HomeMy WebLinkAbout0063 KNOTTY PINE LANE - Health 63 KNOTTY PINE LANEL _ `y
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c� Commonwealth of Massachusetts
�n ►p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
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 filling out forms A. Inspector Information 5(9-1
on the computer,
use only the tab Chad Hathaway
key to move your Name of Inspector
cursor-do not Hathaway Septic Inspections
use the return Company Name
key.
P.O.Box
151
,� Company Address
Forestdale Ma 02644
City/Town State Zip Code
774 274 2581 12866
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
6/10/2020
ector's Si ure Date
The system inspector shal;dayvsof
mit, copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 3 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
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:
This inspection is not a guarantee and applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described components. This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
Information on care and do's and don't's can be found at town health dept or mass ov
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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�n
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. Cityrrown 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 1/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped.
❑ ® 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 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 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
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
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)]
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
2001 As built card
Number of current residents:
2
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
p, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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: owner pumps every 3 years. Tank due for pumping
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
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:
tank origanal Dbox and leaching 2001
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 4.5'
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 24'+ see asbuilt
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
no signs of leaks or poor venting
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 4'feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
H10 1000 gal tank. riser with steel cover on inlet.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
8'x5'
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
18"
Scum thickness
6" �
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? tape and sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Baffles in place no visable rott or leaks. tank at working level. recommend tank to be pumped as
maintenance
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. Cityrrown 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):
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.):
D133 has riser in place cover down 1' below grade. No decay or leaks no carry overs
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
rn Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2) 3'xl'x50'
infultrators
❑ 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
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.):
both rows of infultrators have 4" pvc caps at grade. cap#4 has 10" of water in it. Cap#3 is dry with
no signs of being full in past. Flow from DBox primarly flows to Cap#4 infultrators
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. Cityrrown 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.):
l5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
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: 26
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: 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:
town GIS mapping lot el. 60 in area of septic. lake weguaquet is el. 29
You must describe how you established the high ground water elevation:
bottom of septic el. 54'
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
f
chusetts
Commonwealth of Massa
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Knotty Pine Lane
Property Address
Blaisdell
Owner Owner's Name
information is required for every Centerville Ma 6/10/2020
page. Cityfrown 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
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
13
Master Bath
I
r
BED ROOM
Living Room
Laundry
®14 Garage
Den
Bath Dining
Bed Room
Okitchen
Cl01 }
63 Knotty Pine Lane
Main House
_ 11�
A,.
0'-4•
e�
l Bed Room
Main House Basement
JOrL Closet
/
26'-6'
® •SYCC�
Kitchen/dining
.Living Room
O 9'-21
Bath0
C
3' '-6 2'- -11'
63 Knotty Pine Lane 57
Apartment
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission oo perat—e) ou must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: 5 /ITI17 Fill in please:
APPLICANT'S YOUR NAME/S:
BUSINESS YOUR HOME ADDRESS: /c .e ..-le J
-74
`Jvw TELEPHONE # Home Telephone Number
NAME OF CORPORATION:
NAME DFNEW BUSINESS i^KA Y1,6c • X 5 , �'37 M TYPE OF BUSINESS
IS THIS A HOME OCCUPATION? YES - NO
ADDRESS OF BUSINESS. . �-
MAP PARCEL NUMBER I "l1 (Assessing)
�. er� T&4 ;� , Ile- yup , v,7.G3Z .� ..
When starting a new business there are several things you m.ust do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
nd licenses required to legally operate your business in town.
Rd. & Main Street) to make sure you have the appropriate permits a
1. BUILDING COMMISSIONER' 0 F CE MUST COMPLY WITH HOME OCCUPATION
This individual has been ' f of any per r uiremerits that pertain to this type of business. RULES AND REGULATIONS. FAILURE T®
COMPLY MAY AEUUl=T 1N FINES,. .
Authorized Signat e**
COMMENTS: - 0
Lam `
2. BOARD OF HEALTH MUST COMPLY WITH ALL
This.individual has been informed of 'e r ments that pertain to this type of business. � iRDOIIS MATERIALS REGULATIONS
Authorized Sign at 'e
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature"
COMMENTS:
Commonwealth of Massachusetts
_ u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 1/3/14
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 filling out forms A. General Information
on the computer,
key to ly move tab
b 1. Inspector: 14
a�
key to move our
cursor-do not MARK L WHITE
use the return Name of Inspector
key. BOUSE HOUSE ENTERPRISE
r� Company Name
PO BOX 492
Company Address
FORESTDALE MA 02644
City/Town State Zip Code
508-888-2010 S 113381
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
0 Passes ElConditionally Passes ❑ Fails ,A 1,,j OFl4144///
G^.
t❑ Needs Further Evaluation by the Local Approving Authority `moo MARK
-� WHIT =
c No.S13381 Cn
-w 1/3/14
.. %, r•••FRriF �•�o�.
cis spector's Signa ure Date ���ii S I N SPA
=- fie system inspector shall submit a copy of this inspection report to the Approving Authority(Board
�. df Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
O 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.
I �
t5ins•11I10 Title 5 Official 4P.tl n Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 1/3/14
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:
01 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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):
t5ins•11110
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owners Name
information is required for every CENTERVILLE MA 02632 1/3/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cost.)
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 ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND below):
(Explain
❑ 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 Offldal Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�. 63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owners Name
information is CENTERVILLE
required for every MA 02632 1/3/14
page. City/Town 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.
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ F-1 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS.or cesspool
❑ E] Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t51ns-11/10 Title 5 Offtdal Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurfac
e Sewage Disposal System Form Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information is CENTERVILLE
required for every MA 02632 1/3/14
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:
❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ n 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.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ E 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-
1 0,000g pd.
❑ n 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 Systems:Large S
g y ms: 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.
t51ns•11/10
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information is
required CENTERVILLE MA 02632 1/3/1 4
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
ID ❑ 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?
0 ❑ Has the system received normal flows in the previous two week period?
E] Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ 0 Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
0 ❑ Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
n ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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?
ID ❑ Was the facility owner(and occupants if different from owner)provided with
information on the.proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15,302(5)]
D. System Information
Residential Flow Conditions:
' Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 G.P.D.
t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information isrequied or every CENTERVILLE
MA 02632 1/3/14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1-1000 GALLON SEPTIC TANK 1-DB5 DISTRIBUTION BOX 16 INFILTRATORS
Number of current residents:
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2011-97,000 2012-64,000
Sump pump? ❑ Yes ❑Q No
Last date of occupancy: CURRENT
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203): y�gpd)
Gallons per da
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-11f10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information
required for every CENTERVILLE MA 02632 1/3/14
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: NOVEMBER 26,2013 PER BOUSE HOUSE ENTERPRISE
Was system pumped as part of the inspection? ❑ Yes N No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
0 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):
t51ns•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
requir required
is CENTERVILLE MA 02632 1/3/14
required for every
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:
ORIGINAL SYSTEM IN 1980, NEW LEACHING INSTALLED 6/12/01
Were sewage odors detected when arriving at the site? ❑ Yes ■❑ No
Building Sewer(locate on site plan):
Depth below grade: 57"feet
Material of construction:
❑ cast iron 0140 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
MAIN LINE IS CLEAR AND JOINTS APPEAR TIGHT, WITH NO SIGNS OF LEAKAGE
Septic Tank(locate on site plan):
51"
Depth below grade: feet
Material of construction:
All 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:
Sludge depth:
0
t51ns•11/10 Title 6 Offldal Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
•� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE L N
Property Address
JOHN BLAISDELL
Owner Owner's Name
requirefo is CENTERVILLE MA 02632 1/3/14
required for every
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 5211
Scum thickness O
$rr
Distance from top of scum to top of outlet tee or baffle
8111
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? SLUDGE JUDGE AND TAPE MEASURE
Comments (on.pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
INLET AND OUTLET BAFFLES ARE IN PLACE AND STRUCTURALLY SOUND
LIQUID LEVELS IN RELATIONSHIP TO OUTLET INVERT ARE AT GOOD LEVELS,NO SIGNS OF LEAKING
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
y El 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
t5lns•11110 Title 5 Offlcial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
•� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information
required for every CENTERVILLE MA 02632 1/3/14
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 Title 5 Official Inspection Form:Subsurface Sewage Disposal
P 9System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 1/3/14
page. City/Town 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 LIQUID LEVEL AT INVERT WITH LEVELERS IN PLACE
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.):
NO SIGNS OF ANY SOLID CARRYOVER OR LEAKAGE
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
f
• Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System 9 p Form Not for Volun
tary nta As
sessments
ssessments
63 KNOTTY PINE L N
Property Address
JOHN BLAISDELL
Owner Owner's Name
information is CENTERVILLE MA 02632 1/3/14
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
1001X3'INFILTRATORS
R. 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.):
NO SIGNS OF HYDRAULIC FAILURE, NO STANDING LIQUID,NO PONDING OR DAMP SOIL
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
t5lns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
• Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owners Name
information is GENTERVILLE
required for every MA 02632 1/3/14
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
Commonwealth of Massachusetts
_ - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information is CENTERVILLE
required for every MA 02632 1/3/14
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
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal
p g p System•Page 15 of 17
r
�\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owners Name
information is required for every CENTERVILLE MA 02632 1/3/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑■ Check Slope
Surface water
Check cellar
0 Shallow wells
Estimated depth to high ground water: 331
feet
Please indicate all methods used to determine the high ground water elevation:
0 Obtained from system design plans on record
If checked, date of design plan reviewed: JUNE 12, 2001
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:
PLANS ON FILE AT BOARD OF HEALTH DATED 6/12/01
SHOWED NO GROUNDWATER TO 331
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51ns•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 KNOTTY PINE LN
Property Address
JOHN BLAISDELL
Owner Owner's Name
information is
required for every CENTERVILLE MA 02632 1/3/14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
■0 Inspection Summary:A, B, C, D, or E checked
■0 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
i
t5lns-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
V
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a _ car co
- 4c) '
I
31- t
Y=;R;HS T AP. - `iLriHD Oter: i r �isl .
'i2009 �grABLE. ' '08 DEC 11 " A 9 :17
JAN 2- �� 6
GROWTH MANAGEMENT Town of Barnstable
Zoning Board of Appeals
Comprehensive Permit.Decision and Notice
Appeal 2008-046—Blaisdell
Decision- Chapter 40B Comprehensive Permit
Applicant: John Blaisdell,Amanda Blaisdell and Stephanie A. Blaisdell,
Property Address: 63 Knotty Pine Lane Centerville
Assessor's"Map/Parcel: Map 191,Parcel 075
Zoning: Residential RC Zoning District
Applicants:
The applicants are John Blaisdell,Amanda Blasdell and Stephanie A. Blaisdell, Stephanie resides at 63 Knotty Pine
Lane, Centerville, MA. Stephanie A. Blaisdell was granted title to the property by deed recorded in the Barnstable
Land Court Registry on March 28, 2008 as recorded in document numbered 1,086,175 and certificate of title number .
185562.
Relief Requested:
The applicant has applied for a Comprehensive Permit under Chapter 40B of the General Laws of the Commonwealth
of Massachusetts, and in accordance with Article II of Chapter Nine of the Code of the town of Barnstable,more
commonly termed the"Accessory Affordable Apartment Program."
The zoning relief necessary for this Comprehensive Permit to be issued is that of a variance. Section 9-14 of the Code
—Amnesty Program to permit an accessory apartment unit within the lower level of the single-family owner-occupied
residential dwelling. The issuance of this Comprehensive Permit would allow for a one bedroom accessory affordable
apartment unit in the lower level.
Locus and Background:
The property at issue is a 0.34-acre lot located at 63 Knotty Pine Lane Centerville MA. The lot was developed in 1970
with a-single-family ranch style home. The effective living area of the in residence is 1,514 square feet. The
accessory apartment is a one bedroom unit located in the lower level of the principal dwelling. The square footage of
the rental area is approximately 520 square feet:
The lot is served by public water and on-site septic, and is located Within an Aquifer Protection Overlay District. The
town of Barnstable's Public Health Division reviewed the application,and on August 19,2008, approved a total of
three (3)bedrooms at the property with the existing on site septic system., _
Procedural Summary:
A,site approval letter was issued.for the property by Town Manager John Klimm on September 17,2008, in
accordance with MGL Chapter 40B and 760 CMR. Notice of the site approval letter was sent to the Department of
Housing and Community Development in accordance with the requirements of CMR 760. An"application for a
Comprehensive Permit was then filed"at the Town Clerk's Office and the Office of the Zoning Board of Appeals.
A public hearing before the Zoning Board'of Appeals Hearing Officer.was duly advertised in the Barnstable Patriot on
October 10 2008.and October,17,2008,and notices were sent to all abutters in accordance with MGL Chapter 40B.
Town of Barnstable Health Inspector
pFTNE 1p� Office Hours
o Regulatory Services 8:00—9:30
Thomas F.Geiler,Director 3:30—4:30
BMWSTABLE, * Only
MASS. � Public Health Division
rfDPolp'�A Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT QUESTIONNAIRE
1. General Information:
Address: 63 Knotty Pine Lane, Centerville Map 191 Parcel 075
Name: Stephanie Blaisdell Phone: 508-778-0884
2. How many bedrooms exist on your property now? 3
Are you planning to add any bedrooms? No
2a. Please include a copy of your floor plans for the entire property.
3. Is the dwelling connected to public sewer? YES or NO
If the dwelling is connected to public sewer, skip questions 4-9 below.
4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public
supply wells?
S. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER?
6. Is a disposal works construction permit on fil YES or NO
6a.If yes, how many bedrooms were approved according to this permit?
Bedrooms. t
C ,-
-n
7. Were any building permits obtained for construction of additional bedrooms? YES,or Na-
8. Is there an engineered septic system plan on file at the Health Division YES or NO u'
r
9. e septic system been inspected by a DEP certified inspector within the last t o years-7
YES or NO
--------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY
TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY
The Public Health Division has no ON ction to bedrooms at this property.
Signed: Date: J 106
Inspector(Print): V-to4vv5�q Mcj ee,
Q;/heal th/wpfiles/amnestyapp
Master Bath
BED ROOM
Living Room
Laundry
Garage
Den
Bath
Dining
Bed Room
0 O Kitchen
CU
63 Knotty Pine Lane
Main House
0'-0 ;r
0'-4'
Bed Room
LI Main House Basement
Closet
0'-7'
26'-6"
Kitchen/dining
Living Room
Bath Eo
9'-2'
1101 cfl I
3' ,-6' 2'- -IV
63 Knotty Pine Lane Cj2�
Apartment
p111E1
oil The Town of Barnstable
Growth Management Department
i63q. �0
367 Main Street, 3rd Floor
Hyannis,MA 02601
Tel:508-862-4678 Fax:508-862-4782
August 8,2008
John C.Klimm,Town Manager
Janet Joakim,Town Council President
Barnstable Town Hall
367 Main Street
Hyannis,MA 02601
Re: Stephanie A. Blaisdell- 63 Knotty Pine Lane, Centerville MA; one-bedroom accessory
unit lower level of principal dwelling. Unit is currently occupied.
Re:Judith A. Cardiges - 51 Chase St, Hyannis MA; one-bedroom accessory unit upper level
of principal dwelling. Unit is currently unoccupied.
Re: Roger M. Gahnem-323 South St, Hyannis MA;two-bedroom accessory unit upper level
of principal dwelling. Unit currently occupied
Re: Douglas C. Sipiora- 16 Huckins Neck Rd St, Centerville MA;two-bedroom accessory
unit upper level of principal dwelling. Unit is currently unoccupied.
This letter is to inform you that the Accessory Affordable Apartment (Amnesty) Progra�xm has�n
received four requests for a project eligibility letters under the Community Development-Block;
Grant (GDBG) Fund and under Article II of Chapter Nine of the Code of the Town=of Barnstable
and the criteria for the Local Chapter 40B Program.
tV �
This office is reviewing the requests. If the Town has any comments on the project, pl ase forovard
them to me so that they can be addressed in the site approval letter. This letter gives u official
notice of our receipt of the above application(s). We will issue a decision as to the acc ptability of
the sites and the consistency of this development within the guidelines of CDBG.
Sincerely,
Cindy Dabkows
Affordable Accessory Apartment Coordinator
Growth Management Department
cc: Building Division
Health Division
01 _2m
RtW R OD _
TOWN OF BARNSTABLE
LOCATION. :: .
SEWAGE
VILLAGE Ile
ASSESSOR'S MAP & LOT-/ -7
INSTALLER'S NAME&PHONE NO. C. 1-24
SEPTIC TANK CAPACITY 100
LEACHING FACILITY: (type) AG (size):
NO. OF BEDROOMS
:BUILDER OR:OWNER
PERMIT DATE: COMPLIANCE DATE: V
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bott m.of Leaching aching Facility Feet
Private Water Supply Well and Leaching F.ap lit
i y,,,(Ifany wells exist
on site or,within 200:fee-fbfleachi facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
n
uibiishd b Y oea
lea
ching facility)
Reefw
..............
0. -W
_Q
r
.13
1Y
0
0 b9l 37Xdl
7"d
y! No. Fee
66 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Ztpprication for �Diopoga[ 6p.5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Nam r
e s and Tel.No.
Assessor's Map/Parcel ��
Le-17iivi Ze 10
Installer's Name,Address,and fiT 1.No. Designer's Name,Address and Tel.No.
C5'oss) ��sys-
Ila t3ox
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 O gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) S . 5.
o"C S7 .e
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued hi Board of Health.
Signed G `Date
Application Approved 4 Date Ante l; 216& f
Application Di$approved for the following reasons
Permit No. ,0�gr7 , Date Issued V
4
No. !v fJ/f/1/ 7�!f� Fee '5
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Rppficatton for Zigonl 6p!5temc Construction Permit .r
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. "> Owner's Name,Address and Tel.No.
1, l� �, •7 7`/• /i, r L ,, r .��,.. /3q�L/n�!i
Assessor's Map/Parcel �
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
).�. !�<. too .• ��'oFs) `17h-9S�S"
Type of Building: I
Dwelling No.of Bedroomas 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 -` gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date,,' r
Title {,114_ylll*"-e,
_s Size of Septic Tank Type of S.A.S.
Description of Soil
r�
� 1
Nature of Repairs or Alterations(Answer when applicable)_� S <,/� n� S/a S
/G l:f �1 vim,/a rf c✓1 57��P
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance'of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued Mhi Board of Health. -
Signed & Date 4:5� '
Application Approved by ,�, Date ��.
Application Disapproved for the following reasons
Permit No. 2e,0 1 e-e- Date Issued
——— -- ——— ——--———--————— ————— ———
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Comphance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( )
Abandoned( )by 1. /1�1 //�
at /'3 /? r has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction PeLwiu't I Tda/" dated A, Z a
Installer 1 C /7, Designer
The issuance of t 's perrru shall not be construed as a guarantee that the system-will function aesigned.
Date i`' , n Inspector sar,?it
-------------------
No. C�_, Q � ��-�- /�— . Fee _
r THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mt5po5ar *p5tem Con.5trurtton Vertnit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at 1! %- ,e Z h /r. fr r vs Ile
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of/this
. it.
Date: f,W,— �'!s T5 / Approvedlf}�--� � �A.l�•e/�
TOWN OF BARNSTABLE
LOCATION SEWAGE aO�I—36y
VILLAGE ASSESSOR'S MAP & LOT I9--G7S�
INSTALLER'S NAME&PHONE NO. C• 4 lf0
SEPTIC TANK CAPACITY %000S - �k,'s/�g
LEACHING FACILITY: (type) /4� Z "lf�c�D�S (size)
NO. OF BEDROOMS 7
BUILDER OR OWNER
PERMIT DATE: G-/a`O I COMPLIANCE DATE: b Z U r U ,
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
r y
�� A !3
I
91 9 75�
1/6199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that-the application for disposal works
construction permit signed by me dated G -/a- , concerning the
property located at o�- 3 `%� P all of the
J
following criteria:
/ This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
/• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed ;
�• There are no variances requested or needed.
�• The bottom of.the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation.[Adjust the groundwater table using the Frimptor method when
applicable]
/• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
.Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) le;411
B) G.W.Elevation 33+the MAX.High G.W.Adjustment. - 33
DIFFERENCE BETWEEN A and B ✓' 3
SIGNED: DATE: g� -AZ-0
[Please Skew<proposed plan of system on back].
NOTICE
Based upon the above information,a repair permit will be issued for_3 bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
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