HomeMy WebLinkAbout0065 JOYCE ANNE ROAD - Health 65 Joyce Anne Road
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Centerville
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TOWN OF BARNSTABLE
LOCATION GS Sogcc. Ann Rat SEWAGE# 2p y - 13
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�VILLAGE (2cn4cr y►11 G ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. E'XCwyaLA to^ y')7 - ols
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) _D anX Onl U (size)
NO.OF BEDROOMS
OWNER Goralon Nawor-il.
PERMIT DATE: S••S-/y COMPLIANCE DATE:
Separation Distance Between the: .
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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No � THE COMMONWEA
LTH OF MASSACHUSE TS FEE
BOARD OF HEALTH
Aln OF RGrrlSfa .iP
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System [:]Individual Components
L,,-,-4 6o r�� �u_)0 C,7_8
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Map/Parcel# d s
Lot# - Telephone#
Inst lens Nam���5 � � � Designer's Name
A r- Address
Telephone# Telephone#
Type of Building: /d�',(lC_Q_, Lot Size Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required) gpd Calculated design flow gpd Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place a system in operation until a Certificate of Compliance has been issued by the Board of Health.
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Signed y-23-
Inspections
VV
I� FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
N..o:' / THE COMMONWEALTH OF MASSACHUSETTS FEE w {
u
�y BOARD OF HEALTH
O1= CirnSf� hl>a
' APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( .) Abandon ( ) - []Complete System ❑Individual Components
t' am
`.,1C. V/ V _) jr ��e T O is N(
Map/Parcel# ' �!y .ryns
Lot# iJ f76 6
Telephone#
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L Ins[a�ler's// Nam J r �.�� / A/) /A Designer's Name
mot! 1 (✓�.-`l/I! Adrlet' ILY/f Address ^y
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Telephone# Telephone#
Type of Building: /K eS 1 tj-f'n f_ .. Lot Size Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria-( )
Other fixtures
Design Flow(min.required) gpd Calculated design flow gpd Design flow provided gpd
-Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) .�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
- a
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE,S and further agrees not to place a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed D g v'1 2 3 it\
Inspections l�•. it , .
V
FORM 1 -APPLICATION FOR DSCP DEP APPROVED FORM 5/96
t 1
` NO. i0 THE COMMONWEALTH OF MASSACHUSETTS FEE
_JB rirnS`fa b (-e BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired YZ
Upgraded( ),Abandoned( )
n+ion
has been installed id accordance with the pro isions of 310 CMR 15.00 (Title 5) and the approved design-plans/as-built
plans relating to application No. dated /�� Approved Design Flow I(gpd
Installer eobc' 'T ff! / ... .A � IC
A ' V
JV
Designer: I-A Ins ector
The issuance of this certificate shall not be construed as a guarantee that//��"essystem will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROci/E,•D FORM 5/96
N • / THE COMMONWEALTH OF MASSACHUSETTS FEE
11JC�1� I �� BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is her by granted.to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) an individual sewage
disposal system at �\ L�' - •f\ ) r)-f` 1 vt I as described
I
in the application for Disposal System Construction Permit No. / 1 dated
Provided: Cons ruction s' Il be completed within three years of the date of this per��Al' cak nditions must be met.
r Date / Board of Health
FORM 2 — DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON
IV
ti
'down of Barnstable Barnstable
°p THE)ply
Regulatory Services Department AMmeficaCft
nA A MASS. 01 Public Health Division ' �m
T M �Q
O°A 1,659.
TfD MAt° 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scalie,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 1010 0000 2851 2613
April 10, 2014
Mr. &Mrs. Gordon Haworth
65 Joyce Anne Road
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5.
The septic system located at 65 Joyce Anne Road, Centerville, MA, was last inspected
on 3/28/2014 by Matthew Gilfoy, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Conditionally Passes"
under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• The distribution box must be replaced.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this.notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE B ARD OF HEALTH
o s McKean, R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\conditionally passed\65 Joyce Anne Rd cent 2014.doc
' Commonwealth of Massachusetts
W _Title 5 Official Inspection Form
Subsurface Sewage Di osal System Form Not for Voluntary Assessments
M 65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
:
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:When A
filling . General Information- -
onnt thhe out forms computer, �1 I 6q5s
use only the tab 1. Inspector: `
key to move your
- _.
cursor-do not. Matthew Gilfoy..
use the return
key. Name of Inspector
B & B Excavation,lnc. - -
� Company Name
14 Teaberry Lane
Company Address
Forestdale p MA 02644
City/Town State Zip Code
508-477-0653 S 113640
Telephone Number License.Number
I,
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience.in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15000). The system:
❑ Passes. ® Conditionally Passes ❑ .Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/31/14
Inspector's Signatu e - Date - -The system inspector shall submit.a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the-system owner shall submit the.
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer,.if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how.the system.will perform in the future under
the same or different:conditions:of use.
II
t5ins•11/10:: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
65 Joyce Ann Road
M
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
Distribution box is deteriorated and in poor condition and must be replaced
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N FIND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/ day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
65 Joyce Ann Road
M
Property Address ....
Gordon Haworth
Owner. Owner's Name
information is Centerville MA 02632 3/28/14
required for every
page. Cltyrrown - State Zip Code. _ - Date of Inspection
C. Checklist ..
Check if the following have been done..You must:indicate":yes" or"no as to each of the following:
Yes No
® Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 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 propermaintenance.of subsurface sewage disposal systems?
The size and location of the Soil.Absorption System (SAS) on the site has.
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® Determined in the field(if any of the failure criteria related to-Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3: Number.of bedrooms(actual), 2
DESIGN flow based.on 310 CMR 15.203(for example: 110 gpd x#of bedrooms) 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System:•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 65 Joyce Ann Road
M
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1,8.,
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage.
Septic Tank(locate on site plan):
1'2"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No
Dimensions: 1000 gal
Sludge depth:
5"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up but pumping is
recommended.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City1rown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box is in poor condition and must be replaced
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: (1)U diameter
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appears to be in working condition. Does have some high staining but
okay per BOH.
/3 N01
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
65 Joyce Ann Road
�M
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is
required or every
Centerville MA 02632 3/28/14
f
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
1
I= 12 `
133 = 34'
El
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >12
feet
Please indicate,all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: July 1981Date
❑ 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:
per plan & permit on file at BOH
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 65 Joyce Ann Road
Property Address
Gordon Haworth
Owner Owner's Name
information is required for every Centerville MA 02632 3/28/14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
A
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
LOCATION- SEWAGE PERMIT NO.
VILLAGE (�
INSTA LLER'S NAME i ADDRESS
4 00 1, S
BUILDER OR OWNER _
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ,� _ 3
r - •
.Z 2
Fy 0
t
...... Fxs......................a..
`�- THE COMMCNWEACTH OF'MASSACHUSETTS..
J BOAR Off' HEALTH
a J II ....................... ...... ......OF......:... 0.000n_J� .
AppfirFation for Disposal Marks Tonstrnrtiun 1hrutit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at: r-.
LC�T l ' C) C 0 M_,t, ,
..- -- - •--..... -•-•a-•------•-••....`.:�... 'l-t:fs...l �G---- -----------------------------------------
�� �L�4a ,n-Address iz or L t No.
�Q l T T�1 `..Ci
�� f_ __/ Address
........
Installer Address
U Type of Building Size Lot...../ V�..... ...............Sq. feet
a Dwelling—No. of Bedrooms__--.-_,_l--------------------------------Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ....'...................... No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fix ur .-• -•-- • • ---•----------------•-----------••-•••-------------------•---••=--•••-•----•-••••--•-----•-•••......-••••--•••-•••.••----
---- -- ------ -
Design Flow............... ......______ _ .gallon®per person per day. Total daily flow........ o_._.__._.............__gallons.
Septic Tank—Liquid capacityga�o�is Length................ Width................ Diameter------- Depth_._
W Disposal Trench—No. .................... Width..... ,---...------- Total Length..................._.Total leaching area....................sq. ft.
= x
Seepage Pit No.....�............. Diameter....... ......... Depth below inlet.................... Total leaching area..... ft.
Z Other Distribution box ( ) Dosing
a Percolation Test Results Performed by...... ........................
............................ Date............................. -..
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._ d. ...
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water�q_g..4—J0
(� T------- .............••-.... .
0 Description of Soil••.0...........................Q.....................-f" �'G656L4- --- - ...................................................
--
UW ---•---------- .........................................................................................................................................................................................
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
..........................
-..----------------------------
-•----------
..
Agreement:
{
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been'iss d y the bo of health.
Signed---....--•- ----------•-----••• ...................................................
Date
--1 � ��- �... ................................
Application Approved By.....- � ......... 1..
Date
Application Disapproved for the following reasons-----------------------------------------------•---------------••----------------•-----------------..........--•-
...---•--...--•-•--•-------------------------------------•-----•-•-•--•---•------.....---...-•-------•------•-••••-•---•--•-•---•--•----•-•-------•----------•-•-•-• -----------• ......................
Date
PermitNo......................................................... Issued_.......................................................
Date
E v�
NoC2............ i Fims............._...............
• THE COMMO'NWEAL`rH OF MASSACHUSETTS
BOARD{�OF HEALTH
0 f.e) �..............OF..... ........................ 1. .................................
Appliration for Disposal Works Tonotrnrtion ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: {� -n ( /
LU i" �'1 O(,(C L. v ✓L,t I d . ��'t-�S/u l
_..
.(...-Location=Address.................................. .. ......... ...... Lot No.•--...............------.............----
1 ............... or
.......... -- I ../.. ..
W A,-(Z'� �� CC)A)<j7TlW 'U L71 d Y) \�' Address
a ........................................................................•----•----•-••....._...... ••--••••--•---------•---••----......................•... ....._.._...............................
Installer Address
Type of Building Size Lot.................... ..Sq. feet
Dwelling—No. of Bedrooms......5':................................Expansion Attic ( ) Garbage Grinder (kJ)j
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P.I Other fixju� -----....---•--•••-•--•-•-----•-•-•-•-••-••••-•-••••--•••-----•-•---•----••-•----------------------•-•-••----••••---••••..........--•------•----•••-•
d
W Design Flow............... .......... albs per person per day. Total daily flow........ ......................gallons.
IxSeptic Tank—Liquid*capacity--.._.-taeilons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....... Diameter.................... Depth below inlet.................... Total leaching area... -97v...sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) iry
Percolation Test Results Performed by__..../--.'.�.Z.. ............................................... Date...__._ / /
,aa Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.._
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__a..� 1_4r"'
........................... ---------------•-- ---•-----...........--------••••-•----------..----•-.........................................................
O Description of Soil.....0 ---7-- L o o n,( D G!6j�Q/
x 7 ` , /2 ' G-a- ,, ered �d �'dt4 J rd1 -•/
c.>
W
UNature of Repairs or Alterations—Answer when applicable_____________________________•-_-__•--•._-__-______-_________---__-_------------___•_-_--_-_--.
-•-------------------•-•----•--•---••------•----------......---•-••-----------------...............-----...------------------------------------•-----------------------------------......-------•----•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI:4 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.by the board.of health.
Signed•••• . _/---K_ ----- �.....
Application Approved By............... � �� -� 5�l/at
-------------------------------------------------------------- ..............
Date
Application Disapproved for the following reasons------------------------------------------- ----------------------------------•----------------------••---•---.
--•----•-•--•-•••••-•--•.....•••••--•-•-•-•-•-•••---•••-•-••••---•'------------•-••-••--.......---•-------•••--•-••--•••••-••-••--•-•-••-•••-••••--------------------•-•-•---•-----•----•-•••--...._._
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_-- BOARD OF HEALTH
.....!...�....� ..............OF...........(..�'I...l�....S..!.�. :`.. ........................
Trrtifiratr of Tomplionrr
THIS7IS. TO CERTIFY, That the Individual Sewage Disposal System constructed (�) or Repaired ( )
by .............................................................�( �`7U c. `-i rk............---- •------•-------- -
at.......................................,1 ]cts�all�r-' a N "`
............................................................
has been installed in accordance with the provisions of ;DTI F 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N�&•' -_---- ................. dated............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................................... -1.... - 11.............. Inspector..................... - - ---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
-/ BOARD--OF HEALTH!
........................................... i'1 OF.._...........C� / J .........................
a......................... FEE.--:.)..............
Disposal Works Tonotrurtion rrmit
Permission is hereby granted. •-�•(4-•----�' C� ----------------------------------------------------------•----....................
to Construct (�,Yor Repair ( } an Individuab S wage Disposal System
Street
as shown on the application for Disposal Works Construct' �-grmit No._r .` �.... Dated...._.._..:�......�-X-J•=.. ......_..
�� Board of Health
DATE v ......F1
.......
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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