5��v
CASTINGS.ION
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
MW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
my- 134 Hillside Drive
Property Address
William E.Anderson, Trs., Hillside Nominee Trust
Owner Owners Name
information is Centerville MA 02632 April 7, 2011
required for every p
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
/ I
on the computer, �u/J
use only the tab
key to move your 1. Inspector:
cursor-do not David D. Coughanowr
use the return Name of inspector
key.
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
Cityrrown State Zip Code
508 364 0894 1328
Telephone Number License Number
B. Certification
- I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15:340 of
11
Title 5(310 CMR 15.000).The system: r
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
April 7, 2011 f "'
^y 3
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.
tSms-0901 Title 5 Official Inspection Form:Subsurface SewagTisposaj System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'( 134 Hillside Drive
Property Address
William E.Anderson, Trs., Hillside Nominee Trust
Owner Owner's Name
information is required for every Centerville MA 02632 April 7, 2011
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair,as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
15ms-ORM Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
O mmonwea)th :of Massachusetts
Title 5 Officialnspection Form
Subsurface`-.Sewage)Disposal System-Form-.Not for Voluntary Assessments
134 Hillside Drive
Property Address
William E. Anderson, Trs., Hillside Nominee Trust
Owner owner's Name
information is Centerville MA 02.632 Aril 7, 2011
required for every p
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static waterlevel 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 broke_n 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 belowy
0. obstruction is removed ❑ Y ❑, N ❑ NO (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'3'10>CMR
15.303(1)(b)that the system is not functioning in a manner which will protect pubi health,
safety and the environment:.
❑ Cesspool or privy is within 50 feet.of a surface.water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
iSins-09l08 Title 5 Official Inspection Form:Subsurface Sewage,Mposal System•Page3 01:17
Gommonwealth,of:Massachusetts
4'- - Tine. 5 Official Inspection. Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
134 Hillside Drive
Ptroperty Address
William,11 Anderson, Trs., Hillside Nominee Trust
Owner Owner`s Name_
I0uit df6ti�n e Centerville MA 02632 Aril 7, 2011
requied for•,every' p
page... Cityrrown State Zip Code Date of Inspection
B, Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supp)ier, 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.
1.00.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 land 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 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
0 0 Backup of sewage into facility or system component due.to overloaded.or
clogged SAS or cesspool
Discharge or poriding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
E 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6`' below invert or available volume is less,
than '/z day flow
t5'ins?09108 Title 5 Official inspection Form:Subsurface Sewage 6isposa(System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Hillside Drive
,p —
Property Address
William E.Anderson, Trs., Hillside Nominee Trust
Owner Owner's Name
information is Centerville MA 02632 April 7, 2011
required for every p
page. Cityrrown 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 16.304.The system owner should contact the appropriate
regional office of the Department.
t5'ms•09= Title 5 official Inspedion Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Hillside Drive
Property Address
William E. Anderson, Trs., Hillside Nominee Trust
Owner Owner's Name
information is required for every Centerville MA 02632 April 7, 2011
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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 or 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Hillside Drive
Property Address
William E.Anderson, Trs., Hillside Nominee Trust
Owner Owner's Name
information is Centerville MA 02632 Aril 7 2011
required for every p
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 282 gpd
Detail:
2009-2010
Sump pump? ❑ Yes ® No
Last date of occupancy: not determined
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:
15ins-09= Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 7 of 17
Gomrnonwealtti of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1,34 Hillside Drive
Property Address
William E. Anderson, Trs., Hillside Nominee Trust
Owner Owner's Name.
,information
for every ation ie
required Centerville MA 02632 April 7,2011_
-
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: -
Was system pumped as part of the inspection? ❑ Yes E No
If yes; volume pumped: gallons.
How was quantity pumped,determined?
Reason for pumping: -
Type of System:
z Septic tank, distribution box, soil absorption system
❑ Single.cesspool
❑ Overflow cesspool
❑ Privy
El 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•09108. 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
134 Hillside Drive
Property Address
William E.Anderson,Trs., Hillside Nominee Trust
Owner Owner's Name
information is Centerville MA 02632 Aril 7 2011
required for every A
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:
Age 3+ years. Certificate of Compliance dated April 27, 2007.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Sewer line is under foundation slab with no access for inspection. PVC cleanout with cap to suface in
back yard.
Septic Tank(locate on site plan):
Depth below grade: 1
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:
10.5 ft x 6 ft x 5 ft(1500 gal)
Sludge depth: 4 in
t5ins-091121 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Cotnmonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
134 Hillside Drive
Property-Address
William E. Anderson, Trs., Hillside Nominee Trust
Owner Owner's Name
information is Centerville. MA 02632 April 7 201.1
required for every,
page. C tyrTown State Zip Code Date of Inspection
D. S_ystem Information (cont.)
Septic Tank (coat;)
.Distance from top of sludge to bottom of outlet tee or baffle 30 in
Scum thickness 1.in _
Distance from top of scum to top of outlet tee or baffle 9 in -
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design plan
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 is not required at this time but maintenance pumping is recommended within and every two
years. Tank.appears structurally sound and functioning as intended. No evidence of in
inorout
was observed.
Grease Trap (locate on site plan):
.Depth below grade: feet
.Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explainj:
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
15ins>;,09108 Title 5 Official Inspection Form:Subsurface Sewage.0isposal,System•Page 16 of97
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
134 Hillside Drive
Property Address
William E.Anderson, Trs., Hillside Nominee Trust
Owner Owners Name
information is
required forreveiy Centerville MA 02632 -April 7, 2011
page. Cityrrown State Zip Code Crate 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 plany;.
Depth below grade:
Material of construction:
❑iconcrete ❑ 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.
We of last pumping: Date
Comments (condition of alarm and floatswitches, etc,,):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5fis,;:`oW08 Title 5 official Inspection Form:'Subsurface Sawa Disposal,System Page;ta'oi 17
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
`Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments
134 Hillside.Drive
,Property Address
'William E,Anderson, Trs., Hillside Nominee Trust
Owner Owner`sNarne
information is Centerville MA 02632 April 7 2011.
required foreGery p � -
pe9e': CityfTown 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
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is under paved driveway with no access provided. System has instead been evaluated:
according to the condition of the leachinggallery (see page 13).
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc:)
Soil Absorption System (SAS) (locate on site plan, excavation not required);.
If SAS not located., explain why:
t5tns:r.09/08: Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 12:of'17
l
-Commonwealth of Massachusetts
Tiftle 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
« — 134 Hillside.Drive
Property Address
William E. Anderson, Trs., Hillside Nominee Trust
Owner Owner's Name
information is
Centerville MA 02632 Aril 7, 201`1
required for every April
page. CityrTown State. Zip Code Date-of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number-.
leaching galleries number: 1
❑ leaching trenches number, length-
❑ leaching fields number, dimensions°
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technologys
Comments (note.condition of soil, signs of hydraulic-failure, level of'ponding, damp soil, condition of
vegetation, etc,):
Soils.above leaching gallery appear,unsaturated. No:evidence.of surface p.onding, breakout,aush
vegetation, or other evidence of hydraulic failure was observed. An observation.hole was,dug into
leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils.
No standing effluent was observed to a depth of 1 feet below the top of the stone.
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 solid's layer,
Depth of`scum layer
Dimensions of.cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑' No
'15ins 69108 Title 5 official Inspection Form:Subsurface.Sewage gisposal,Splem•Page:13-of 17
F
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1,34 Hillside Drive.
Property Address
William E`. Anderson, Trs., Hillside Nominee Trust
Owner Owner's Name
information is Center.,ville MA 02632` Aril 7, 20'11
required for every, p
page. Cityrr 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.):
t5 n5: 09108' Title 5,0fficial inspection Form:Subsurface sewage oisposal sy tem.:Rage-14 of 17
Commonwealth of Massachusetts
_ Tt`Ie, 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`134 Hillside Drive
Property Address
William E. Anderson, Trs., Hillside Nominee Trust
Owner Owner's.Name
information is Centerville _MA 02632 Aril 7,2011
required for-:every- _p
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:
0 hand-sketch in the area below
❑ drawing attached separately
A G
2¢' 46
2, 26
A
P
I Z
'01
3
G f-�Z Y
ru.SlD 'DRtU G
t5iiis .09l08, Tille,5 Official Inspection Form:Subsurface.Sewage`Disposal System 7 Page=15 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
>134 Hillside Drive
Property Address
William E. Anderson, Trs., Hillside Nominee Trust
Owner Owner's Name'
information is
,
required for every p
Centerville MA 02632 April 7, 2011
-
page,e: CityMwn 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: 5+ ft
feet
Please indicate all methods used to determine the high ground water elevation:
ED Obtained from system design plans on record
If checked, date of design plan reviewed: 7/17/07Date
❑ 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:
Y,ou'must describe how you established the high ground water elevation:
Septic design plan shows bottom of leaching gallery to be 5.92 feet above the bottom of a witnessed
test pit in which no groundwater mottling was noted.
i
i
Before filing this Inspection Report, please see Report Completeness Checklist on-..next`paglp;.
t5ins+,09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal'S,ystem•..P6ge'16`.of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
134 Hillside Drive
Property Address
William E. Anderson, Trs., Hillside Nominee Trust
Owner Owner's'Name
information is. Centerville MA 02632 A nl 7, 2011
required for every P. .
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
!Sinn-..09106: Title 5 Official Inspection Form;Subsurface:Sewage;Disposal.System•Page,17 of 17.
t
W"rIla E. Robinson, Sr. Septic Service
& = 0. Box 1089
fCenrfl1ea XA 02632
775-8776
Peter M. Daigle Fax 790-1694
1550 Falmouth Road, Suite 15
Centerville, MA 02632
March 2, 2007
i^RE, 134 Hillside,.Drive Centerville, MA-
Attorney Daigle:
Regarding your letter of the Lambert's property at 134 Hillside Drive, I went to DEP,the
Board of Health,and the Building Department. Whoever said that this system has failed
and a small hole punched in the cover, could not look down. If he had removed the cover
he could see a new T-Y with a new Title 5 leach system near the carport.
The house has had major changes: a two-car garage, additional room on the back of the
house and a new kitchen with a dishwasher and garbage disposal, which Brian Gosnell
did before selling the house to the Lamberts. This was done with no permits from the
Board of Health or the Building Department. They all agree with me that I am in the
44ght and are now looking into illegal work that has been done.
Whoever told Mr. Lambert that the system failed did not turn in failed report to the Board
of Health unless Mr. Lambert,himself,decided it failed.
I am sending a copy of the as-built of the new leach system that Mr. Samaris had us
install in 1992. Mr. Samaris lived in the house by himself and there was little water
usage prior to selling the home and the illegal changes made. Now you feel I should pay
for someone else's mistakes.
Don Desmaris(Board of Health),Brian Dudley(DEP)and Jack LeBeouf(Building Dept)
all agree with me. As far as we're concerned this is the end of the matter.
Sincerely,
Wm. E. Robinson, Sr.
C: Board of Health
Building Department
DEP
Attorney Matt Dupuey
TOWN OF BARNSTABLE
'L-OCATION SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL /93 — S C/
INSTALLERS NAME&PHONE NO. C 1 7/ -9399
SEPTIC TANK CAPACITY /Y2-ro
LEACHING FACILITY:(type)_ �_ ^ a (size) x 3y
NO.OF BEDROOMS S
OWNER
PERMIT DATE: l COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility.(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) " Feet
FURNISHED BY
G � �
° v
0
9
No. Fee ®�
TKE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0[pplication for �Digpoga[ *p5tent Congtructton J)ermtt
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) LvJ Complete System ❑Individual Components
Location Address or Lot No. /,7 ' rr /�� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel /!7` f—S/ p',)'7y'.�j �p `tea A.
Installer's �
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size 7�P� sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 33 gpd
Plan Date .Tuff, 760`7 Number of sheets Revision Date 171- _-
Title f+�-c ��ah !9 /-j 9 /7l'A-T'.
Size of Septic Tank jryo a4 Type of S.A.S. oa - AZIQ ou G�.�4 4-e"
Description of Soil S, P f'�A17
Nature of Repairs or Alterations(Answer when applicable) f-"k ,r4'. -"-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar of Health.
Signe �+ Date
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
L_---------------------ter.�.r�� — - - ------ - ----------
No. :, " } Fee /0(/
THEC014�� MONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION-- TOWN.OFjBARNSTABLE, MASSACHUSETTS Yes
t
Zfpplication for Otoogaf. i§vitem Cow5truction Permit
Application for a Permit to Construct O Repair o/Upgrade O Abandon O ecomplete System ❑Individual Components
Location Address or lot No./ / lro,lr lu.H�1-�i
Owner's Name,Address,and Tel.No.
foil f...w✓,/✓1' - /7�/////j, f d�•
Assessor's Map/Parcel ° /J S_�� (p V'-)7}-. F:Jri'rJF -} F�a�ry/�� fy!n
Installer's Name,Address,and'Tel.No. Designer's Name,Address and Tel.No.
jJ
Type of Building: J
Dwelling No.of Bedrooms Lot Size 3 7 fe) sq. ft. Garbage Grinder (/4')
ly
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 -7 gpd Design flow provided T 3 & d
w Plan Date `7 G.„' `7 Number of sheets Revision Date gp
Title ri t ��ay o /� /�� .�. DIr
Size of Septic Tank /S`vo ,X �. Type of S.A.S. c;2 fz4 4G/
Description of Soil Sr v li 17
Nature of Repairs or Alterations(Answer when applicable) --d U}fa l/ /�✓t�/ �� r>in� /�r�% ,h'�p h
y f '
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title�5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health
y
Signed
'� , 7� S. Ei�y M Date
Application Approved by (► Date
Application Disapproved by: Date
for the following reasons
Permit No. Date'`Issued
— ———
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On/-site Sewage
Disposal System Constructed ( ) Repaired (!� ) Upgraded ( )
Abandoned( )by ff 11'-1��0��`a 40�►3/ry</ia '-
at /3 ev /-,Ar•'j, /-)/L , /-_',, ///, has been constructed in accordance
with the provisions
//of Title 5 and the
��for Disposal System Construction Permit No. '-� dated
Installer 1�0/'/d��l� � ( c�r�J 7/t-.,sr 1`i�+� Designer
#bedrooms 3 Approved d s gri flow .� '�e+ v V gpd
��
The issuance of this permit shall /ot. "e�coons�trjued as a guarantee that the system will fu cn tiorrt's\'despigned. + ""
Date / /j''l Inspector ��, ' %�-
-————————————————
No. a5 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
lwigo.gal Q�p!5tem CP0 ,5truction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( )
System located at / /� 5. �• DA Z..w
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of t is
Date �� Approved by
FROM :down cape engineering ire FAX NO. :150e3629ee0 Rug. 02 2007 01:46PM P1
Town of Barnstable
Regulatory Services
Thomas F. Gei]er,Director
Public Health Dhisiol4
Tbonaas McKean,Director
0*
200 M$in Street.,Hyannis, M.A 02601
office: 50S-862_4644 Fay:: 505-790.63(�4-
Wta)ler d Aesianer Certification Form
Date. Seg'age Permit; o2O07- 3 ' Assessors M%Lp7arce) X34
Aesiglaer: ULAI rN a19C' Installer:
Address; r n ?address:
Larmo+t
r —
0 7/-7-d`Icy- ld z issued a permit to install a
(date) (izlscalier
septic*,stem at ',J� i, t � based on a design drawn b),
(adCL*eS5)
d 7 a
dam
C� 1 cerdt! that the septic system referenced above -was installed subs=ibaby according W
the design, which may include minor approved- changes such as later. relocation of the
distribution box and/or septic Z2I11L
I verify that the srptie n,stem referenced above was instalied with max changes (i.e.
greater than ld' ).ateral relaxation or he SAS or an-v. vertical relocation of any component
of the septic synem) but in accord&&n.ce with Smie & Local Regulations. Plan revision or
cenified as-built by designer to follow.
(lns,al er's Signature) c
�Q�ct. c�2.
er s$ienatute) (.affix Designer's Stamp Here)
PVF,,ASE RETLRN TO BARNS ABLE PUBLIC.lIREAL H 1�1^��ISION. �£RTI7?1CATE OF
COMP IANC'E WLT, NOT BE ISSUQ) UN-11L $QTH TI-i S FOXM AnT3 AS-BUILT CART) ARE
RECEJ\7ED i iC HEALTk1 DIVISIGN, THANK YOU.
h• La.el,i,/cnn;rlllr.cinncr CenifiCaiibn FoTT7] 3-?6-04.dc�t -
06/22/2004 14:49 5087908134 LAMBERT'S C-VILLE PAGE 02
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUI3SURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_ 13 4 H i 1 1 _s i d o nr
CenfPrvi 11P- MA 02632
Owner's Name:�Si ayon Cam�ri
Owner's Address:
Date of Inspection: 7 �-p
Name or inspector:(please print) Wi 1 1 i am F. . Rabi nson SAC.
Company Name: William E. Robinson Septic Service .
Mailing Address: P O Box 1089
Centerville MA
Telephone Number:
CERTIFICATION STATEMENT
1 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. 1 am a DEP
approved system Inspector pursuant to Section.AS340 of Title S(310 CMR 15.000} The system:
L.,Se Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date•
--e 2
The system inspector shall submit a copy of this inspection report f 10,000
o
to the Approving Authority(Board of Healthor
DEP)within 36 days of completing this inspection.rf the system Is a shared system or has a design flow gpd or greater,the inspector and the system owner shall submit the ort to the appropriate regional ow of the
authority,
DEP.The original should be seat to the system owner and copies se rep e nt to the buyer,if applicable,and the approving
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at thst
time.This inspectlon does not address how the system will perform!n the future under the same or different
conditions of use.
Title S Inspection Form 6/151200o
page I
06/22/2004 14:49 5087908134 LAMBERT'S C-VILLE PAGE 03
Page 2 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS.
S SS TS
SUBSURFACE SEWAGE DISPOSAL ASYSTEM INSPECT
ION FORM
CERTIFICATION(continued)
Property Address: 134 Hillside Dr.
Loan
e vi e�
Owner: Samaras
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/A-LY-A—y-E complete all of Section D
A. Sy tem Passes:
l ave not found any information which indicates that any of the failure criteria described in 310 CtvLR
lh
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
D. ystem Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repair d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answe yes,no or not determined(Y,N,ND)in the for the following statements.If'bol determined-pkase
explain
e septic lank is metal and over 20 years old'.or the septic tank(whether metal or not)is structurally
unsoun ,exhibits substantial infiltration or exfiltrstion'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 me 1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicati g that the tank is less than 20 years old is available.
ND ex lain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
obstru ted pipe(&)or due to a broken,settled or uneven distribution box_System will pats inspection if(with
appro al of Board of Health):
broken pipe(s)are replaced
obst cation is Temoved
distribution box is leveled or replaced
ND ex lain:
The system required pumping more than 4 dmcs a year due to broken cr obstructed pipe(s).The system will
pass in pection if(with approval of the Board of Health):
broken pipe(s)are replaced
obsMxtkm is n�notrod
ND plain:
06/22/2004 14:49 5087908134 V LAMBERT'S C—VILLE PAGE 04
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 134 Hillside D _
Centerville, MA 02632
Owner: gamari;:
Date of fospectlon: 9-/7-r a.
C F her Evaluation is Required by the Board of licalth:
onditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing o protect public health,safety or the environment.
1. Sy tem will pass unless Roard of Healeb determines in accordance with 310 CMR 15.303(l)(b)that the
sys ern is not functioning In a manner which will protect public health,safety and the environment:
Cesspool or privy is within So feet of a surface water
T Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. Sys m will fail unless the Board of Health(and Public Water Supp::er,if any)determines that the
system 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
Sur cc 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 front a
rivate water supply well".Method used to determine distance
'This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. 0 ther:
3
06/22/2004 14:49 5087908134 LAMBERT'S C-VILLE PAGE 05
rage 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ART L
CERTIFICATION(continued)
Property Address: 134 Hillside Dr.
Centerville MA 02632
Owner: i
Date of inspection:
D. System Failure Criteria applicable to all systems:.
Yo mum indicatc')+es"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 pond
in&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 availablevolume is less than'/r day flo
Requved pumping more than 4 times in the last year N T due to clogged or obstructed i e 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
warwater supply. '
r supply.
rtion . a tesspool or privy is within a Zone 1 of a public well.
AnyAny portion of a cesspool or privy is within SO feet of a private ureter supply well. vale wsuet
Any portion of a cesspool or privy is less than 100 feet but greater than SO feet from a private
supply well with no acceptable water quality analysis.jTbis system passes if the well water analysis,
performed at a DEP cerlified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well Is free from pollution from that facility-And
the
that ftCe of ammonia
other failure erilerla
nitrogen and nitrate nitrogen is equal to or less than S ppm,provided
are triggered.A copy or the analysis must be attached to this forma
(Yes/No)The systemfalls. 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. 1 Large Systems:
To be considered a large system the system must serve a facility with a design now or 10,000 gpd to 15,000
gpd
You ust indicate either'yes'or"no"to each of the following:
(The 0 (lowing criteria apply to large systems in addition to rite criteria above)
yes n .
the systcm is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a smfate drinking water supply
_ the system is located in a nitrogen sensitive area(]ntertm Wellhead Protection Area—1WPA)or a mapped
one 11 of a public water supply well Ir
I f you hav answered"yes"to any question is Sc=.nn E the systcm is rffisidered a significant thrta4 or answered
"yes"in S ction 1)above the large system has farlsd_The vwner or operator of airy 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.T system owner should contact the appropriate regional office of the Department.
4
06/22/2004 14:49 5087908134 LAMBERT'S C-VILLE PAGE 06
Page 5 of I 1 .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 3 4 Hillside dr.
en ervi e, MA 02632 .
Owner: Samar s
Date of lospectlon: -/ -0 2
Check if the following have been done.You must indicate')fes"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 7
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?
Ll_ Was the site inspected for signs ofbreak out
t-/— Wcre all system components,excluding the SAS,located on site 7.
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 %cwagc disposal systems?
The slxe and location of the Soil Absorption System(SAS)on the site has been determined based on-
Yes no /
V 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(3)(b))
5
06/22/2004 14: 49 5087908134 LAMBERT'S C—VILLE PAGE 07
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION-
134 Hillside Dr.
Property Address: -
en ervi e— 02632
Owner: Samaris
Date of Inspection: 0
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):-3- Number of bedrooms(actual):,
DESIGN(low based on 310 CMR 15.203 (for example: 110 gpd x q of bedrooms): '
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):,-Ly (if yes separate inspection required)
Laundry system inspected(yes or no):& 0
Seasonal use:(yes.or no):ALO
Water meter readings,if avai�ble(last 2 years usage(gpd)): 01 - 53,000 gal.
Sump pump(yes or no): . 00- 50,000 gal.
Last date of occupancy: T-17-� 7-
COM 1 RCIAIANDUSTRIAL
Type of_
tablishment:
Design Do (based on 310 CMR 15.203): gpd
Basis of de ign Dow(scats/persons/sgft,etc j:
Grease tra present(yes or no):
Industrial aste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water mct r readings,if available:
Last date o occupancy/use:
OTHER escribe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as pan of the inspection(yes or no):
if yes,volume pumped: -_gallons--Now was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
�gle 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)
_Tight tattle `Attach a copy of the DEP approval
_Other(describe):
Approximate age of all compone ts,date ytstalled(if knowQ and source of information:
Were sewage odors detected when arriving at the site(yes or no): d
I 6
L
06/22/2004 14:49 5087908134 LAMBERT'S C-VILLE PAGE 08
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Hillside Dr.
CentervilleL MA 02632
Owner: Samaris
Date of Inspection:
BUILD G SEWER(locate on site plan)
Depth be ow grade:
Material of construction:—cast iron _4D PVC_other(explain):
Distance from private water supply well or suction line:
Comme is(on condition of joints,venting,evidence of leakage,etc.):
SEPTI ANK:__.(locate on site plan),.
Depth bclo grade:
Material o construction:_concrele_metal fiberglass__polyethylene
_other(e plain)
if tank is cial list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of
certificate
Dimensio S.
Sludge de the
Distance om top of sludge to bottom of outlet tee or baflle:
Scum thi kness:
Distance from top of scum to top of outict tee or baffle:
Distant from bottom of scum to bottom ofouticifte'or baffle:
How w e dimensions determined:
Comm is(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as tela d to outlet invert,evidence of.leakage,etc.):
GREA E TRAP:_(locate on site plan)
Depth b low grade•._
Material of construction:_concrete_metal`fiberglass___polyethylene•_other
(explain
Dimensi ns:
Scum thi kness:
Distance om top of scrim to top of outlet tee or baffle:
Distance om bottom of scum to bottom-of outict tee or baffle:
Date of 1 It pumping:
Comment (on pumping recommendations,inlet and outict tee or baffle condition,structural integrity,liquid levels
as related o outlet invert,evidence or leakage,etc.):
I
7
06/22/2004 14:49 5087908134 LAMBERT'S C-VILLE PAGE 09
Page 8 0f 11
ASSESSIdEN
OFFICIAL.INSY
ECTION FORM—NOT FOR VOLUNTARY
7S
SUBSURFACE SEWAGE DISYOSSP ART CySTEM INSPECTION
SYSTEM INFORMATION(continued)
134 Hillside .DA 02632
Property Address: er v� e _ _
en
pwner: Samar 1 s
Date of lospeelion:
'Z--
TIGHT or HOLDING
TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below gra e: fiber
metal glass�pvlyethylene ther(expla'tn):
Material of const ction:—concrete
Dimensions: allons
Capacity: allonsiday
Design Flow:
Alarm present(Ye o no): es or no
Alarm level:_ - Alarm in working order(y )
Date of last pumping:
Comments(condition f alarm and float switches,etc.):
DISTRIBUTION B X:—(if present must be opened)(locale on site plan)
Depth of liquid love above outlet invert: to outlets equal,any
evidence of solids carryover,any evidence of
Comments(note if bo is level and distribution
leakage into or out of x,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order yes or no):
Alarms in Forking order[;yes or no): etc.):.
Comments(note eondid n f pump chamber,condition of PUMPS and appurtenances,
8
06/22/2004 14: 49 5087908134 LAMBERT'S C—VILLE PAGE 10
Page 9 of l l
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: 1 3 4 Hillside Dr.
Cent ervL e, M 02632
Owner: Samaris
Dale of Inspection: '�--
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,eseavatiodnot required)
If SAS not located explain why:
T)
eaching pits,number:
leaching chambers,number: �•
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs or hydraulic failure,level of ponding,darnp soil,condition of vegetation,
etc.);
CESSPOOLS: (cesspool must be pumped as,part of inspection)(locate on site.plan)
Number and configuration: c7�
Depth-top of liquid to inlet invert:_3- 1
Depth of solids layer: < _ —
Depth of scum layer:
Dimensions of cesspool t
Materials of construction:_J6 /� s
Indication of groundwater inflow(yes or no):
Comments(note,condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
losolids:
(locate on site plan)
nstruction:
e condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
06/22/2004 14:49 5087908134 LAMBERT'S C-VILLE PAGE 11
Page 10 of 1 I
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Hi 1 l c_i AP Dr,
Cen v; 11 e, MA 02632
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
y1
10
06/22/2004 14: 49 5087908134 LAMBERT'S C—VILLE PAGE 12
..... .. ._._.....-...-..........
fast I l o[11
pE ASSESSMENTS
FFICIAL INSPECTION FORM—NOT FOR VOLUNg
OSUBSRACE SEWAGE DISPOSAL SYSTEM INSPECTION FRM
RC
SYSTEM INFORMATION(continued)
134 Hillside Dr.
Property Address: e A 02632
Centerv�-
Owner SamarlS
Date of Inspeclloo:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells oe—
Estimated depth to ground water V'9 feet
Please indicate(check)all methods used to delermine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole with Sp 15o feet of SAS)
Checked with local Board of health-explain:^�� ph j <
Checked with local excavators.installers-(attach doctttnentatio )
Accessed USGS database-explain:
You must describ,Sq how you established the high ground water elevation:
aN ,
I) '
j r
Fxs•. 30.� O........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH ®onay
TOWN OF BARNSTABLE
Appliration for Di_qp.o sal Works Tontitrurt' rrutt
om
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
137 Hillside Drive, Ce ............................... .......------•--••-••-•----......-----••••-••-••--•--------•.----••..............................•.
-Location-Address or Lot No.
Stevev Samaras Same
......................-...-...................................................................... --•......•-••---•----...--••--••----....-••--............-••••--•-•••......---..............------
Owner Address
a W.E. Robinson_Septic Service P.O. Box 1089, Centerville , MA
.....................................................
Installer Address
UType of Building Size Lot............................Sq. feet
�-t Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a, Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width_............. Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of.Test Pit---_................ Depth to ground water........................
a ----------•-----------------••------------------•----------•--------•---------....-•---•-----•-•---.........---........--------..................•-----......
O Description of Soil..........Grave 1
U ----•----•-•-••-•••-----••---•--••••-•----......--•..................••-•-------=--•----•....----•----••-•----••---•---•--•---------••-
W
V Nature of Repairs or Alterations—Answer when applicable.____Tw o:,:stone-paed infiltrators
_ k •- - -
-----•----•-----••--------------------------•-----------------------------------------------------------•-------------••••--------•-•--•-
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 unders• 'ed further agrees not to place the
system in operation until a Certificate of Compliance
G� h ih^^'a�nd of health.Signed -........................................................ l---�------- -- �------'-----�-----
�-
Dace
Application Approved By ........ . ..... 7...-----
............................................................. Date
Application Disapproved for the following reasons- -------------------- ------------ ------------------ -------------- .------------.--...... .-------- ..............
----- --- ------------------------------ ----------- -- --- -------------------- -------- ----------------------- ------------------................................................... ..........................-------------
Date
` Permit No. ......... -----------6.. p....---- --..�..- Issued - -- ------------------------ -- ---------- -- ----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE ,
Appliratiuu for Dispuiittl Warkii Tonstrurtiun ramit
_ - Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
137 Hillside Drive, Centerville f
Location-Address or Lot No.
Stevev Samaras Same
....... ---------------••---•-------•-•----••------•-- --.....----.._.._..---------------------•-••••-----...•••-•••-----••-•--••---•---......-----------
Owner Address
W W.E. Robinson Septic Service P.O. Box 1089, Centerville, MA
----------------------------------•--••......• ......................................................
Installer Address
� Type of Building Size Lot__________________________Sq. feet
I--1 Dwelling—No. of Bedrooms.............3----------------------------Expansion Attic ( ) Garbage Grinder ( )
e of Building 0.a Other—Ti yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
_
WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water•___--------_-•-_______-
LT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-..---_____-_-__----_---
a -----••----------------------------------------•....---------•------------------._......------••••••.........................................................
0 Description of Soil..........
W
V .--------------------------•-------------....------....-••-------------------••-----••....------•----------•-•-----•-•-•--------------••......-•--------------•••----•••------------•.....-----•---•----
W
x ---------••-----------------•--------------------------------------•--------•--••----------••----------•---------••-••--•••-------------------------•••---------------•-----•-----------•-....._.._.....
U Nature of Repairs or Alterations—Answer when applicable____7,Kgn s t o p e•-A 3 C k e d___i n f l t r a to r s--------
•--•----------------------•---•-------•-•-•-------------•-•--•------------•••--------••••-----.....••---•------•------••--•------••---------•--•------•••-•--------------•................--•--•--•-....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued �hef o rd of health.
Signed` ell ... ..-i Dare
Application Approved By --"---..-"----__--C -" -
' ---------.............'-..._........._.......-...-._....._...._.. Dare
Application Disapproved for the following reasons- ---------------------- -------------------------------------------------------------------------------------
------------------------------------------------- ----------------------------------------------- -----------.- . ------------------------------------------------------------------------------- ------------------
-Date
------------------
Permit No. -------C.. .�------------ ...........
...d Issued _ —
. .. .- ..........-...-.-....-- -........___---....._.__.
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1
TOWN-OF BARNSTABLE
Cle>rtifivite of Cfoutpliarcxe
THIS IS TO CERTIFY, That the Individual Sewag,Disposal System constructed ( ) or Repaired ( X )
W E Robinson Septic Service, C�"ntervil:le, MA
by �----------------------------- --- --- ---....------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Insraller
atl37 Hillside Drive, Centerville, MA
----- ------------------------ ..----------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. •. .`a-�1 .--.. dated .. ......... ......... .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE )A.1; � =9 ` ----- Inspector =- 1 ----------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.....;•. _.: ?. d FEE..$3 0..d 0....
�i��ru�ttl urk� �uatutr�rtiun rrmit
Permission is hereby granted....................................................................------------------------•---•-----................................_--..
to Construct ( ) or Repair ( Xll Sew ale Individual Sea.e Disposal System
137 Hillside Drive, Centervgille, MA
atNo.-------•--•-----••--•-------•-------------------•-----------•---------.....••--••-••••-••••....-----••---------------------•------------•-•-•-................................................
Street
as shown on the application for Disposal Works Construction Permit NoA_ fJ- __ Dated..........................................
---------------------------- V----
----------------------.-------------------------
_ Board of Health
DATE----------------7................. .Z.........
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS
TOWN OF BARNSTABLE
LOCATION j �'/ Icy°^ I/,S rCd a= u SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. , rye °-- � '�;;�`� 7
SEPTIC TANK CAPACITYD 0 C)
LEACHING FACILITY:(type),) ,-='. ..t 4 (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER , l ���'�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:/o
VARIANCE GRANTED: Yes No
i 4
�X i1 c
U� C S7 j
��n
, SYSTEM PROFILE NOTES
TOP FFLOOR AT EL. 72.04
APPROXIMATED NGVD Rt. 6 Rd.
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT To SCALE) ACCESS COVER TO'WITHIN 3 OF FIN. GRADE 1. DATUM IS o �e��jee
ACCESS COVER (WATERTIGHT} TO Ca 'n
72.5' MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE LOPE REQUIRED OVER SYSTEM 2. MUNICIPAL WATER IS EXISTING Crosby
odY cap
'S \\�d
2% S Q 7 L2 �° ape
2" DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.'' Street L �q
RUN PIPE LEVEL OR GEOTEXTILE FABRIC yak side o���
*70.03' FOR FIRST 2' , o
PROPOSED 150d 3 MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO
GALLON SEPTIC 68 25' H- 10
68.5' TANK H- 10 68.22'
( -} E �� 67.56' 5. PIPE JOINTS TO BE MADE WATERTIGHT. yPequaquet
67.73 0000 O C] � Q0
CO Lake
Z7.4
2 Q Q Q Q Q Q Q Q 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH a .�
( 2.5% SLOPE) �6" CRUSHED STONE OR MECHANICAL Q Q Q Q Q Q O 0 O
j COMPACTION. (15.221 [21) 2' Q Q Q Q Q Q Q 0 0 MASS. ENVIRONMENTAL CODE TITLE V. o o
4 0 65.42 o
� - - 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO o0d
TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. �0ke�
INLET DEPTH = 10„ °
0
OUTLET DEPTH = 14" ( 1 % SLOPE) ( 1 % SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
1 SLAB 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
FOUNDATION 61' SEPTIC TANK 52' D' BOX 16° LEACHING 5.92'
FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION LOCUS .MAP
f OBTAINED FROM BOARD OF HEALTH.
SCALE: 1" = 2,000'f
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES AND ALL 10. CONTRACTOR SHALL B.E. RESPONSIBLE FOR CALLING
BUILDING SEWER OUTLETS AND ELEVATIONS BO TTOM TH-2 EL. 595' DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION ASSESSORS MAP 193 PARCEL 54
PRIOR TO INSTALLING ANY PORTION OF . OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO
SEPTIC SYSTEM COMMENCEMENT OF WORK. LOCUS IS WITHIN GP OVERLAY DISTRICT
11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
REMOVED 5' BENEATH AND AROUND THE PROPOSED
LEGEND LEACHING FACILITY.
100.0 PROPOSED SPOT ELEVATION I SYSTEM DESIGN:
+100.00 EXISTING SPOT ELEVATION GARBAGE DISPOSER IS NOT ALLOWED
i
100 0 PROPOSED CONTOUR DESIGN FLOW: 3 BEDROOMS 0 110 GPD = 330 GPD
it 100 EXISTING CONTOUR �,Si 2� X�` USE A 330 GPD DESIGN FLOW
/ $1 k
1 Sp���k � . __...._, �_.. _SEPTIC TANK: 330_ GPD, (2) = 660
8 79 8 �.S'� -
/ USE A 1500 GAL. SEPTIC TANK
j�
INV OUT 60 LO 7
ELEv=7o.o3' 1 / a LEACHING:
TEST HOLE LOGS 9 ,79 `�6 �' �3 �� SIDES: 2 (30 + 9.83) 2 (.74) = 118 GPD
BOTTOM 30 x 9.83 (.74) = 218 GPD
ENGINEER: DAVID FLAHERTY, R.S. WOOD RET.
WALL 1� -` ANTI GSIX f TOTAL: 454 S.F. 336 GPD
WITNESS: DONNA MIORANDI, R.S. BENCHMARK G c� T
DATE: JUNE 28, 2007 CORNER BRICK PATIO G�-� -ePcE - ........, USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
PERC. RATE = < 2 MIN/INCH WITH 4' STONE AT ENDS, 2.5' AT SIDES AND 5'
o `' G��� f COORNER'STEP BETWEEN UNITS
CLASS SOILS P# _ 1
N �
11807 ' ' GAS c / ELEV=71.6'
CESSPOOL CLEA 0 METER I/ l f
ELEV. ELEV. PER OWNER f MA
i
" 71.3' 71.5' 1`° `�EXISTING APPROVED DATE BOARD OF HEALTH
O 0 DWELLING 4,
ON ItF
A A HOT TUB.. \ FFLOOR EL=72.04' /�
LS LS ON BLOCK PATIO � • �, �/ o TITLE 5 SITE PLAN
}� ` �i / C9
10YR 3/2 10YR 3/2 �5 / �\ /� O OF
4" 71.0' 7" 70.9' �x� ,, �� w /
B B 94. �x� ,, ;;�/ %` S 134 HILLSIDE _DR.
LS LS p / / z (CENTERVILLE) BARNSTABLE, MA
32" 10YR 6/6 68.6' 10YR 6/6
30" 69.0' � ' / L \\ PREPARED FOR
p DRIVE
X SHED \TH; - , BORTOLOTTI CONSTJ
C
s `PERC MARK LAMBERT
k
MFS MFS X ri~ � `�� Y '2 \� DATE. JULY 6, 2007
TH-
2.5Y 6/4 2.5Y 6/4 N /
/ off 508-362-4541
fax 508 362-9880
N OFOF 4f
q�ys
132" 60.3' 144" 59.5' ���� ARNE s9cyGN o`'� RNE Hss9��c down cope engln eerin g, Inc.
H OJALA Cl VIL ENGINEERS
Scale: =20 " OJ LAND SURVEYORS
NO GROUNDWATER ENCOUNTERED 7 U o. OIL
of 939 Main Street - YARMOUTHPORT, MASS.
0792
10 20 30 40 50 FEET pA �q JALA, ��P ; �° `�
DCE #07-133 H�Sl1RVE a SSo®NAL ENG� 07-133 BORTOLOTTI LAMBERT.DWG (DDF)