HomeMy WebLinkAbout0028 HOLLY HILL ROAD - Health 28 HOLLY HILL ROAD, CENTERVILLE
A= 188106
11/l
UPC 12534
No.2_ �
HASTINGS. MN
r
108- (oco
• � ° Commonwealth of Massachusetts r _ r - /-0
Title 5 Official Inspection Form -
�'
i Subsurface Sewage Disposal System Form,-:Not for Voluntary,Assessments t. , .
r,+a
28 Holly Hill Rd
Property Address
Michael Ingham
Owner Owner's Name /
information is
required for every Centerville �/ MA 02632 4-12-21 .
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information s 333
Shawn Mcelroy
Name of Inspector
Upper Cape"Septic Services' '
Company Name
P.O. Box 73
Company Address
East Falmouth MA.. 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full.compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage'tlisposal system at thepr6perty 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 expedence'in the proper function and
maintenance of on-site sewage'disposal systems.After conducting this inspectiofi'l have determined that
the system: '
1.• ® Passes
2. ❑ ;Conditionally Passes
• 1n 1 ... ` `, t, jI 1 as •
3. ❑ •Needs Further Evaluation by the Local Approving Authority ,.
4. ❑ Fails
4-12-21
I.spector'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 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.
I
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
i'.p Title 5 Official Inspectionflform �' r
iai Subsurface Sewage Disposal System Form--Not for Voluntary Assessments
28 Holly Hill Rd
Property Address
Michael Ingham
Owner Owner's Name
information is required for every Centerville MA 02632 4-12-21
#
page. City/Town State Zip Code Date of Inspection
C. Inspection summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4`and 6.
1)' System Passes: °t
® 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 criterianot evaluated are
indicated below.
Comments:
System is in good working.order with no sign of failure.
2)' System Conditionally Passes:''' '
❑ One or more system components as described in the"ConditionalPass" 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" tY, 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 ON ❑ ND (Explain below):
LIN
t5insp.doc•rev.7126t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
��F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Holly Hill Rd
J'
Property Address
Michael Ingham t
Owner Owner's Name
information is required for every Centerville F MA 02632 4-12-21
page. City/Town 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.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑N ❑ .ND (Explain below):
obstruction is removed ❑ 'Y ❑W ❑ 'ND (Explain below):
❑ distribution box is leveled or replaced' ❑Y ❑ N ❑ 'ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑Y El ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:-
El.
❑. 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. r '
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety`and the envir'onmerit:`
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
I
Title 5 Official Inspection Form
i P Subsurface Sewage Disposal System Form Not for Voluntary Assessmentsa
`h
28 Holly Hill Rd
Property Address
Michael Ingham r.
Owner Owner's Name
information is required for every Centerville MA 02632 4-12-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) '
❑ Cesspool or privy is within 50 feet of a6surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS,and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within,50 feet;of a private water
supply well.
r ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
` more from a private water supply well**.' '
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
C. Other: t t
4) System Failure Criteria'Applicable to All Systems:k,,.
e You must indicate "Yes"or"No"to each of the following for all inspections:
< Yes No _ a.
El ® Backup of sewage into facility,or system coti ponent due to overloaded or
clogged SAS or cesspool ` ' '
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form . .
�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . Ft
=1r. g 28 Holly Hill Rd >
Property Address
Michael Ingham
Owner Owner's Name
information is Centerville ' MA 02632 4-12-21
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes. No I .
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 '/day flow ' ` ' I 1-
❑ ® 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
❑ ® f r tributary to a'suiface water supply. '
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
} ❑ " ® Any'portion of a cesspool•or privy is within 50 feet of a private water supply well.
® An portion of a cesspo
ol or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
+ system passes'if the well-water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
; , 10,000 gpd. t
f 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.,1
5) ,Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to'15,000 gpd.
-For large systems, you must indicate either"yes" or"no"to each of the-following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.'7/28/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts s r s F
Title 5 Official Inspection Form
01 Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
28 Holly Hill Rd -
r ,
Property Address
Michael Ingham
Owner Owner's Name
information is required for every Centerville MA 02632 4-12-21.
page. City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.) h ..
If you have answered "yes"to any`question in Section`C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of.the Department.
6. You must indicate "yes" or 'no"for each of the,following for all inspections:
Yes No r
❑ ® 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
f this inspection?
/ ❑ , ® Were as built plans of the system obtained and examined? (If they were not
available•note as N`
1® ❑ Was the facility or dwelling inspected for signs of sewage back up?
E, -® ❑ Was the site inspected for signs of break out?
® ' ❑ Were all'system components,excluding the SAS, located on site?
® Y❑ "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,'de
pth"of sludge and depth of scum?
® - ❑ Wasthe 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'exam le, a plan at the Board of Health.y
® ❑ Determined in the field (if-any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
I
Commonwealth of Massachusetts
,. Title 5 Official Inspection Form' ..n. }
} I01 Subsurface SewagerDisposal System.Form -Not for Voluntary Assessments
.._ , ; 28 Holly Hill Rd
Property Address
Michael Ingham
Owner Owner's Name
information is Centerville -+ + MA 02632 4-12-21 :.
required for every
page. City/Town } State Zip Code Date of Inspection
D. System Information i ;}
1. Residential Flow Conditions: -1 1- ,-1,;,
Number of bedrooms (design): N/A Number of bedrooms.(actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
Description:
Number of current residents: 2
L Does residence have a garbage grinder?: ❑ Yes ® No
Does residence have a water treatment unit? r . ,• .r. ❑ Yes ® No
If yes, discharges to: -
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
f {
Sump pump? ^ ❑ Yes ® No
Last date of occupancy: 1. , ,; 4-2021
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
cam,, Commonwealth of Massachusetts
,. Title 5 Official Inspection"'Form' is rt
fl Subsurface Sewage Disposal System,Form -Not for Vol untary,Assessmentsw '
f 28 Holly -�Hill Rd
Property Address
Michael Ingham `}
Owner Owner's Name
information is required for every Centerville MA 02632 4-12=21`•
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) '' t
2. Commercial/Industrial Flow Conditions:
Type of Establishment:' r
Design flow(based on 310 CMR 15.203): r cauoris per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): '
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? - ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
r . How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.r�"I Subsurface Sewage Disposal System Form --Not for.Voluntary Assessments .,C
28 Holly Hill Rd
Property Address
Michael Ingham
Owner Owner's Name
information is
required for every Centerville MA 02632 4-12-21
page. City/Town r„^ State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System: 1L
® Septic tank, distribution box, soil absorption system, e r R
❑ Single cesspool
• ❑,. ,l i Overflow cesspool ,
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract ,
❑ Tight tank.Attach a;copy of the DEP approval.
❑ Other(describe):
Approximate`age of all components, date installed,(if known) and source of information:
1980's
Were sewage odors detected,when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
_
Depth below grade: 24"feet '
` Material of construction:'" t "
® cast iron r.' ® 40"PVC ❑ other(explain):' `' r
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc•rev.'7/26/2018. _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form r
�i Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments t
28 Holly Hill Rd
Property Address
Michael Ingham t
Owner Owner's Name
information is Centerville MA 02632 4-12-21,
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) _ :i ..
6. Septic Tank (locate on site plan):
18"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ' '❑lpolyethylene ❑ other(explain)
If tank is metal,'Iist e:a <
g � years
Is age confirmed by a Certificate ofr Compliance?. (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? L Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts w
3 Title 5 Official Inspection -Form"
r
IFI Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
:= 28 Holly Hill Rd
Property Address
Michael Ingham
Owner Owner's Name
information is Centerville ! j ,
required for every MA 02632 4-12-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: -
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: _,.. , , . rls:) , t . ' ! r
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related'to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
concrete
El ❑ metal [I fiberglass El polyethylene El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18'
Commonwealth of Massachusetts f
3 Title 5 Official Inspection Form
tQ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
28 Holly Hill Rd {
Property Address
Michael Ingham
Owner Owner's Name
information is required for every Centerville ` MA 02632 4-12-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑' No
Alarm level: Afarnn'in working order:' ❑ Yes ❑ No
Date of last pumping: "' Date
Comments (condition of alarm and float switches, etc.):
T.
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution'Box;(if;prbsent must be opened)(locate on •site;plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from pit.
»F
3
P
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts ,
Title 5 OfficialIhspection Form
hl Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments ,.7
28 Holly Hill Rd
Property Address
Michael Ingham
Owner Owner's Name
information is required for every Centerville MA 02632 4-12-21
page. City/Town State Zip Code Date of Inspection .
D. System Information (cont.) �.
10. Pump Chamber(locate on site plan): _
Pumps in working order: ' " ❑ Yes ❑ No*
° Alarms in working order: " ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
' ® ' leaching pits sf° riumber: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
�c Commonwealth of Massachusetts F -
Title 5 Official Inspection -Form
ibl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Holly Hill Rd
Property Address r
Michael Ingham
Owner Owner's Name
information is required for every Centerville ca MA 02632 4-12-21 _
page.e. 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.):
Leach pit in good condition and holding 24" of water with stain line at 36"below inlet invert.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):,
Number and configuration
Depth—top of liquid to inlet invert r+ =
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts . . .
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form =Not-for Voluntary Assessments
28 Holly Hill Rd
Property Address
Michael Ingham
Owner Owner's Name
information is required for every Centerville MA 02632 4-12-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) i
13. Privy (locate on site plan): '
Materials of construction: `
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
,
t5insp.doc•rev.W2612018 .• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts ,3 ►
fill Title 5 Official. Inspection Form:
01
i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A' _
28 Holly Hill Rd
Property Address
Michael Ingham
Owner Owner's Name
information is
required for every Centerville MA 02632 4-12-21 f
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public_ water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
4- 1
[1
1:
p
ry, -Z� 73 r
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
r Commonwealth of Massachusetts r
Title 5 Official Inspection Form
,ryp Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
28 Holly Hill Rd
Property Address
Michael Ingham
Owner Owner's Name
information is required for every Centerville, MA 02632 4-12-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ;
15. Site Exam:
❑ Check Slope
❑ Surface water ;
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20'+
feet '
Please indicate all methods used to determine the high groundwater elevation:
❑ Obtained from system design plans on record
-If checked, date of design plan reviewed: Date '
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts '` '` ':. ^=r+4. .
Title 5 Offic`ial . l nspection - Forr�n
Ii Subsurface Sewage Disposal System Form -Not for Voluntary°Assessments
28 Holly Hill Rd r
Property Address
Michael Ingham
Owner Owner's Name
information is Centerville MA 02632 4-12-21
required for every '
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist � -
Complete all applicable sections of this form inclusive of: c
® 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
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
s�rC1 .;Jt1 ;�'.� -,r.:. ��lr-?r; ! .. ..ii y - .•. 1�`C� ��
DATE: 7/30/9601,
PROPERTY ADDRESS: 28 Holly iIi:11 Road
Centel vi_l__le Mass .
AUG '1 2 19
02632 � o,o
c)
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1_-1000 gallon septic tank.
2. 1--Distribution box.
3 . 1 -•1000 gallon leaching pit.
Based bn my 1nK;1PCflon, I certify the following conditions:
1 . This is a title five septic system. '( 78 Code ' )
• 2. The Septic system is in prober working
order at the present time.
SIGNATURY-- ,O
Name: J. P . Macomber Jr..
Company:_J• P_Macon�ber & Son Inc.
- -----------
Address:_ _��___,__�____,-__
—
--Centezr, 11eLr1ass_^02"632
Phone:___SQ87THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANT
Y
JOSEPH P. MACOMBER &x SW INC.
Tanb.a-Ca&,tpools.Leachtleloy
. Pumpmd & InttaII&d
Town Sewer Connection:
P.O. Box 66 ' Centerville, MA 02632-0066
775-3338 775-6412
f .
Commonweatth of Massachusetts
Executive Office of Environmental Affairs
_. a artment of
Envffiironmental Protection
William F.Weld
GOVOMor Trudy Cox@
Argeo Paul Ceiluccl 8—"Y
U.Gowmor David B.Struhs
C.onwnWlorrr
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 28 Holly Hill Road Centerville,Ma.AddreasofOwner.
Date of Inspection:7/2 3/9 6 (If different)
Name of Inspector. Joseph P.Macomber Jr.
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site se ge disposal systems. The system:
Passes
Conditionally Passes
— Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signat7/_4
tij�I t/
11 Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYST PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303,
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
�f One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes
inspection.
Indicate yes , or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not)
I- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfUtration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston, Massachusetts 02108 • FAX(617) 556-1049 • Telephone(617)292-SW
��Printed on Recycled Paper
r
1�.
SUBSURFACE; SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
28 Holly Hill Road Centerville ,Mass .
Owacr; Lewis Rive
7/23/96
B1 SYSTEM CONDITIONALLY PASSES (wuti„u(-i)
Sewage backup or breakout or h,�h static water level observed in the distribution box is due to broken or obstructed
or due to a broken, settled or uneven distribution box. The system will pipe(s)
Health): pass if(with approval of the Board of
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
/D The system n+quired pumping more than four timts`a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED 13Y THE BOARD OF HEALTH:
/YD Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the envirorunent.
i',lis UNLESS BOARD OF HEALTH DETERMINES THAT TIIE SY5"i'EM IS NOT F'UN6T10N1NG IvL't-NER WIIICII WILL PROTECT TIIE PUBLIC HEALTH AND SAFETY AND THE ENVI RONMENT: IN A
d�f) C.uis,aol or privy is within 50 f(,L; of a surface water
V l'e_:s;,,ol cr priV is within 50 L�tt of a bordering vegetated wetland or a salt marsh.
2) S:'-'TLhi VriI.L FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
Dr"I'EI(lf1,tT.•',� THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFE:1'Y AND THE ENVIRONMENT:
system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
c!er supply.
has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
`•.as a septic tank and soil absorption
rp system and is within 50 feet of a private water supply well.
f he !:'.eui has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
>;>:) r. . unlcas a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from F>11utiou from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm
9) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Holly Hill Road Centerville ,Mass . '
Owner. Lewis Rive
Date of Inspection: 7/2 3/9 6
D) SYSTEM FAILS:
•
_ /0 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
&` Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of-ULi ground or surface waters due to an overloaded or clogged SAS or
cesspool.
&d Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
j..e,,neh lam'
N6) liquid depth in ecsspaal is less than 6"below invert or available volume is less than U2 day flow.
Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
( ` Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
AV 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. It the well bas been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
! the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please vonsult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ProBertyAddresa: 28 Holly Hill Road Centerville,Mass .
Owner: Lewis Rive
Date of Inspection: 7/2 3/9 6 •
Check if the following have been done: `
IZl U=ping information was requested of the owner, or.`+pant, and Board of Health.
., one of the system components have been pumped for at least two weeks and the
systemrmal
during that period. barge volumes of water have not been introduced into the systerecently or as receiving hi flow rates
part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A
.L/The facility or dwelling was inspected for signs of sewage backup,
/The system does not receive non4ardtary or industrial waste flow
,• The site was inspected for signs of breakout.
ZAII system components,Z' uding the Soil Absorption System, have been located on the site.
ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was ins
_2 material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. Pad for condition of baffles or
size and location of the Soil Absorption System on the site has been determined based on
approximated by non-intrusive methods. formation or
_j/The facility owner(and occupants, if different from owner) were provided with information on
Surface Disposal System. Proper maintenance of Sub-
(revised 11/03/95) 4
.......__, .. . _..::1; I;. l J�;1;. SYSTEM: .I'Sr:,".r
IG:. : .,...,.
PART C
INFOR.14AT10N
28 Holly Hill Road Centerville,Mass .
Lewis Rive
7/23/96
NwaiJur of currant 1"Wtunts: 1-:7—
Carbare grinder(Yu or no):�� yam
e— .
Soasotutl use (}•oc or no):
45
Last duto of olcupancy:
Duiy-n flow:
Grea:e trap prc,:::.a: (yl.:: cr )�
Industrial Wiute Holdiva'I'Lrtk proiert: (,yee ur noji!/�l
Water aleter rwdinp, if
"t date of occupancy: �- ---
OT`Ii1:.It: (Dac�crit.e) /�!r't
(A.-M- ZA11NFOIULITION
PU:.) PIN*0 it' i uaoru:atic:..
/r�, ° _.._._._.____...__._...---.__._.......
_._..
Syctoa: pwup-d ;a r.u.t cf i.-Urticticu: (yac or —
I.rya;, vulu,r:e pu:tticl: _ .!J/�iv io::c
T'YPc'. OF-SI'ST::..
.Srfitic
�..•l G.: .-_..... .. J l',: utt,;_i: .;vi ut:i. lt:sp:c'lic, cwoi'•di, L; ally)
,u'1)Ito`::, ' ... ',if kr•ol\n` ;d oource of information:
Sowarge CcdOru dotty Vd H't,erl ar;:.:nl; It the ei_-J iyrc or ;..:j Ab
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: 28 Holly Hill Road Centerville ,Mass .
Owner: Lewis Rive
Date of Inspection: 7/23/96
SEPTIC TANK: CN C
(locate on site plan)
Depth below grade:107v
Material of construction: Y concrete _metal _FRP _other(explair,)
Dimensions: " / .' 41'W"' CG di _
Sludge depth: 7
Distance from top o0ludge to bottom of outlet tee or baffle:ZEAC,
Scum thickness:_%j d�t
Distance from top of scum to top of outlet tee or baffle: ��G�'
Distance from bottom of scum to bottom of outlet tee or baffle,._ /7Ge.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid level in relation to outlet invert, structural
-,rity, evidence of leakage, etc.) Pump septic, tank every 3�years.; Inlet & outlet tees ire
in- ' lace ; Liquid lever n i re1a� ori to outlet i 'vert is t!
"tank is structurally sound•The seiptic
No epairs are. needed at the 1�resent t;ma _
GREASE TRAP. A✓�/Ve
(locate on site plan)
Depth below grade:,'A�1�
Material of constrt!rtion-,AXzoncrete _metal _FRP —other(explain)
AW._
Dimensions'
Scum thickness:.&_..
Distance from top wt scum to top of outlet tee or bahle:_A101
Distance from bottom of cram t- honnm of outlet tee or bahle:'AW
r
Comments:
(recommendation for pumping, condi—ri of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, e ence of leakage, etc.i
(revised 8/15/95) 6
PART C
SYSTEM INFORMATION(continued)
Property Address: 28 Holly Hill Road Centerville,Mass .
Owner. Lewis Rive
Date of Inspection: 7/2 3/9 6
TIGHT OR HOLDING TANK: L,12V6.1
(locate on site plan) s
Depth below grade: 2
Material of constr cation:/1//Pconcrete_metal FRP other(explain) .
�f
Dimensions:
Capacity:_ A0 gallons
Design flow•_ 42 gallons/day
Alarm level: Nh
Comments:
(condition f inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of lea ,ge to or out of box,etc.
Distribution box is level;No evidence of solids carry over; o evi a ce
_ ea a,ae in or out of the distribution box, No r Dgirs nppdod Atpresent timp
PUMP CHAMBER:•��Pe,
(locate on site plan)
Pumps in worldng order:(yes or no)-
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
a�� S •
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddresa:28 Holly Hill Road Centerville,Mass.
Owner. Lewis Rive +
Date of Inspection: 7/2 3/9 6 i
SOIL ABSORPTION SYSTEM(Sayuodq.4,fA u�/'dG45T,Gei .may.�flr�:
(locate on sit•plan,if possible;ezcavation act required,but may be approximated by non-intrusive methods) ,
If not determined to be present,explain •
leaching pits,number: 1 -
. leaching chambers,numbers
leading galleries,number.
leaching trenches,numberlength:
leaching fields,number, ions:
overnow cesspool,number:
Comments:(note condition of soil,signs of�d�aulie fgilyrre,level pipondir,&condition of va tatioa,etc.)
Fine sand; signs of h" draullie Iailure or pondiig; Al ve e a ion is
normal. No repairs need.dd °,at the present t1me.
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: 44
Depth of solids layer:
Depth of scum layer.
Dimensions of cesspool
Material of construction:
Indication of groundwater N
inflow(cesspool must be pumped as part of inspection) dt.4
Co n :(note condition of soil,signs of hydraulic failure,level of.ponding,Condition of vegetation,etc.)
d E.Y�r1�P�J7
PRIVY-
(locate on site plan)
Materials of construction: /L'/9 Dimensions /1�J9
Depth of solids:_
Co ts:(note condition of soil,aigns of hydraulic failure,level of ponding,condition of vegetation,etc.)
..i
(revised 11/03/95)• 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM
PART B
SYSTEM INFORMATION continued
`f SKETCH OF SEWAGE L:SPOSAL SYSTEM:
include ties to at least two permanent references landmarks. or benchmarks
locate all wells within in ,
Centerville Ost•erville Marstons Mills
Water Company
428-6691
,s.
DEPTH TO GROUNDWATER
16...�r+_ - depth Co groundwater �
Inikth�Od--L� determi n��t,i can nt-.'`anr�rn�C�H1 •'
SAVRIW* .j s. iii M Ay
:0 1- 93 a
a.
e �
THE: COMMONV, EALTH OF MASSACHUSETTS
BO,,R' , OF HEALTH
TOWN OF BARNSTABLE
No...9y�� ,�. FEE.1...30:.00...
Uii.p ati 1 Work' Qi 3D1rudiun ramit
Permission is hereby granted.....J . P. J r .
............. ...........................................................................................................
to Construct ( ) or Repair �X) an Individual SeN 'agc Disposal System
at No......?.$...H.a.1.1y....Ri ll...R a.a.d....kxi. ermi.. .].p.........................-----.......................................................................
Street
as shown on the application for Disposal Works Cotistrt::tion Permit o .. _.:.. Dated...... ..-.�.�!.-, ..
r. .............................................................._
DATE................- ..I...� .'. .. .................................... Board of Health
FORM 36508 HOBBS Jk WARREN.INC.,PUBLISHERS
THE COMMONWEALTH OF MA SACHUSETTS a
BOARD OF HEA; TH
TOWN OF BARNST.-�.BLE
. C2ertifiL�ztc ,:` C�DIti�?IlKt10E
THIS IS TO CERTIF,Y,'That the Individual Sewat :isposal Sys::em con. :-uct,'.i ( ) or Repaired kXX )
by J :P.Macom'oe.r Jr .
........................................
at .......2 ....Ho11�:....H.i.1.1....Road.....Cen,ta.rvi.11.e..................................................... ...... I............ ...........................................
has been installed in accordance with the: provisions of T1TI.E 5 of The State L!,irt;,unent, Code !rscribed in
the application for Disposal Works Construction Permit No. ..... dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE.r' AS A GUAR, :JTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...... ...? ...Jf'1.......................................... Inspector(::::(` .... ..... :�1 ,,......':...................
V)i
- Sb1Y 3r�1
THE. COMMONWEALTH OF MASSACHUSETTS
DEPARTM NT OF ENVIRONIMENTTAL PROTECTIC16,1N
BE IT KNOWN, THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the -ion of Water Pollution Contro.
TOWN OF bari18 6&ula 110ARD OF HEALTH j
•I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
F•••r.rh�r••.•:: --.rrr.-.-rn�r..n•rt:rrrrramsrrr'�:•n'+.—n•rrrrrmtry anttve"•T+nrrw.saee+�m�'eA'ren esmn .v+•+t•e•r•sr•�r•.•r•�
-TYPE OR PRINT CI.EARLI'-
PROPERTY INSPECTED
STREET ADDRESS 28 Holly Hill Road CeAterville,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Lewis RivA
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr. .
COMPANY NAME J.P.Macomber & Sdr?f `Inc.
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632,
Street Town or City State LIP
COMPANY TELEPHONE ( 508J 775 - 3338 FAX (790 ) 1578-
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate, and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one: .
XXXXXXXXXSystem PASSED _
The inspection i4hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated areas stated in the FAILURE CRITERIA section of
this form.
System ,FAILED*
The inspection' which I have conducted has found that the system fails to
protect the jiublic health and the environment in accordance with Title
5 , 3.10 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Si nature 1l 7 30 96
P g � Date � �
.�% One copy of this c rtification must be provided to the OWNER, the BUYER
( where applic4 and the BOARD OF HEALTH.
* If the inspection FAILED, this owner orq.op operator shall u
8 pgrade ' the system.
within o'ne year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CHR 15 . 305 .
partd.doc
ti
DATE :3/19/98
PROPERTY ADDRESS: 28 Holly Hill Road
Centerville,Mass . ��
4 _
02632 s
:?
On the above date, I Inspected the septic system `apt the'^°,aJpoov"e
This system consists of the following: h`grryoFP3rrlk t
1 . 1 -1000 gallon septic tank. 6'
2 . 1 -Distribution box.
3 . 1 -1000 gallon precast leaching pit.
oa6ea on my Intkc�ectlon, I certlly the following coridltlons:
4 . This is a title five septic system. (' 78 Code )
5 . The leaching pit is dry.
6 . The septic system is in proper working
order at the present time.
• SIGNATURE : ��/,��✓��'/.
Name : J . P , Macomber Jr...
---- - --.---------------
Company:�_ P_Maconber- &- Son_Inc .
_ _Cencerville �Mess__02632
Pnone : __ _� �7338_______ i
THIS CERTIFICATION! GOES HOT CONSTITUTE A GUARANTY OR WARRA. ,iT !
[1E6PoH P, MACOMBER & SON, INC.
T+nkrC.upoolrL�ichllelda
Pump.d L Iniull►C
Town Sowor Connoctloni
x 66 ' Centerville, MA 02632.0066
115-3 3 38 l 7 S-6-a 12
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617.292.5500
WILLIASI F H ELD TRUD'i
Govcmor Sc
ARGEO PAUL CELLUCCI DA`ID B S i
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Comm
PART A
CERTIFICATION
Property Address: 28 Holly Hill Road Centervill6t,ddress of Owner:
Date of Inspection:3/1 9/9 8 (If different)
Name of Inspector:Jngpnh R Ma—mber• Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J.P.Macomber & Son Inc.
Mailing Address: BOX 66 Centerville,Mass . 02632
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below s Uue, accu
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function a!
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date: j /
The System Inspecto shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing MIS
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 sub,
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system o,
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CN1R 1 5.3
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined-, expla n Nhy no:
,( The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate o
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspect on
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfillratjon, or t
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a confor-ming septic tan
as approved by the Board of Health.
(revised 04/25/91) Page 1 of 10
DEP on the World Wide Web: hnp:/nvww.magnet state.ma us/oep
Printed on Recycied Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) dc ,
Property Address: 28 Holly Hill Road Centerville,Mass.
Owner: Lori Jenkins
Date of Inspection: 3/1 9/98
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obsiruci.ed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspeclton if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
A,0 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to proven the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A mANN'ER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
,Q Cesspool or privy is within 50 feet of a surface water
ZD Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water suppi) or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well
.{>Q The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
,fL The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or
less than 5 ppm. Method used to determine distance —� (approximation not valid).
3) OTHER
(zrvi&ed P&go 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
`1 PART A
CERTIFICATION (continued)
Property Address: 28 Holly Hill Road Centerville,Mass .
Owner: Lori Jenkins
Date of Inspection: 3/1 9/9 8
D) SYSTEM FAILS:
You must indicate er:•.er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined to 310 CMR 15.303 he bass
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary ;o correct
the failure.
Yes No
..C/ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged S.�S or
cesspool.
Static liquid level in the dV,'{tribution ox above outlet invert due to an overloaded'or clogged SAS or cesspool
�T•l4�i'y
Liquid depth in cosspoel is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets)
Number of times pumped _
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supp
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information
(revised 04/25/)1) ➢.9. 3 of 10
V\
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.) PART B
CHECKLIST <•
Property Address: 28 Holly Hill Road Centerville,Mass .
Owner: Lori Jenkins
Date of Inspection: 3/1 9/9 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes t/No_ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,ALcling the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)]
(revised 04/25/97) P&g• 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
J PART C
SYSTEM INFORMATION
Property Address: 28 Holly Hill Road Centerville,Mass .
Owner: Lori Jenkins
Date of Inspection:3/1 9/9 8
FLOW CONDITIONS
RESIDENTIAL:
Design flow: # ' .p.d./bedroom for S.A.S.
Number of bedrooms: "k'mv X�
Number of Current residents:
Garbage grinder (yes or no):�
Laundry connected to system (yes or no):_zV__5
Seasonal use (yes or no):Jey)
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no): Vp IK,
Last date of occupancy:
COMMERCIAUINDUSTRIAL•
Type of establishment: /V
Design flow; X,7,4gallons/day
Grease trap present: (yes or no)2229
Industrial Waste Holding Tank present: (yes or no).Azl
Non-sanitary waste discharged to the Title 5 system: (yes or no)W4
Water meter readings, if available:
A4
Last date of occupancy: WA
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS nd urce of in mation:
T
System pumped as part of inspection: (yes or no)-295
yes, volume pumped: a ns
Reason for pumping:
of-
TYPE OFSYSTEM
_Septic tank/distribution box/soil absorption system
,d2�g2 Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other 4"9
APPROXI TE AGE f all components, ate installed known) and source of information:
Sewage odors detected when arriving at the site: (yes or no),,9
(revised 04/25/97) Page 5 of 10
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Holly Hill Road Centerville,Mass .
Owner: Lori Jenkins
Date of Inspection: 3/1 9/9 8
BUILDING SEWER:
(Locate on site plan)
!I
Depth below grader
Material of construction: _cast iron Z40 PVC _other (explain)
Distance from g/rivate water supply well or suction line
Diameter _
Corpmegts: (condition of joints, ventin evidence of leakage, etc.)
SEPTIC TANK:1(Ve2 9,4l14AV5
(locate on site plan)
Depth below grader
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal,
list age &L4 Is age confirmed by Certificate of Compliance�(Yes/No)
Dimensions:
Sludge depth:
Distance from top of dge to bottom of outlet tee or baffle:
Scum thickness: )q
Distance from top of scum to top of outlet tee or baffle: CJ
Distance from bottom of scum to botto of outlet t or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, con diti of inlet and outlet tees or baffles, dept of liquid level in relation to outlet rove�ruCtural
integrity, evidence of leakage, etc.) ��� l-
GREASE TRAPAWe
(locate on site plan)
Depth below grade:w/�'
Material of constructions l/concretaI`LmetaI4V ff iberglass 4APolyethylene lI&ther(explain)
AX
Dimensions: A!A
Scum thickness: "
Distance from top of scum to top of outlet tee or baffle:.A16?
Distance from bottom of scum to bottom of outlet tee or baffle:'!6y—
Date of last pumping: A441
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structura'
integrity, evid ce of leakage, etc.)
(revised 04/25/27) Page 6 of 10
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properl7 Address: 28 Holly Hill Road Centerville,Mass .
ONner: Lori Jenkins
Date of Inspection: 3/19/98
TIGHT OR HOLDING TANK:�y Tank must be pumped prier to, or at time, of inspection)
(locate on site plan)
Depth below grade: A14
Material of construct ionx//l concrete A44metal4& Fiberglass.,U&olyethylene.AL/lother(explain)
wA
Dimensions: X114
Capaciry _d-IA gallons
Design flo.. AJ/P gallons/day
Alarm Ie.el _Alarm to working orderAZd Yes;4J Nu
Date of previous pumping: A)/*
Comments
(condition of inlet tee, condition of alarm and float switches, etc )
DISTRIBUTION BOX:,
tlocate on site plan)
Depin c: I-cA level above outlet inven:
COmmer:s
(noLf.,ii level and distrib tion is equal, evidence of olid s carry ver, evidence of leakage into or out of box, etc.)
r Tr
PUMP CHAnt6ER:�LCir—
(locate on site plan)
Pumps r. -orking order: (Yes or No)—&.d
Alarms in ,.orking order (Yes or No)-7"
Comments
(note condition of pump chamber, condition of pumps and appunenances, etc.)
(rrvi•.e 041/15/97) P.g• 7 of 10
-t
` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION (continued) - Is
Property Address: 28 Holly Hill Road Centerville,Mass .
Owner: Lori Jenkins
Date of Inspection: 3/1 9/98 _
SOIL ABSORPTION SYSTEM (SAS):. DG�O
(locate on site plan, if possible, excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: /
leaching pits, number:!
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:�_
leaching fields, number, dime sions:_01D
overflow cesspool, number:
Alternative system:
Name of Technology: g
Comments:
(note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation, etc.)
C j
CESSPOOLS: dA/p_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: .4141
Depth of solids layer: WA
Depth of scum layer: 4ed
Dimensions of cesspool: A14
Materials of construction:
Indication of groundwater: IV/77
inflow (cesspool must be pumped as pan of inspection)
s Qre 7' I"GS0iU
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: /r�i� Dimensions: /I/�
Depth of solids:4/V
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
L l"Y iS
(revised 04/25/97) ?ago a of 10
I
-�G
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:28 Holly Hill Road Centerville,Mass.
O+ ner: Lori Jenkins
Date of Inspection: 3/1 9/9 8
SKETCH Of SEWAGE DISPOSAL SYSTEM:
i. :,,.ae ties to at least two permanent references landmarks or benchmarks
1--ate all wells within 100' (Locate where public water supply comes into house)
I•^sum ,�� II.H ►-�(.�fi{ F+�
0
f /
oo
\ /
Ap
-------------
Page 9 of 10
') SUBSURFACE SEWAGE DISP,: A SYSTEM INSPECTION FORM
SYSTEM.INFOI:' • ;iON (continued) v
Properly Address: 28 Holly Hill Road Centerville,Mass. ,
Owner' Lori Jenkins
Date of Inspection: 3/1 9/98
Depth to Groundwater aL Feet
Please indicate all the methods used to determine High Groundwater EIL-xion:
Obtained from Design Plans on record
bservation of Site (Abuning property, observation hole, basenkrtt s.imp etc.)
—ZzDetermine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
heck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groun�a.erElevation. Must be completed)
Used Ground Water Contours Map.
Gahrety & Miller Model
12/16/94
(revised 0{/15/97) Pic, ��ot 10
i
TOWN OF Barnstable LWARD OF IIEALTII
SUIISUIIFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
` �.•.T.•{�T••. :'.t_�.Itl.^�T.7ST.'AI'R.TS.1"tT}QTf}TT'r^•.'1�41TI1 i.1110rTATTt11ii RT'RIMiTTRT1 . fRf.I•ITRTTRTS TP•`TT�T�.:�,-e_.-'r--ti. .�.
-TYPL OR PRINT CI.EARLY-
PROPERTY INSFECTED
STREET ADDRESS 28 Holly Hill Road Centerville,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Lori Jenkins
FART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Ino•Te '
COMPANY ADDRESS Box 66 Centerville,Mass . 02632
Street Town or Clty St.It 11P
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578
et
CERTIFICATION STATEMENT a
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of .-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
�ystem PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any fail�, rre
criteria not evaluated are as stated in the - FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have con iIcted has found that the system falls to
Protect the jiublic health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature DateJ
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the DOARD OF 11EAL'I'!1.
* If the inspection FAILED, the owner or"" _Perator shall upgrade the ayotem
within one ,year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CMR 15 . 305 .
partd . doc
Q��� ST�iBLFs =r
SE. WOB-It
MACFmal CII EU�.DFsR Oft,t3'Si�AIER <:
on l7wtancoresaehe:
MWAOW edC Ietathe$�aomofl a hE gEacGity
Pxtbta�rSuFp�Y' flAll
Ra
g +acituy' €a parr exist
oasis a� a � )
Edge and gi 1Nettaud Ig (i€at ►wettaad exist
A �
fo
a o Y
3
r
'Ll - 177
.
APPROVED
No Barnstable Conservedw Department F:cs
A
..... .... Q....Ql�.
, A GO NWEALTH OF MASSACHUSETTS
Signed p R D O F H E A LT H
1 (0
TOWN OF BARNSTABLE J g 0
, pphration for Eliovoml 10orkii Tomitrnrtion Vantit
Application is hereby made for a Permit to Construct ( ) or Repair (Kg) an Individual Sewage Disposal
System at:
..aB.... ...Cen t.azu.i lle----------- -------------•---------•---------••-•-•----•----•••••--------------...._....---------------.--.--•
I M. Rives Location-Address or Lot No.
.
Owner Address
aJ.P .ma c ombe r J r . -------------------•------•-------------- -••----•-•------------------
Installer Address
Type of Building Size Lot............................Sq. feet
�-, Dwelling X-No. of Bedrooms_______________3____-_-__--__-_-_--.-___Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons_______3___-____--_--.-.-- 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.
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.....................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ------------------------------------•-•------•-----------------•-----. •-----------.....---...........•---------------...---••••---•-----------------------.
0 Description of Soil............................................................................................ AR�6... Gr.ave l----------------------------------.-•-•-
W
V ..........•--•--------------------------------------------•---•-------------•••-•---•------------------------------------•---•---•---------•---.---------•--------•-------------••--•--------•-----•----
W
UNature of Repairs or Alterations—Answer when applicable.-Qla t___ces_spool-s..-•-Install 1--1000...aa.11on
tank 1-distribution 1.-1-000---gallon- leach pit-_-bcked n stone
-------- .............................................................
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 Complia ce has -eeqissued by the b and o ealth.
Signed .... ..... ' ��... ..�......... 4�1.6�9°:
Dace
Application Approved By ......... .... ........ ... �t'e�g".. �
Application Disapproved for the following reasonf: ----------............._--....---------------.._---------------------------------------------.....---------------------------
g Dare
Permit No. ------- ....Lt............1..7. .7 Issued
..............
Dace
- ► 77
r �
No.:.. _....... Fimic .$....8 .:.. �.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH I o
TOWN OF BARNSTABLE f `�
,ppliratiou for Diti-poiial Worlai Tontitrurtiou lirrutit
Application is hereby made for a Permit to Construct ( ) or Repair (KX) an Individual Sewage Disposal
System at:
2R ....Rna.d....C<e i;_ecy1'.l1e........... ..................................................................................................
I .M. Rive Location-Address or Lot No.
Owner Address
J.P.maeomher Jr.
Itistauer Address
UType of Building Size Lot............................Sq feet
�. Dwelling X-No. of Bedrooms...............3-_-.__-____________---___Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons.__.___3_________---_--_-- 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.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1--4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
pZ4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
P4 -•••------•--•-••---...---•----------•-•----•-••--•--••. -••-------•....-•--•----•-......••................•-••-•••••-••---•---••-••--....--••.....•--......
ODescription of Soil------------------------------------------------------------------•---•-•------••--------- Sand--&--•Gravel--------•---------------............----
x
w
x •--•--••-------------•-----------•-••----------••------•-•----------••--•••-------------•......--------------- .......................................... ..............................................
U Nature of Repairs or Alterations—Answer when applicable-Omit __cesspools. I_n__s_t__a_l1_ 1-1.0___0__0__ g_ allon
tank 1—distribution box 1-1000 a11on leach
-•------------------------- ........................................................... --------------�1-t--• acked..in stone .
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 Complia "ce has been issu/e� by the b�o'ard o'health.
Si ned ..... .. . . /��/�..� 4/16/94
g ..._-——--*--- --- ---- ------'--..........-'-'--- .................Dace-'-'------=------
Application Approved By -------- "--p- {---------- ........................... �/. ef41
Application Disapproved for the following reasons: ...... .. ....... ................. ' .......................... .................. -' . ......
r'
.......... . .. ...................................................................... ............................. ..
t, Date
PermitNo. `�..... .... .....`7. ...................... Issued ...................................... ..... ---
Dace
\ _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
QLE1tifirate of (11omplian e
TJHIS IS TO CERTIF�, That the Individual Sewage Disposal System constructed ( ) or Repaired XXX )
J P.Macomber r .
by ........ ... - - -_........................ .. - ..:.-------------------------------
In,01,
at
28 Holly Hill Road Centerville
..........................................-------.....--------------...------------..._....----------------.................----------------------......--------------------------------............-----------------------------
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. ...... .. -...1._ .. -------- dated .------.--------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
.�„� Inspecto /'........_.. ./ --
DATE...._........ $` ._.._._.. ,-,,rt17.4-7..
--------------------- ------------------------------------/--------
-------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r� TOWN OF BARNSTABLE 3 .
No...1..y��.�.�. FEE..........0 00..............
. . , �t��n�tt1 urk� �uu�trx�rtuau �lerutit
J.P.Macomber Jr.
Permissionis hereby granted------ -------------------------------------------------••------------• -•-----•-•••-•-----------------•----••-••---...----••-----••---......
to Construct ( ) or Repair �X) an Individual Sewage Disposal System
at No.......28 Holly Hill Road Centerville
Street
as shown on the application for Disposal Works Construction Permit o... -!�;7�__ Dated------ V......
•-•--•-••----•-•--•---•-.... -1--------------------------------------------------------------
Board of Health
DATE.__.._..-••-- --"-.�.c�.' . ....--•..................
FORM 36508 HOBBS rI<WARREN,INC..PUBLISHERS
TOWN OF BARNSTABLE
LOCATION p <. SEWAGE # ! ` - /7 7
VILLAGE1,2a �I11 ASSESSOR'S MAP 6z LOT/98 a C
INSTALLER'S NAME Sz PHONE NO.
SEPTIC TANK CAPACITY /OD®
LEACHING FACILITY:(type) '�i (size) /Dd C)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
Bi "tMER OR OWNER It
DATE PERMIT ISSUED: 4/
DATE COMPLIANCE ISSUED: �`
VARIANCE GRANTED: Yes No
��
\ ��' -`$S
,..
i �
�� .
��
TOWN OFFBARNSTABLE qC1 /7 7 "
LOCATION _ /�I1 SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ��' ' (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Wate-,Supply Well and Leaching Facility (If any wells exist
on site ithin 200 feet of leaching facility) Feet
Edge of" id and Leaching Facili (If any wetlands exist
wit' ,.'eet eachin f ili Feet
Fu: � L
J �