HomeMy WebLinkAbout0190 HOLLY POINT ROAD - Health 190 Holly Point Road
Centerville
A=232-035
UPC 12534
.2.153LOR �rCq
TOWN OF BARNSTABLE
OCATION 190 HoiiU P o.i.ni Road SEWAGE # 9/13103
-VILLAGE Cen;�e2y.Li e, Na,3,3. _ASSESSOR'S MAP & LOT232-035
INSTALLER'S NAME&PHONE NO. 1• !• Nacome,e2 J z.
SEPTIC TANK CAPACITY 1000 g a.E i o n z 1—B o x
LEACHINGFACILITY: (type) 1—LP-600 12'X4 ' (size)1000 gaiionh
NO. OF BEDROOMS 3
BUILDEROROWNER Ku22)ey Rook-6 Zn��ecz<ion
PERMITDATE: 9/13/0 3 COMPLIANCE DATE: 9113103
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 achi g facility) Feet
Furnished byf�.,c����/�%
,! s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.,V
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name /
required for Centerville V Ma 02632 4-1-21
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. Inspector Information CC
When filling out p J)_�F (5 3 a
forms on the
computer, use Douglas A Brown
only the tab key Name of Inspector
to move your D.A.Brown Inc
cursor-do not Company Name
use the return
key. P.o Box 145
Company Address
i
rQ Centerville Ma 02632
City/Town State Zip Code
508-420-4534 S14297
�00 Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title
5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
4-1-21
Tn§rMT6'rsSigTTature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
�d I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^ � 190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. Cityfrown 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:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
At time of inspection this system met all minimum passing requirements. This report can not predict
the future performance under the same or increased use. This passing report is only good for real
estate transfer and can not be used in connection with any building permits etc because there is only
3.2 ft separation from bottom of s.a.s to ground water.This is what I was told by Board of Health. For
exact rules and regulations in regards to this report contact the Barnstable Board of Health.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
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Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u!� 190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. Cityfrown 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 ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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Commonwealth of Massachusetts
�u I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u � 190 Holly Point Rd
Property Address
Poli
Owner Owner's Name
information is
required for Centerville Ma 02632 4-1-21
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 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
L � 190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
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
❑ ® 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 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5 Large Systems: To be considered a large system g y gthe 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
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Commonwealth of Massachusetts
�n i.? Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L � 190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
According to attached permit this system consists of a 1500 tank, d-box, and a 600 gallon pit with 3 ft
of stone.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ❑ No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ 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:
2019---------397 2020--------304 gpd
Sump pump? ❑ Yes ❑ No
Last date of occupancy: seasonal
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
I
Commonwealth of Massachusetts
�m p Title 5 Official Inspection Form
f Subsurface Sewage Disposal System Form Not for Voluntary Assessments
190 Holly Point Rd
v
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
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Commonwealth of Massachusetts
�. Title 5 ,Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
10-31-86 off permit
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ 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.):
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2
t 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: 1500 per permit
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
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 was functioning properly at time of inspection.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
I
Commonwealth of Massachusetts
�9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
q
Depth of liquid level above outlet invert
p
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.):
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Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
I,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
^ � 190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1 600 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
I
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pit was functioning properly at time of inspection
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
r
Commonwealth of Massachusetts
l-� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ,
I
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
riR Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v—
190 Holly Point Rd
Property Address
Poli
Owner
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
Commonwealth of Massachusetts
,. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every 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: 3.2feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Shot water level of lake with laser and compared to bottom of pit per previous inspection report
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
�m I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 Holly Point Rd
Property Address
Owner Poli
information is Owner's Name
required for Centerville Ma 02632 4-1-21
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued)
Property Address: 190 Hoii� Poini Road
Cent z/i vie e, 7a 6..
Owner: lIa.cveu Rook-
.
Date of Inspection: 9113103
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.
6 ,
wt s
19 0. N,,i l y Po un ^rci
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► THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/•�� ,?............OF.......... ��r �1 ......
-----
App iration for Disposal Works Tontrur#ion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (4-r an Individual Sewage Disposal
S at
Locati 1 dr s .--_or.Lot No.
. ............................ -••-•-•--•---•-•-•--------- -----••.......-----------...._....._.........
O er Address
a ------ ' r - ............................... --...........---......--•••---............. ........-----..............................
Installer Address }
Type of Buildings Size Lot............................Sq. feet
U Dwelling 4-;No. of Bedrooms....... .............................Expansion Attic ( ) Garbage Grinder ( }
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .............................................................:........................................................................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
C� Septic Tank—Li uid ca acity............gallons Len •--•--••------- Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
�y Seepage Pit No-----_------------- Diameter.................... Depth below inlet.................... Total leaching area......--.........sq. ft. �
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date........................................
aTest Pit No. l................minutes per inch Depth of Test Pit-----............... Depth to ground water..._....................
fs Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------.................
A+' ........ . ........----•.-• ..................................••----•••--•....................................
r
0 Description of Soil...._.3 ( '
0 -
V -•---------------------------------•-----•----•--•---•---...--•-.............
W ......................•••---•----•...................--•....--•---------------------......•----••-•-••-••-••-•...•-••-..-•--�................
V Nature of Repairs or Alterations—Answer when applicable.....�.:./.....1� ... ........
---- o 'r
---------------------------------------------------------•------------...... t�`..............-----••.•----------- ........�e�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TAIL T'. , 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by e b rd of health. !•
Signed. . ....... ........ .........t
Application Approved B .. _ ---•- ....... ........... . ! a 3 t ?...
Application Disapproved for the following reasons:.............................................................................................................. ,
---••-------•-•............................................•--•---•-••--•--•--•--••-----•--•----------------••---••--------•--•---.........•••••---------•-•--••••-................................-
Date
PermitNo......:......... ......L(2. ... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD (?,F HEALTH
r
/..�Els•,Q'�......OF....... sl. ...........................................
Tertif irFate of Tomplittnre
THE IS TO C.U&TIFy�I TWhh Individual wage Disposal System constructed or Repaired
by 1_2AI -
t )
. ./
s I 'taller , p
at........... ........_.._... /°..................-•-•--.....`.'.........•--•-........ .J .......................................................
has been instailed in accordance with the provisions of TITIE 5 of The State Sanitary Code as dgscribed in the
application for Disposal Works Construction Permit No, .....:...... ........ .... dated........:..�- >'I.;-_C................
THE ISSUANCE OF THIS C TIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT fHE
SYSTEM WILL FUNCTION ACTOR ��7,
DATE... ....................... : `-�..• Inspector......J....�!.----•-.............................................................
..j................
D ATE : 9/1_3_/_0
���
PROPERTY ADDRESS _ 190- 11oi-ey- Point Road
Cente2v.iP.2e, (�ahh ----- S �
------ Taw EPl92o
02632 NOF o,?
On lhe ' above date, I inspected the septic systerrr-at the above address.
Tnis system consists of the lollowing:
1. 1- 1000 ga-Hon zepa is tank, MAP
2• 7-Dietaigut.ion fox.
3. 7-600 ga22on paecazt Peaeh.ing pit. PARCEL S�
8aseo on my inspection, I certify the lollowing conditions: LOT -
4. 7h.i, i.6 a tithe ;give zept.ic zytitem. (78 Code)
5. The aeptic zyztem ih in /2,co/2e2 woaking oadea
at the pAehent time.
6. Pumped aseptic tank at time o/ .i'n-6pection. �
7. Glazte watea iz 250 ge.2ow the invent pipe o�
the ieaehing pit. ( 12'X4 ' )
SIGNATUR ,
Fame ' P . _Macomber Jr .
� ompany : ,�4��Q2 P�_ ��S4mt2�r_ d_ Son, Inc .
5'zx. _ 6- - -- --- ------
- - -Ce.nse:Yt.t_�,_ �a . _2Z672- 006
� ^.one _ _508_• 775: ) ) )8 --- - - --- ,
TrjS CERTIFICATION OOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tinks•Cesspools•Le+chllelds
Pumped & Installed
Town Swer Connections
P 0 80x 66 Centeivinr. MA 02632.0066
775.3738 775.6412
1
I
COMMONWEALTH OF MASSACHUSETTS
t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r '
it
TITLE'5 �"
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 190 floiiy Po-in. Road
Owner's Name7la2Ley Rooks
Owner's Address: Same
Date of Inspection: 9113103
Name of Inspector: (please print) oee h P. Nacomge2 a/t.
Company Name: _ a. P. nacomgelt (t Son Inc.
Mailing Address: Box 66
Na,3,6 02632
Telephone Number: 508-775— 3338
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
2zPasses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Signature:
Inspec
tor's Si Date: �d
�1
The system inspector shall bmit 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:1 90 Ko.P.t?y Po in Road
Cen.teay.i.P.2e, 17aa16.
Owner: Kalcvey 100kc6
Date of lnspection: 9113103
Inspection Summary: Cbeck A,B,C,D or E/ LA WAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
7h2 A 'Qy r nuAip i6 to R2opeA wo/tk.ing oadea
t .time. —.
B. System Conditionally Passes:
Vrl 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.
Answer yes, no or not determined (Y,N,ND) in the 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.
ND explain:
�y 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)arc replaced
obstruction,is removed
distribution box is leveled or replaced
ND explain:
X-le, 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
obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 190 80-tey PO int /toad
Cen.t<e/cu.iiie, Na,6,3.
Owner: Ka2uey K 00
Date of lospectiou: 9113103
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in it manner which will protect public health,safety and the environment:
A)O Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health,safety and environment:
/Ud The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
s��uryyf��ace water supply or tributary to a surface water supply.
4/0 The system has a septic tank and SAS and the SAS is within a Zone I 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 b t 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 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, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A . '
CERTIFICATION(continued)
Property Address: 190 RO-tey 10o irz.t Road
erz eavt e, a,3.6.
Owner: 1la2vey / oo .s
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool i,I'6o 6A'X4"')
Liquid depth in ppI is less than 6"below invert or available volume is less than h.day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped J- �il�0!c ,y
&��Any
ny portion of the SAS, cesspool or privy is below high ground water elevation.
portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
— /water supply.
y 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 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, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
/Ul) (Yes/No)The system fails. 1 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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ 2the system is within 400 feet of a surface drinking water supply
v le system is within 200 feet of a tributary to a surface drinking water supply
t�
— _ he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page S of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B '
CHECKLIST
Property Address: 190 Hoiiy Point Road
Cente2v.e e, a73.
Owner: Naaveu Rook-6
Date or lospection: 9/13/03
Check if the following have been done. You must indicate ' s"or"no" as to each of the following:
------------
Ycs No/
l Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period ?
2
Have large volumes of water been introduced to the system recently or as an of this
p inspection ?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
2_ Was the facility or dwelling inspected for signs of sewage
8 g back up?
_ Was the site inspected for signs of break out ?
�_ Were all system components,p Xluding the SAS, located on site ?
2._ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? on
_ Was the facility owner(and occupants if different from owner)provided with information on the
maintenance of subsurface sewage disposal systems ? proper
The size and location or the Soll Absorption System (SAS) on the site has been determined based on:
Yes no>
l/ Existing information. For example, a plan at the Board of Health.
I"/_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of di
is unacceptable) (310 CMR 15.302(3)(b)) P stance
S
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:190 Ho.P.Py Point Road
en eltvt e, Naz,3.
Owner:/Zaaye.q Rookb
Date of Inspection: 9'113103
RESIDENTUL FLOW CONDITIONS r,.;...
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x N of bedrooms): �;X 1 00
Number of current residents: 9,
Does residence have a garbage grinder(yes or no):
�
Is laundry on a separate sewage system,(yes or no): (if yes separate inspection required)
Laundry system inspected (yes
Seasonal use: (yes or no):if
0 Z000=149, 000 yaiion.s=408. Z2 G%D
Water meter readings, if available (last 2 years usage(gpd)).
Sump pump(yes or no):NVQ _ 9a-2.Pona=4 30. 1 4 gl)D
Last date of occupancy:
COMM ERCIALIWDUSTRIAL
Type o(cscablishmcni:
Design now(based on 310 CieM 15.203): d
Basis of design flow(seats/penons/sgft,etc.):
Grease trap present(yes or no): ,
Industrial waste holding tank present(yes or no):, f
Non•saniury waste discharged to the Title 5 system(yes or no)42/ )
Water meter readings, if available: /¢
Last date 6f occupancy/use: Xto
OTHER (describe):
GENERAL INFORMATION
Pumping Records Na. n. an on temgea 2002
Source of information: it 7k .P 2001 9 Se y Nay �
Was system pumped as pan of the inspection(yes or no):
if cs, volume um ed: gallons •• 'H w was u ti um ed determined?
Reason for pumping: ' .6cum � �o 11ITa�.�ac�e2h we2e
R2e e
TYPE OF SYSTEM
L/Septic tank, distribution box, soil absorption system
NO Single cesspool
Overflow cesspool
Privy
Sharcd system(yes or no)(if yes, attach previous inspection records, if any)
47
eD InnovativdAItem&tive technology. Attach a copy of the current operation and maintenance contract (to be
obtained bom system owner)
/ bight tank e,47 Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no): ,4'6
6
Page 7 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 190 /Lo.P.Py Point Road
Cent e2v.i.P.Pe,Plaaz.
Owner: Ka2vey Rook-6
Date of Inspection: 9113103
BUILDING SEWER (locate on site plan)
Depth below grade: _ /
Materials of consrruction:/2Acast iron _Z40 PVC other(explain):
Distance from private water supply well or suction line: /G 'f
Comments (on condition of joints, venting, evidence of leakage, etc.):
,70.inth aRRean tight. No evidence o .Pgakage The zurtem .iz
vented thaouyh the Zoo/ vent'3.
SEPTIC TANK: ✓ (locate on site plan) id4o WW1.. a
Depth below grade: �
Material of construction: concrete lipmetal-e/ld fiberglassl( polyethylene
other(explairt
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):-'U (attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bonom of outlet tee or baffle:
Scum thickness: n _
Distance from top of scum to top of outlet tee or baffle: d
Distance from bonom of scum to bonom of outlet tee or baffle:
How were dimensions determined: Puml2ed at time o-7—Z rz.612ect.io12.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage, etc.):
PUM Ze t.ic tank annua. aAga e di.612o.6ae .i.6 2ehent. Ineet
outiet tge,3 a/te .in ac�e. 7he tan i.s icTc u2a y eosin and 6howh no
evidence o� 2eakayL-:
GREASE TRAP44,,�'(locate on site plan)
Depth below grade:
Material of construction:li3Y concrete ikmetalWfiberglass�olyethyleneNi9 other
(explain): ii/r!
Dimensions: �
Scum thickness: 4U/
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bottom of outlet tee or baffle: .e�
Date of last pumping: V, _
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
�non67 fnrin L6 U0 'j;nn A a g
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 190 Ko2.Py Point Road
en t e2v.Z - a,3-s.
Owner: Kazvet Rooks
Date of Inspection: 9/13/0 3
r-
TIGHT or HOLDING TANW (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: zM
Material of construction: a concrete metal,eq fiberglass�olyethyleneA64 other(explain):
NA
Dimensions:
Capacity: AIM gallons
Design Flow: gallons/day
Alarm present(yes or no): �00_
Alarm level:� Alarm in working order(yes or no):,(0
Date of last pumping:_A;?�
Comments(condition of alarm and float switches,etc.):
7.i.ght o2 hoiding tank.6 ate not �,ze.6ent.
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-i,6t2ikut.ion Sox haz one Zate2a2 N�2 evidence oZ hoe.id.6 ca22y oven.
No evidence oleakaae into o2 out oZ the &ox
PUMP CHAMBER,(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
PumR chamgez i.6 not Rae.sent
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 190 Ko.2.2_y Po int Road
Cent e2v.i.P.Pe. Na,3.3.
Owner: Ka2ve Rook
Date of Inspection: 3
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
1-600 ga.P.Pon p/zecaat .Peuchiny 12.ii. ( 12'X4 ' )
If SAS not located explain why:
Locat d ' aage 10
Type
leaching pits,number:
leaching chambers,number: 0
leaching galleries,number: O
leaching trenches,number, length: 61
leaching fields,number,dimensions: 0
overflow cesspool, number:
innovative/alternative system Type/name of technology:%T,r�
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
Loamu .6and to medium hand No h.ign.e o/ hydaaueie �a.i2uae
Q2 aond-nU Vegetation i,6 noama-P
CESSPOOLS(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: Q
Depth-top of liquid to inlet invert: A)4
Depth of solids layer: �f,9
Depth of scum layer: A-24
Dimensions of cesspool: �J,9
Materials of construction.
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
C'oh,3rzoo26 ate not n2e.6ent
PRIVYf/� (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.):
L2.ivu ins not aae,3ent
9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 190 Ho Point Road
Cente/zvil e,
Owner: Hgzveu Rook.e
Date of Inspection: 9/13/0 3
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.
10
i
'Page I I of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 190 Koay Point /Road
en t e7137 11 e, 711
Owner: Kaave y Rook-6
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 4 0, feet
Please indicate (check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record - if checked,date of design plan reviewed:N,4
Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: NR
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: httl?:1/town. gaan,3tagie• ma. u,3.
You must describe how you established the high ground water elevation:
U-6ed ah/zP-1-U 9 Mi-eieA Nodg4, 12116194 gaound watea e2evationz agove hea ievei.
U.6ed: ZS-gS: 09zetvation we data. June-
lUzed: USGS: Technicai guiietin 92-000- 1 / .Pate 33 Rnnua2 2angez o� g2ound
wstte2 ePevat coJt� nnuaz,U 1992
no
6 ba
Leaching
Pit y, :cct
J
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per
p Fnmpter Method
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted t
feet.
groundwater table is ���'
11
r.n r.•-n.rn-'.T�\.'R:n+r•rtwrll�.n1'w7.r�+.r rrn+.�,trl�.•wT q�nly nlrw�nlnn .rT•r-sT-7--n-.
(' 13Q2RbtQ�.Qe �.
TOWN OF BOARD OF HEALTH
0 S1111SU11FACE SEWAGE D131'U3AL SYSTEM INSPFCTION FORM - PART D •- CERTIFICATWN
-.rn-r••.•...—r.,i,-.��n+** n.�rw�rrsw•.*►r.�.�.�uw.�wwvr-T�+wvw�+www��� rww v,.,-r.- r�.-.. �. A
-TYPE OR PRINT CI.EARLY-
P110PERTY INSPECTED
STREET ADDRESS190 floUpy Point Road CeateaUi�Pe, (7¢.�e.
ASSESSORS MAP , BLOCK AND PARCEL I 232,�d35
OWNER' s NAME Kaavey Rooms
PART D - CERTIFICATION
NAME OF INSPECTORJoseph P.Macomber .Jr.
COMPANY NAME J P Macomber & Soa In(514
COMPANY ADDRESSBox 66 Centerville Mass . 02632
Stnat Town or C ty Stat• i1P
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1578
R
CERTIFICATION STATEMENT
0r I certify that I have personally 'inspected the sewage disposaj system nt
this nddress and that the information reported is true , accurate , and
omplete as of the time Of insPection , The Inspection was performed and any
ecommendatiorls regarding upgrade , maintenance , and repair. are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
u ) it ;+, �•
Check one ; •
.ZzSysteui PASSED
The inspection which I have conducted has not found any information
which Indicates that the system fails to adequately protect public
he-R1t11 Or' the environment as defined in 310 CMR 16 , 303 , Any failure
criteria not evalunted are as stated in the FAILURE CRITERIA sectiol) of
this form .
System FAILED#
The inspection whicl, I have con cted has found that the system fails to
Protect the pilblic health and the environment in accordance with Title
51 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
0Inspector Signature Date 5�Ls`��
(ne copy of this certification must be provided to the OWNER, the BUYER
ere applicable ) and the BOARD OF HEAL'I'll,
* If the inspection FAILED, the owner or `oparator shall u
within one year of the date of the inspection, unless allowed dortrequiredm
otherwise as provided in 3.10 CMR 16 , 306 .
partd . doc
TOWN BARNSTABLE
LOCATION SEWAGE # T IU"J
VILLAGE (2Qi1l7eAW 1l� ASSESSOR'S MAP & LOT 212—.0 6'
INSTALLER'S NAME PHONE NO. V
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) P jtie,(size) ;
NO. OF BEDROOMS PRIVATE WELL-OR PUBLIC WATER
BUILDER OR OWNER� � 1
DATE PERMIT ISSUED: 7 j
M2
DATE . COMPLIANCE ISSUED: Z 32
VARIANCE GRANTED: Yes No
I l
f
1 b
o A
D.
I,y �_ (� , •d V
- .�
" SaESS0s Pgf �,O:
f
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............OF........A.00.ke. 19Z i
Appliraftan for Uhipmal Works Tonstrnrtinn ranat
Application is hereby made for a Permit to Construct ( ) or Repair (4o an Individual Sewage Disposal
System at-
,�e� Locati dr s or Lot No.
"' _ ...--•.......................... _____-......----••---•.....-.._........_....._
O Address er ................................
Installer Address
Type of Building Size Lot............................Sq. feet
V DwellingNo. of Bedrooms.__.___ Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
el Otherfixtures -------------------------------------------------------------•------------•--••--•-------•--•-•--•••-•-•---
W Design Flow............................................gallons per person per day. Total daily flow..............._._____._____________________gallons.
04 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
fX4 Test Pit No. 2..._............minutes per inch Depth of Test Pit.................... Depth to ground water......._................
a -•-•--••-•-- - ------•--_•---- -______-•----------------
-------------------------------------
--------------------
0 Description of Soil----- ------
U -----------------------------------------
••--------------------------
__-•----------------------------•---•-------------------------------•----------------------••---•---
U Nature of Repairs or Alterations—Answer when applicable.----- :._ _ �� ��4-_
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
T"1T
the provisions of 'T y t ,.a.•. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by e b rd ofh ealth.
Signed r -- --•-- �8 f-a
Application Approved BY-e ------ ••---• _ .......... .......................... ......
Date
Application Disapproved for the following reasons:..............................................................................................................
-------------------------------------------------.._...-•-•--•-•-•--••--•------• ----••------••••---••---•-•----------------------------------
Date
Permit No.. ! :...... _ -F_'�"'---- Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
..............OF...... ::�-—-----------------
Appliration for Uispoiial Works Totwuurtion Ponat
Application is hereby
made for a Permit to Construct or Repair (� Individual Sewage Disposal
SyS;tr,M -
.............a
t .............. . ..................... ................................................................................
L ' 6dd
' t .fss or Lot No.
.... ........./.........O'M . ................................. ..................................................................................................
ner
0
.................................... ............................................Address......................................................
Installer Address
Type of Building/ Size Lot............................Sq. feet
Dwelling No. of Bedrooms._.._._ 3...............................Expansion Attic Garbage Grinder
Other—Type of Building ---------------------------- No. of persons.....................__..___ Showers Cafeteria
P4Other fixtures ..........................................................................................................................
W ---------------------------
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:14 Septic Tank—Liquid capacity............gallons Length................ Width...___..._...... Diameter-_-__-__-___--__ Depth......-.........
Disposal Trench—No..................... Width...-......_....___.. Total Length......_....._....... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter-----------------_ Depth below inlet_..............__... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit...._...........__.. Depth to ground water.._....._.._.........-_.
fs Test Pit No. 2................minutes per inch Depth of Test Pit.........._......_.. Depth to ground water---______-_-____--___-_-
---------- ---------------- ---------------------------------------------------------------------------------
0 Description of Soil..... . . ............ ..................................................................................
�4
U .........................................................................................................................................................................................................
W
............... .............................................................................................. ----------- -----------------7- ------------------------............
U Nature of Repairs or Alterations—Answer when applicable_________________________________ ..........
.................................................................................
Agreement:
------------ ----------T'h"....undersigned... ""'....a_gr"e"e_s'....to....install...the....a"f_or'e"deScr'ib'ed' Individual Sewage Disposal System in accordance with
the provisions of'T"_7 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been, issued b e and of,
Sign
....... ................................
D I t
Application Approved By-----.... �41�2�._-1............................... .......................... ......
_;�_ late............
Application Disapproved for the following reasons:..............................................................................................................
.......................................................................................................................................................................................................
Date
Permit ---------11.64g.��..... Issue(L.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0 HEALTH
..........e./ �
.....OF........ .....................................
TH;S IS TO CVRTIF.Y)T h Individual ewage Disposal System constructed or Repaired (A-10,
by 4
4b ta--Ii; ------------------------------------------------------
a..................... ... ... .......
t
;)Oe------------------------------------------------------------------------- ---------&-------------------------------------------------------
has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as d9scribed in the
7 0;69 application for Disposal Works Construction Permit No7. .......... ........ .... dated--- ................
THE ISSUANCE OF THIS C TIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTIQN-4ATISFACTO"-.
..........DATE.................................... . ...........�w... Inspector......J/_'/ .............................................................
7? THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
0.1
_.OF....... .............
NI ..................... FEE.................
onstrud it ramit
Permission is hereby grante!,--...... .. .............. ....... ........................................................
-A
A
7 to Constr r. pa'r n vidual Se. g(oisposal S em
.. ..........
at No..... ...... ....... .... .. ...... ................ ...........................('.:
..............................................................
Street <-
.,� li& 5�- )
as shown on the application for Disposal Works Construction Permit_No.�u................. Dated--_------_ .. ..........�p
. .......
........... ....................
DA - ---------- .......... Board of Health2�p........... X
Ilk
FOR" 1 255 HOBBS & WARREN. INC., PUBLISHERS
k
Assessor's offioe (1st flooW.' +� osTHE
Assessor's map,and lot number ....ui L� 7"..� :.�`,J EPTIC SYSTE �4
Ail MUST BE p
L3oard of Health'43rd floor): �r' f'TAL.L. w o
3 b . I►bs ED 1N Ct*PUANCEft
�ewage Permit. number ..................:................... �� WITH TIT4E E 11AUSTAnLL S
Efigineering Department (3rd floorj: ` E 1WIRONME 'oo M6 9•
House number. ..:...........:...........
......... '.. �i`/O FJS', NT4'L.CODE AND
�:'� TOWN REGULATIONS APPLICATIONS PROCESSED 8:30,9:30 iA.M, 'and. 1:00•.2:00 P.M. only
t
TOWN; OF BARNSTABLE
B;UItUING � INSPECTOR
n'
APPLICATION:FOR PERMIT TO '..I4.!.�...>r�4. ...: 4. 71d.."vl n.r........................................................
TYPEOF: CONSTRUCTION ........ p.Q.�..............:.,............................................................... ............• ......
........01.1........7...................,9..8..4
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a ermit accord' to the following information:
f to y Go � ! o
Location ............/..7..d.......5�. .... ..........�.. .liPl.tl�1/1.I.l.fr..... Q.rr......(
3
Proposed Use .:...... 1
77 //
Zoning District .R..oj...................'..........................a,..Fire District ....G/rGQ�G.I mI.1IG......0.5/l1gr..Y.11le.............
Name of Owner ...J6.7A1W.gr..o�....1/r.& ............................Address ./49..!-KK(SI.KG.�C.f.V.�
Name of 'Builder A,4—M..O...y.:.:SI/.rt4.......................Address .YGAV.rf-*►.:DC..../C."--a�4s.A.445..................
• Name of Architect lAr.r. ......Lkaka..te................Address .7.S.. G.I.A...S7........V.V.GfT...f( rW/..G.A...M..,
Numberof Rooms ...................I..�n/�x...........................................Foundation ....._..........................................................................
Exterior .Wh1h.....Cd0,.r.JA-)1 ...... g ... I-./. � ..5.!1.(k.. . �............
Floors .......... WA4. .......................................................Interior ........5/l4<,irf.4/-..................................................
Heating ............................................................................:......Plumbing .....................................,............................................
Fireplace ..................................................................................Approximate Cost .......!�39 f:QpQ........................................,
Definitive Plan Approved by Planning Board -----_-------------_-----------19--------- Area ....6.,�y..a$.q;,,+ f'•,:,.„
Diagram of Lot and Building with Dimensions Fe
SUBJECT TO APPROVAL OF BOARD OF HEALTH I N'��
' LIL
S h
AA
Nov &S&L
1'00¢'
i
b ,
.I
OCCUPANCY PERMITS REQUIRED FO NEW DWELLINGS. u�
I hereby agree to conform to ail the Rules and Regulations of the Town of Barnstable regarding the above
construction.
:. e
Name . ...... ....(.''.`:..............................'
Construction Supervisor's License ..K.V..7 cT7........,...
R90istable Assessing Search Results Page 1 of 2
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Home: Departments:Assessors Division:Property Assessment Search Results
190 HOLL Y POINT ROAD
Owner.
ROOKS, HARVEY Property Sketch Legend -
Map/ParceUPamel Extension -
232 /035/
Mailing Address
ROOKS, HARVEY
is
k:
6199 FINSBURY CT EAST POINTE F
PALM BEACH GARDENS,FL.33418 >.
Assessed Values:
Appraised Value Assessed Value
Building Value: $155 100 $155100
Extra Features: $4,300 $4,300
Outbuildings: $600 $600
Land Value: $173,500 $173,500 Interactive Property Map: Map requires Pkv in:
Totals:$333,500 $333.500 1 have visited the maps before Y
Show Me The Mao
Apr#2001 photos available
Sales History:
Owner. Sale Date Book/Page: Sale Price:
FISHER,ROBERT P 1/15/1996 C139478 $263,500
GOODMAN-GRAY,BARBARA E C82857 $0
ROOKS,HARVEY 4/8/1999 C152648 $345.000
Tax Information: Tax Rates: (per$1,000 of valuation)
Town Tax $3,134.90 Town Fire District Rates Other Rates
9.40 Barnstable 288 Land Bank 3%of Town Tax
C.O.M.M. FO Tax $513.59 C.O.M.M. 1.54
Cotuit 1.88
Land Bank Tax $94.05 Hyannis 289
West Barnstable 1.96
http://www.town.bamstable-ma us/tob02/Depts/AdministrativeServices/FinanceJAssessing/... 7/3/2003
- , Bnmstable Assessing Search Results Page 2 of 2
Total:$3,742.54 Due to rounding differences these values may vary
Land and Building Information
Land Building
Lot Size(Acres) 0.36 Year Built 1964
Appraised Value$173,500 Living Area 2347
Assessed Value $173,500 Replacement Cost$168,549
Depreciation 18
Building Value 155,100
Construction Details
Style Colonial Interior Floors CarpetHardwood
Model Residential Interior Walls Drywall
Grade Average Grade Heat Fuel Gas
Stories 2 Stories Heat Type Hot Air
Exterior Wails Wood Shingle AC Type Central �_'�?
Roof Structure Gable/Hip Bedrooms 4 Bedrooms U'-
Roof Cover Asph/F GIs/Cmp Bathrooms 3 Bathrooms
Total Rooms 7 Rooms
Extra Building Features
Code Description Units/SO ft Appraised Value Assessed Value
BFA Bsmt Fin--Aver 150 $1,800 $1,800
FPL2 Fireplace 1 $2,500 $2,500
SHED Shed 80 $600 $600
Property Sketch legend
BAS First Floor,Living Area FST Utility Area(Finished Interior) UAT Atfc Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished)
FAT Atfc Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
FOP Open or Screened in Porch TQS Three Quarters Story(Finished)
http://www.town.bamstable.ma.us/tobO2/Depts/AdministrafveServices/Finance/Assessing/... 7/3/2003
BAXTER NYE ENGINEERING & SURVEYING
Registered Professional Engineers and Land Surveyors
78 North Street,3`dFloor,Hyannis,MA 02601 Tel:(508)771-7502 Fax: (508)771-7622
June 2,2006
Mr.Thomas McKean
Health Department,Town Offices
200 Main Street
Hyannis,MA 02601
RE: 190 Holly Point Road
Centerville
Dear Mr.McKean;
On behalf of my client,Edmund Poli,I am requesting that the matter of the number of bedrooms at 190 Holly Point
Road be placed on the agenda for the June 13T,
3 ,2006 meeting.
According to the Town's Website,this meeting will occur at 3:00 P.M.in the Town Gaud Hearing Room.
I thank you for your consideration in this matter.
Very truly yours,
dba Baxter Nye Engineering&Surveying
Smart Engineering Design LLC
S en A,Wilson,P.E.
cc: E.Poli,J.Ryan
Y1. cam.
s ti
-Ij 4
Ref: 2005-231
Page 1
Land Surveys • Site Design • Subdivisions • Septic Design • Wetland Filings • Planning
File No li
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BomowerorOwner Edmund& Kat n Poli '
Pro a Address 190 Holl Point Rd '
Gt Centerville coon Barnstable state MA n code 02632
LenderorGiant .P li Mortizaize Grom
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Arrow Appraisal Services,LLC Page 9 of 15
1 ('
I
13'-10�4" g'-llama" IV-81/4 12'-3i4"
3 1/2" 31/2 3 "
m m
Existing Balcony Crawl Space
T.V. Room
-
10
r
Existing _
0 1 n -
11 -8i4 Bedroom 02 X
5'-136 4'-65411 12'-31/4" I "' cil
Q
Existing 3
-3ia" 11'-Z7�8" dressing area Remove door and ke 5-0 C.O,
Existing 2
VAQ Master Bedroom
i i N N
1 2'-10"
b
3 stairwell- own
Existing v 21-411
12'-31/411
=' Master Bath 8'-65411
4 � o
Existing Existing ' X
U Main q Bedroom 1`=' N
Bath v
Crawl Space
J�
2'-5'1 x 4'-e" 21-s" x 41-9"
s 14'-411
75
! i
WIO x 45 STEEL OEAM w/ Ilro 24x24 24x24 24x24
iMC PHRTMOR i THRU pOLTS 0 24"o/c STA66ERRED. =zE i
r NAILER a Ra.40VE D(ISTM6 PATIO&REPLACE w/ FEW
---STEP DFL r—w
1 -___-- PRERE TREAT®JOISTS&Gtt01cE DetnNr�
SISTER NEW VxIV MOOR JOISTS MD(r ----------------- -----� ---- ----- - - --------- w/ MOER6lA55 RALW SYSTB.L WRAP JOISTS
'Tel. TO DOSTM6 JOISTS rO D ffrFJOR WNA .L I M AZ6C TR.M. .
- Lip
MOVE EXl5rMB DECK&FMAGE FEW
PRzi5sLRE TREATEP JOISTS& DEW-o
W/FOER6LASS RAL 4&SYST M JOISTS j
_ M AZEK TRML I
F"A ow&Ra.OGATE EXI5TM6
SSM REMOVE STH'.
JOlSr NAN6ERs. 46,5E OPBJM6. ----- .
I I
---- m D(159 SL®ETR EMST, 5LD6Z
EXIeTaa6 g.VM&wMvnw. ADD rtw
i I 1 tEAt RS&RITIALE w/FEW 049x68 AVERS. _
I I t-
1/2"6YP. DD. T&P ON ! I 1
I I ; I r
rx,r STRAPPM6 0 ICc/c_ I O O
0 0. __
3 I I i I.I Q Q ►v W-Av t&FEW 6OxdS$.tom.
REMOM=& KITCHEN RaWVE oarTm Wow PMa.Mb 1
BEAM DETAIL
o"t -Jj= C-----Ji I _ j I &FmnAcE w/FEW eW!O.T&P
.II rS I I IL
I I DN �_.... TO MATGFt E5TR�6.
F' I IL------------JI 11
O I ------- I I FMWVE&REPLACE DOSrM
- TILE MLOM RffXE EWM6
REAM I T9IM FRAM Lf Wi VANITY w/FEW VANITY&SING.
U
PROVDE 5~sq. STEa C41)m RB EwsrM6 DeOR NEW
lilll 1 23'-0" SPAN ��" UO Or oO AOVE PATAi&REAR WALL
rO MArM MagM . ONE GAR CVARAOE
aRavlvE � VZ'•o ca�c I I N
D MOOR W LDS DEAD LOAD + IO LDS DEAD LOAD = 40 x IZ = 4W PIF. FLLED STM.LALLY Ca" i j � PROVIDE OHE LAYM a'5/b"
ti 00.
W LDS DEAD LOAD + 10 LPS DEAD LOAD - W x IZ = W FLF. N ON A6A r Rom. I 6=== ON WALLS M-W.T&P
ION IK PLF. O _ I
• 95Z PLP i O
(
W L. 9y1- x '159 ?L2,�8 I 24)a4 MLI. .
8 S L--------------------------- - ------ ---
SLW4 x 12 = IP5'% 2 WES MOVE EXIS M WMDOW I in 5Ox70IOV62tEAD DOGTt
f431ME HEADER&ADD FEW
M = A516 1^24"M L WRDOW.
Fb Z4OOO
I000 = 1.50
10 x REMODELED.FIRST FLOOR PLAN "
easTm PARTITIONS SHIow DOR'®TO DE REMW®PATH&REFAR
Ma9p5,LELN65&WALLS TO MATM EXFSTNW.
GENERAL NOTES
rmcToR a AU_r-Ia.D vmry EXI m co wImONS PRIGR To sruzr 6F caNSrRucrm
TION "—L ca rMA TO TM MASS. STATE DL PO GORE ARTICLE %W. 6 t h EDff10M
HALL DE NO. I & Z SPRUCE, PIKE OR FR 'E- IAoOpOo ( KILN DRY )
WA115 SHWl DE Z"x4" snps Ar W"o.c. w/ I/r ePX FLYWAOD. t
-SH[IV* AT ALL VALLEYS, ROOF WEF-S
oY OTHERS FOR 9Efmms, umffm, EEG.
rk %PHEI DOORS SHALL DE EQL& rO 1E1A. REPLACE ALL EXISTM6 WINDOWS w/ NEWA 3
' 'JaF5
i
21
DATE: ,1/0/.99
PROPERTY ADDRESS: A90 '1;'aResid'e Drive
Centerville ,Mass .
'02632
On the above date, I Inspected the septic systom at the above address.
Thla system consists of the following:
1 . 1-1500 gallon septic tank.*
2 . 1-Distribution box .
3 . 1-1000 gallon precast leaching pit . ,ram
eaaad bn my Inec-octlon, I certify the •follow n9�pc�on•d,It'lons
4 . This is a tit16 Five Seotic 'System. '( "-7-As' G6-de T),�
5 . The septic system' is irr ,proper wbrk , ord9't
�
� at tine present time .
�►
6 . P.Umped septic tank at time inspection .
Heavy scum and solids layers existed .
A.,
,y.
SIGNATURr': /
Name : J P_H'acomber Jr... i .
Company•_J, P .Maco0er. & � on•`Inc . .
'f r
Address:
__Cent_e�rvlLe �,t�q�,gs_Q2b32 ` • ' '
Phone:
___50.8..:Z.7..S.-3338_______ -- 1
THIS CERTIFICATION,QQES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P, M OUSER '& SON; INC,
T+nk&-C@ upooli-Lsach(Ielda
. Pump+d 4 Insl I1W
Town Sewer Connections
P.O. Box 66 ' Centerville, MA 02632.0066
77.6-3338 775-6412
u
COMMONWEALTH OF MA,SSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTiON FORM
PART A
CERTIFICATION
Property Address: 190 Lakeside Drive Name of owner`•a r v e y Rooks
Centerville NNjjm99 ss 02632 Addreofownw: 619 ins uryport
Data of Inspection: i/ Palm Beach Gardens Florida 33418
Name of Inspector:(Please Print) T(1 }� M a c o m b e r Jr .
m inspector I am a DEP approved syste pursuant to Section 15.340 of Title 5(310 CMR 16.000)
Company Name: J. P.Macomber & Son Inc .
Making Address: Box 66
Teiept,Numberi0 aft cc£Y r11 e ,M a B B . 8 2 6-2 2
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-:Z3303
age disposal systems. The system:
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails 11"� y
Inspectors S'�r �� r� Date: 14�1
a:
The System Inspecto all submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)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 toVw
system owner•and copies sent to the buyer,if applicable, and the approving authority. .
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
A
�,Printed on R"Ied Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddreas: 190 Lakeside Drive Centerville ,Mass .
Omer: Harvey Rooks
Date of k-pection: 1/13/99
INSPECTION SUMMARY: Check A, .8, C, or A
A. SYSTEM PASSES:
1 have not found any information which indicates that any of the failure conditions described in 310 CMR 1-5.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
AUD Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
- Thu system required pumping-more than fourlmes-a yeardue to broken or obstructed pipe(s). The system wilh mvr"-
Inspection if(with approval of the Board of Health): - --
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 190 Lakeside Drive Centerville ,Mass .
Owner: Harvey Rooks
Date of Impaction: 1/13/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Al 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 environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WiTH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICKYALLPROIECT THE PUBLIC IdEALTHAND SAFETY AND THE EN14BONMENT:
Cesspool or privy Is within 60 feet of surface water
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 ANY)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 of a surface water supply 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.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
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
ALA' 4)4
ti
revised 9/2/98 Page 3of11
R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:190 Lakeside Drive Centerville ,Mass .
Owner: Harvey Rooks
Date of Inspection: 1/13/9 9
D. SYSTEM FAILS:
You must Indicate either'Yes" or"No" to each of the following:
1 have determined that one or more of the following failure conditions exist as described 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.
Yes No
Backup of•sewage intoieciRt+lwr-•sTater+t componentdustAo an overloaded orcloggadSiP1S<or•ceasPod.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in tp.e distrilr n box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cecspoa4ls less than 6" below Invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped&.
Any portion of the 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 surfacp 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
rcoliform bacteria,volatile organic.compounds, ammonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" 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-witWa 200 feet of�tarV40-68urfaoadrw►kiagwater•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 upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
1
1
I
1
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 190 Lakeside Drive Centerville ,Mass .
Owner: Harvey Rooks
Data of Inspection:1/13/9 9
Check if the following have been done:YOU must indicate either "Yes" or"No" as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health.
-None of the system compoa&nts hama bam pusnpad4owat-Jeast two-awaaka aad the'vystam hasJaaaaascaimag a awW 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,.16"luding 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:
_ Existing information. For example, 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)
115.302(3)(b))
The facility owner.(and.nrr,pa t, Jf difleraat troaLCSlfnBrJ,suere.praYidad.with Warmatioa.Dn thn p fnnar mint, f
SubSurface Disposal Systems.
i
1
I
revised 9/2/98 PsQe5of11
1
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 190 Lakeside Drive Centerville ,Mass .
Owner: Harey Rooks
Date of Inspection` 1/1.3/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: I/6 g.p,d./bedr M.
Number of bedrooms(de ign): t Number of bedrooms(8ctu80:1
Total DESIGN
Number of current residents:-
Garbage grinder(yes or no):_
Laundry(separate system) (yes or no): 11D If yes,separataImpection•required
Laundry system Inspected�C(yes or®
Seasonal use(yes or no):-.fib � _I
Water meter readings,if available(last two year's usage(gpd): l,e4A41 hP�'.; Ar'llii T�Q—
Sump Pump(Yes or no): 1Z
Last date of occupancy:
COMMERCIALIINDUSTRIAL• A
Type of establishment: �?
Design flow:_ AM QPd ( Based on 16.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no).f/�
Non-sanitary waste discharged to the Title 6 system: (yes or no)ziQ
Water meter readings,If available: /-/,¢ -
Last date of occupancy: A/1
OTHER:(Describe)
Last date of occupancy: Nfl'
GENERAL INFORMATION
PUMPING R ORDS and ource Inf motion:
System umped as part of inspection: (yes or no)
If yes,volume pumped: / d �allons ))!�-�ff,�
Reason for pumping: "^�
TYPE OF SYSTEM
_y/,LSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
AM Privy
Privy
Shared system(yes or no) (if yes,attach previous inspection records,If any)
4)7 I/A Technology etc.Attach copy of up to date operation and maintenance contract
) Tight Tank XJ,4 Copy of DEP Approval
Other
A OXIMATE GE of all m onents, dat inst Ned ' known)-end Bourse of4nformation: - ✓G D .+,ICJ �.�17
llkomiwll
Sewage odors detected when arriving at the site:.(yes or no) 1L�
revised 9/2/98 Page 6of11
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 190 Lakeside Drive Centerville ,Mass .
Owner: Harvey Rooks
Data of 4upacb°m 1/13/9 9
BUILDING SEWER:
(Locate on site plan)
N
Depth below grader
Material of construction:_cast iron 240 PVC_other(explain)
Distance fromyrivate water supply well or suction line f/G�
Diameter V_
Comments:(condition of Joints,venting,evidence of feakage,•etc.)
Joints appear tight No Py; dt-n�P of 1PakaoP
SEPTIC TANK: DO 44)
(locate on site plan)
Depth below grade:
Material of construction:_L14ncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank Is(petal,list agojI2a. Js.age.coonfwmeodby Certificate
eelof Compliance 4q (Yes/No)
Dimensions: I ►�St1Al/rJ�'�7 ��y��� ��7 �// �
Sludge depth:_ _
Distance from top of sludge to bottom of outlet tee orbaffie:
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottW of out( tee or baffle:_
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet toes or-baffles, depth of liquid level In relation to outlet invert, structural•intogrity,
evidence of leakage,etc.) Pump tank every 2-3 I:P a r p, T n 1 P t P. n ii t l P t - --
are In place ThP tank i c etri1rt-11rg11jT onlind T2Pk sh9^'s
GREASE TRAP: p
(locate on site plan)
Depth below grade:_ !�
Material of construction:,!�4concrete��tnetalVlFiberglassd/APolyethyleneelother(explain)
Dimensions: AIN
Scum thickness: AN
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of sown to bottom of outlet tee or baffle:-4�4
Date of last pumping: ow
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert, structural integrity,
evidence of leakage,etc.)
rease trap is not present .
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 190 Lakeside Drive Centerville ,Mass .
Owner: Harvey Rooks
Data of kupection:1/13/9 9
TIGHT OR HOLDING TANK: LW Tank must be pumped prior to,or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction:)VAconcrete44metal WARberglass&A Polyethylene 4J4other(explain)
ZIA
19
Dimensions: A;Jq
Capacity: gallons
Design flow- gallons/day
Alarm present N
Alarm level:—(i IJ Alarm in working order:YesAk NoA44
Date of previous pumping: ,uR
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
light or holding tanks Arp not pgacnnt
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note-If level and distribution is equal,evidenoe of solids carryover,evidence of leakage Into or out of box, etc.) — - —
Distribution box has one lateral ;Nn avirlanrp of solids car-ry
Q y E r r N n a it i d e n r e o f 1 o H k a 33 6 6 ear—e rr—tht^b _ __
PUMP CHAMBER: Almf
(locate on site plan)
Pumps in working order:(Yes or No)-,IA'
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
ump chamber is not present .
revised 9/2/98 Pagtaof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 190 Lakeside Drive Centerville ,Mass .
Owner: Harvey Rooks
Data of Inspection: 1/13/9 9
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if possible:excavation not required,location may be approximated by non-Intrusive methods)
If not located,explain:
Type' i
leaching pits,number:
leaching chambers,number.
leaching galleries,number:=
leaching trenches,number,length:
leaching fields,number,dimen ono:
overflow cesspool,number: Cl
Alternative system:
Name of Technology: e
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to medium coarse sand - No signG of h3�drattlir•
fail irP or Tnndi ng , All vaoorati�t3 is aasmal . Na damp eell .
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to Inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:_
inflow(cesspool must be pumped as part of inspection)
0
Cesspools are not nrPSPnt _
Comments:
(note condition of soil, signs of hydraulic failure,.level of pending,condition of vegetation, etc.)
esspoo s are not present
PRiVY:/i,,,.
(locate on site plan)
Materjals of construction: /L�J� Dimensions:
Depth of solids: AW
Comments: `=
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
Privy is not present ,
revised9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 190 Lakeside Drive Centerville ,Mass .
Owrw: Harvey Rooks
Date of kmWoction: 1/13/9 9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes Into house)
A"ro nT
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropenyAddress: 190 Lakeside Drive Centerville ,Mass .
Owner: Harvey Rooks
Data of Inspection: 1/13/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
JZ4bserved.Site(Abutting property, bservation hole,basement sump etc.)
_Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_/Checked pumping records
T Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Installed system.
ate_ .
revised 9/2/98 Page 11of11
.— , tmrmrn,nr.v•„rtrsrrlsrirrr+ mrnirna�revsrrn
•m,nrw n ram+••-•n— av�l�+,r*'.nrT .
'I'OWN OF R a r n G t a h l a BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
� F.-•t.•,-T•:-::.—•n,,..-.-,-r,.,,"n•nas„�„ras,.+ran,,.—n•t+•nurnr. n.mn.r.�.�s,-. ,.mn ...,.•r,—•..-„_..�
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 190 Lakeside Drive Centerville ,Mass . '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Harvey Rooks
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.MAcomber Jr .
COMPANY NAME J. P.Macomber & Sca•rt •Inc .
COMPANY ADDRESS Box 11 Centerville ,Mass . 01112.
street Town or City State LIP
COMPANY TELEPHONE ( 508 775 - 3338 FAX (508 I 790- 1578
A
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:
System 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 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con icted has found that the system fails to
protect the public 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 Signatur Date -'f
One copy of this rt.tfication must be provided to the OWNER, the BUYER
_ _4
- (where applicable ) and the I30ARD OF HEAL1`JI.
* It the inspection FAILED, the owner or"Operator shall upgrade '
he aYste
within o'ne year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3,10 CMR 16 . 306 •
partd •doc
DATE: 11 /13_/95
PROPERTY ADDRESS:_-150_Lakg�ide Drive _--
ville Ma s .
. ----------_- _ s ------
02632
------------------------
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . This is a title five septic system. ( 78 Code
2. 1 -1500 gallon septic tank. 1 '41,
3 . 1 -Distribution box. Q .3 1 - 4' pip packed in 3 ' of stone . � N
Based on my inspection, I certify the following conditions �" 01/
1 . This is a title five septic system.
2. The septic system is in proper working order 1'q
?
at the present time . : ;
SIGNATU�j
Name: Joseph—P. Macomber Jr.__
Company:J_P_Macomber—&—Son Inc .
Address: Box 66
__Qm-Lt-exv_L11e--,Ma:ss__02632
Ph one:__D08=77. _---___
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
e
JOSEPH P. MACOMBER & ON, INC.
Tanks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connectiog's
P.O. Box 66 Centerville, MA 02632-0066
.775.3338 775-6412
Ip 4
f q aCommonwealth of Massachusetts
_ t L Executive Office of Environmental Affairs
Department of mEnvironmenta.1 Protection
William F.Weld 6
cw.rnor � .
Trudy Coxe e
S�cnt.ry,EOEA
David B.Struhs
Commiuloner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 190 Lakeside Drive Address of Owner:
Date of Inspection: 11 /13/9 5 (If different)
Name of Inspector:Joseph P. Macoilb.er 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 1 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 sewage disposal systems.,The system:
XXXXX Passes
_ Conditionally Passes
_ Needs Further Evaluation Oy the Local Approving Authority
_ Fails
Inspector's Signature: /` �/i � r Date: 1 1 1
l 3/95
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 repon 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) SYSTEM PASSES:
XXXXXXI have not found any information which,indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
NO One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate es, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
_ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, 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 8/15/95) 1
/612I&S&1049 9 Telephone (617)292-550o
Y=
L�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 190 Lakeside Drive Centerville ,Mass . 02632
Owner: Barbara Goodman
Date of Inspection:) 1 /1 3/9 5
B] SYS 1't" CONDITIONALLY PASSES (continued)
NO Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken piple(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 pipets) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
NO 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 environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
NA Cesspool or privy is within 50 feet of a surface water
RA 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIR0N,�IENT:
NQ- 1he wstem nd5 d >et)til tdnn d16 �Uii db�Urptiuli �,y5tenl deli ti�iiliii'i 1w feci iv a SL facc \':aiC: SUpi;l'j Or t;;b 'a^r' Iv
surface water supply.
NQ- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
NQ_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
N0_ The system has a septic tank and soil absorption system and 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.
D] SYSTEM FAILS:
NO 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.
ND- 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 SAS or
cesspool.
(revised 8/15/55; 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property.Address: 190 Lakeside Drive Centerville ,Mass . 02632
Owner: Barbara Goodman .
Date of Inspection:11 /13/9 5
D) SYSTEM FAILS(continued):
NO Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N-L Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
IM Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
rjQ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
NO Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
NO Any portion of a cesspool or privy is within a Zone I of.a public well.
NA Any portion of a cesspool or privy is within 50 feet of a private water supply well.
NA
_ 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.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
NA The design flow of system is 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:
NA the system is within 400 feet of a surface drinking water supply
NA the system is within 200 feet of a tributary to a surface drinking water supply
NA 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 consult the local regional office of the Department for further information.
i�
(revised 0/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
d
Property Address: 190 Lakeside Drive Cent8rville ,Mass . 02632
Owner: Barbara Goodman
Date of Inspection: 11 /13/9 5
Check if the following have been done:
y1pumping information was requested of the owner, occupant, and Board of Health.
gone 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.
_ZAs built plans have been obtained and examined. Note if they are not available with N/A.
ZThe 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.
141
ZAII system components, iNkluding 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 locatioP of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility ov.ne: (and occupants, if different from owner) were provided with information on the proper maintenance of Sub.
Surface Disposal System.
L(..vi'sed15/95) 4 l
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 190 Lakeside Drive Centerville ,Mass . 02632
Barbara Goodman
Owner:
Date of Inspection:) 1 /13/9 5
o FLOW CONDITIONS
RESIDENTIAL:
Design flow:�l. 40 gallonsper day
Number of bedrooms:,.
Number of current residents: 1
Garbage grinder(yes or no):Ye s
Laundry connected to system (yes or no):Yes
Seasonal use (yes or no):NO
Water meter readings, if available: j 99 3—jn17156. 16
9(. 1 - 8, 000 gallons=186 30 gallnnc r)ar day
Last date of occupancy: J j / /9 5
COMMERCIAUINDUSTRIAL:
Type of establishment: T\TA
Design flow:NA Qallons/day
Grease trap present: (yes or no),"
Industrial Waste Holding Tank present: (yes or no)NA
n-sanitary waste discharged to the Title 5 system: (yes or no)U,
,,water meter readings, if available: TA
Last date of occupancy: WA_
OTHER: (Describe) NA
Last date of occupancy: NA
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped septic tank 2/14/95 Maint T P MgonmhPr P, Rnn Tnn
System pumped as part of inspection: (yes or no)jM
If yes, volume pumped. jLg_ gallons
Reason for pumping: NA
TYPE OF SYSTEM
XXXXX Septic tank/distribution box/soil absorption system
NA Single cesspool
NA Overflow cesspool
NA _ Privy
-NA Shared system (yes or no) (if yes, attach previous inspection records, if any)
IN R Other (explain)
date installed (if known) and source of information: —19 APPROXIMATE AGE of all components, --;
rage odors detected when arriving at the site: (yes or no)NO
(revised 8/15/95) 5J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C-
SYSTEM INFORMATION (continued)
Property Address: 190 Lakeside Drive Centerville ,Mass . 02632
Owner: Barbara Goodman
Date of Inspection:11 /13/9 5
SEPTIC TANK:_J_1 500 gallon septic tank.
(locate on site plan)
Depth below grade: 10 it
Material of construction: concrete _metal _FRP—other(explain)
Dimensions:5 7t1jigh 1 0 t 6tt long 51811 wide
Sludge depth: I ra c e
Distance from top of sludge to bottom of outlet tee or baffle: 5 1 tt
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle: 0
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
int rit , e 'd ce of I a ec Pumpse tic tank annually. Garba e disposal present.
�n e ou t .�e's are fine . Liquid levelin relation to outlet`
invert is 51 " . Tank is structurally sound with no evidence of leakag-e .
GREASE TRAWA
(locate on site [Tan)
Depth below grade:NA
Material of constructionNA concrete _metal _FRP—other(explain)
Dimensions:N A
Scum thickness:�rA
Distance from top of scum to top of outlet tee or baffle: NA
Distance from bottom ni «,im to honom of outlet tee or bahle:11L_
Comments: .
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth-of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
NONE
(revised B/15/95) 6
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 190 Lakeside Drive Centerville ,Mass . 02632
Owner: Barbara Goodman
Date of Inspection: 11 /13/9 5
TIGHT OR HOLDING TANK:JJA ,
(locate on site plan)
Depth below grader_
Material of construction:Njconcrete _metal _FRP _other(explain)
NA
Dimensions: NA
Capacity: gallons
NA
Design flow: gallons/day NA
Alarm level: 11VV�ti
Comments:
(conditioryo inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: YES
(locate on site plan)
Depth of liquid level above outlet invert: NO
Comments:
(note ii level and distribotww. i,eywa!, evidence of solids cam ver, eviden of lei qg into or out of box etc.)
Distribution box is level,No evidence o solids carry outer,
of leakage into or out of the box.
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(yes or no) NA
Comments: NONE
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL,SVSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address:190 Lakeside Drive Centerville ,Mass . 02632
Owner: Barbara Goodman
bate of Inspection: 1 1 /1 3/9 5 ,
SOIL ABSORPTION SYSTEM (SAS):N_4'pit packed` in stone t`� b non-intrusive methods)
(locate on site plan, if possible; excavation not required, buts o
tay be app Y
•
If not determined to be present, explain:
NA
Type:
leaching pits, number: 1
leaching chambers, number: 0
leaching galleries, number: n,_
leaching trenches, number,Iength:�_
leaching fields, number, dimensions:_g
overflow cesspool, number:_
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetat(on,etc.)
fine
pon n . e etation green
CESSPOOLS: NA
(locate on site—plan).
Number and configuration: NA �—
Depth-top of liquid to inlet inven: AT A
Depth of solids layer:
Depth of scum layer: NA
Dimensions of cesspool:
Materials of construction: NA
Indication of groyndwater: ILL-
-inflow (cesspool must be pumped as part of inspection) NA
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
NONE
PRIVY• NA
(locate on site plan)
NA Dimensions: NA
Materials of construction:
Depth of solids: NA
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) NA
NO N
• Yt
(revised 8115195)
f
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 190 Lakeside Drive Centerville ,Mass . 02632
Owner: Barbara Goodman
Date of Inspection: 11 /13/9 5
• o
0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks.or benchmarks
locate all wells within 100'
Town Water
Ad
/
� +
e
IEPTH TO GROUNDWATER
epth to groundwater:11_feet
lethod of determination or approximation: Dug test hole 12 ' 6" During installation. No water
evised 8/10 9s1 9
i'
'll
a•,ennrn rnrrrr—••rr�irnrmr•nTnrm+nasrrrrrirn�rr.-arrTrr-+••rn**+m-ti-es rfarr. sr n-n _ *rTa*e'r.erTrvr+rrr�-.�rrnrirtv.r—•.
TOWN OF Barn at.a hI P BOARD OF HEALTH
`\ SUBSURFACE SEWAGE DISPOSALYSTF'M INSPECTION FORM - PART D •- CERTIFICATION
v �•••rr'I�r•.-::r—r.lrn••.rrr+.•nT.'In•n:rsi t-atr mitt rn'�r*M1•r.-r.+tmr.sirnvr'rRr.TRLas T'� tirA n7rtri7tr[1T+Tr7:TTfTIRVT"Irs•T'•Tr•1r•••r•
-TYPE OR PRINT CI.EARLY-
PI?OPERTY INSPECTED
STREET ADDRESS 190 Lakeside Drive Centerville ,Ma_ss .
ASSESSORS MAP, BLOCK A.ND PARCEL #
OWNER' s NAME Barbara Goodman nrgy )
PARR D - CERTIFICATION r
NAME OF INSPECTOR Joseph P. M camber .Tr- .
COMPANY NAME J•P•Macomber & Son Inc .
COMPANY ADDRESS BOx 66 Centervil•le ,Mass . 02632
Street Town or City Stat• LIP
COMPANY TELEPHONE ( ) - -
.,
� � FAX tSnR �gn 1528
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
m reco ,nendations 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 :
XXXXXX System 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 failure
criteria not evaluated are as 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 public health and - the environment in accordance with Title
5 , 310 CMR 15 . 30.3 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
i
Inspector Signature Date 11 /73/95
. .�_ ----• -- __-
One copy of this c4Ttification must be provided to the OWNER, the BUYER
( where app11cab1e ) and the I30AIlD OF 111EAL711.
* If the inspection FAILED, the owner or*"'• orator shall u p p pgrade ' tho system
within one year of the date of the inspection, unless allowed or required
othPr•wi ra rin nrnvi riarl i n 31 0 C:MR 1 5 . 105 .
i
�1 I Cr
cn z�
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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 Control
t