HomeMy WebLinkAbout0126 LAKESIDE DRIVE EAST - Health 126 Lakeside Drive East, Centerville
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M1 Maureen O'Brien y"
126 Lakeside Drive East
Centerville, MA 02632
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' Maureen O'Brien
1126 Lakeside Drive East
i Centerville, MA 02632 3. Service Type
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Town of Barnstable
Public Health Division
200 Main Streety
Hyannis, MA 02601
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Town of Barnstable Barnstable
OF THE&0,
� Regulatory Services Department A&ftedcaC
BARNS-,TABLE,MASS. Ck• public Health Division m
9�ArEn MA't �� 2007
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304. Thomas A.McKean,CHO
CERTIFIED MAIL# 7006 0810 0000 3524 6888
October 14, 2012
Maureen O'Brien
126 Lakeside Drive East
Centerville, MA 02632
The septic system located 126 Lakeside Drive East, Centerville, MA was last
inspected on 10/9/2012 by James D. Sears, a certified septic inspector for the State of
Massachusetts. The Health Division has determined that the system "Conditionally
Passed".
0 Distribution-box needs to be replaced
You are ordered to repair or replace the septic system within Two (2) years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
�]Lc
R OF TH BOARD OF HEALTH
ean, R.S.
Agent of the Board of Health
Q:\SEPTIC\conditionally passed\126 Lakeside Dr East Cent.doc
• ` Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Nam
information is required for every Centerville MA 02632 10-9-12
"UIV
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form.inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:when
filling out forms A. general Informon ati �
ZH OFrMn NA
on the computer, �.�`�t��.........9;SSgc
use only the tab r�
key to move your 1. Inspector
cursor-do not
use the return pe J A M E S SEARS GR,c
James D. Sears ( ` O -o:
_�;
key. Name of Inspector
Ca ewide Enterprises, LLC °FRTIF�`�°�o��
Company Name �'1/i 5 I N.SP ,```WZ
153 Commercial St. '''1rnc1mn11111 "`�•
Company Address
r Mashpee MA 02649
............... .....__.........
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that 1 have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000).The system,
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10-9-12 a
Spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
t5ins•11/10 Title 5 officialLEV:Subsurface Sewage Disposal System,Rego,of,7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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 exfiitration 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
r 126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information required for e is very Centerville MA 02632 10-9-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes(cunt.):
® 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 o replaced ❑ Y ❑ N ❑ ND(Explain below):
Need to replace D Box
❑ 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•11110 Tdfe 5.official inspection Form:Subsurface
Searage Disposal System•Fage 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�f 126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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
❑ z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in aawpW is less than 6"below invert or available volume is less
than-%day flow
t5ft-11No Title 5 Offiaal tnspecion Fomf:.StMur[ace Sewage Dispose!System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r' 126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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 11 of a public water supply well
If you have answered"yes"to any question in Section €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.
t5hs-11110 TWO 5 Offida!hspacbm Farm:SubsLafaZe She Disposed.System-Page,5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner owner's Narne
information is required for every Centerville MA 02632 10-9-12
page. CityRown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as 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 Meld(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NA Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•11110 Tide 5 MUM 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
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal poly tank D Box and four inflltrator's
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes 0 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 ears usage 2010-76'000Gal
g { Y g {gPd))' 2011-62'000Gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commerciailindustrial 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-11110 TiUe5.Offraal hspGcbm Form:.Subsurfaee.Sawap Disposal.System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 2011
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/Altemative 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
I
Commonwealth of Massachusett
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. CitylTown state Zip Code Date of inspection
D. System Information (cunt.)
Approximate age of all components,date installed(if known)and source of information:
1995 Permit # 95-330
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40
Septic Tank(locate on site plan):
Depth below grade: 10"feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ® polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 Gal Poly
Sludge depth:
2m
t5ins-11110 Tits 5 Official 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
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
O„
Scum thickness
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
1 i3"
How were dimensions determined? Asbuilt-Tape
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.):
Tank at working level, 32"cement cover on outlet, outlet Tee, No sign of overloading
Grease Trap(locate on site plan):
I
Depth below grade: feet
Material of construction:
❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from tap 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
•I I110 Tille 5 artxia+Inspection Form:subsurface.sewage Disposal system-Page 1t)of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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-i 911D Title 5 Offrcial tns on F":.SubsuAaw Sewage Disposal System-Pap i 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is
required for every Centerville MA 02632 10-9-12
page. citylrown state Zip Code Date of Inspection
D. System Information (cunt.)
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.):
D Box is 16"x16"-1'below grade w/one line out,cover and wail's are gone. need to replace D Box
Pump Chamber locate on site plan):
( P )
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:
15ft•f 1f1.0 TW8 5 OftzJ ftPech0n Fwm:Submfffaw Se wap Disposal.System•PW 12 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information
required for every Centerville MA 02632 10-9-12
page. City/town state Zip Code Date of Inspection
D. System Information (cons.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
Cl leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation,etc.):
Leaching is four infiltrators. camera out, no sign of over loading or solid carry over,
prob.above and beside chambers, no sign of over loading
Cesspool's(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 11110 Title 5 Official kq)eC ion Forte:Subs AWO.SevMe Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
iequire tion is required for every Centerville MA 02632 10-9-12
page. cityrrown 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$Of oral Inspection form:Subsuface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen OBrien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cons.).
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
II�
Oil
A oP�A2 8
spe
5-7
13-1 - .5-1/G
4
/3-3 G3CL
t5ins-11r10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is required for every Centerville MA 02632 10-9-12
page. cityrrown 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. 20'+
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
0 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:
Area and lot high
Before Filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•1111 a Title 5 Official irmpeclion 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
126 Lakeside Drive East
Property Address
Maureen O'Brien
Owner Owner's Name
information is
required for every Centerville MA 02632 10-9-12
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Z 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
t5ins-11/1,0 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 17 of 17
No. 0 a Fee O G
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS S
Zipplitation for Misp08al 6pstem ConstCULtion Vermlt
Application for a Permit to Construct( ) Repair(V Upgrade( ) Abandon( ) ❑Complete System individual Components
Location Address or Lot No. 1 �A 3' �,v OwnerName,Address,,aan�d-Tel.No.
Assessor's Map/Parcel '.2� f 0 6-Le, ID,, .
Installer's Name,Address,and Tel.No. 56,g 8 77 Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms aa Lot Size iq/ A sq.ft. Garbage Grinder( )
Other Type of Building OP-5'A No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
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)_Ke 4x
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sign Date
Application Approved by Date oIf
Application Disapproved by Date
for the following reasons
Permit No. r)-0 ( � 3 Date Issued
�t
No. 0 U Fee / G G
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION"=TOWN OF BARNSTABLE, MASSACHUSETTS; S
Zipplicatlon for bisposar &pstem Construction Vera mit—,
Application for a Permit to Construct( ). Repaii Ov/ Upgrade( ) Abandon( ) ❑Complete System v Individual Components
Location Address or Lot No. I A Owner's Name,Address,and Tel.No.s09�`7'79
Assessor's Map/Parcel 34� � � v 1 LLB �i�,�,��1
Installer's Name,Address,and Tel.No. ,4;gi F V77 Designer's Name,Address,and Tel.No.
Type of Building: 1
Dwelling No.of Bedrooms Lot Size AW A sq.ft. Garbage Grinder( )
Other Type of Building _IZ2_5 Ae__iW No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title 1
Size of Septic Tank Type of S.A.S..
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: ," {
Agreement: i
L
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
,,
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed / V Date
Application Approved by ^ Date
Application Disapproved by Date
for the following reasons
Permit No. d 6 ( � V 3 0 Date Issued d / -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(v) Upgraded( )
Abandoned( )by Ca pcL"'�h
at �'�l„ �CR-$A( Cam- F—, C�' y l w-4has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. d l - Z 0 dated l bw
„J
r
Installer C0-Psz W k Da_ Designer
#bedrooms Approved design flo} yU Xgpd
The issuance of this�ermit shall not be construed as a guarantee that the system will function as design/fed. (�
Date Inspector �, i1n1 LLD 2 S
----.---- ------------------,:.-_----.---:- ------- ----------------------- ----------.-----------.---------f
No. a Fee /uG
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction 3permit
Permission is hereby granted to Construct ) Repair lV ) Upgrade( ) Abandon( )
System located at N::,lo LoJ4t3 t X¢-
t
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
}
Provided:Constructio must be completed within three years of the date of this permi(7)
Date l D �,,I I Approved by V L
No. 'awl r. � � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for aitpool *pttem Couttructiou Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) El Complete System El Individual Components
Location Address or Lot No. 12� L 14 k-$ `� 0VG� ChT Owner's Name,Address,and Tel.No.
-ram /`1Av/t�G-!-N e`�/L,✓,.v
Assessor's Map/Parcel C/ /Q LA Qr_ / C 41��vlY6-AA„
43i.1
Installer's Nam eh Addrg ss,and Te.No. Designer's Name,Address and Tel.No.
Cl� WIbr- 1 1 2R1S✓46
53 Comm
Type of Building: t
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
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) T Avk AjmI3 %/- —
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this B f Health. ( /
Signed Date
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. PO XG Date Issued l o
—_-------- _ _---------------------------
r (( /
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIppYication for Dioozar *proem Construction Vermit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 6 L A"5 `-Q t->r'164 1EYhT
Owner's Name,Address,and Tel.No.
. Assessor's Map/Parcel /`1A(oURLc1:_�A N1 `�eI('I_�-
C_.fi%&Lt/►LI ,^jl
i `—
Installer's Name,Add r ss,and Tel.No. Designer's Name,Address and Tel.No.
�i'vTLrZ-PRE 5!5
S 3 Col�tp�l ,
Type of Building: £: j
r
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
7 Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of�,sheets i I Revision Date
Title , E
Size of Septic Tank Type of S.A.S.
Description of Soil
IQ aq
Nature of Repairs or Alterations(Answer when applicable) G/^,� j+j b )c�;' 7y j/1 1V�C klc j6&
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 Environmentdl Code and not^to place the system in operation until a Certificate of
Compliance has been issued by this B and=.f Health.
i
Signed Date -L O I
Application Approved by J 1 DateTj_
Application�isapproved by: Date r
for the following reasons
Permit No. Date Issued !o`
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
1 �
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( )
Abandoned( )by 0f . Lo 1
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit`No. �2D(! —136 dated "��q
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall,not beJ construed as a guarantee that the system will function as,designed.
Date �ll { Inspector t ?J'. w _
✓, --. -
1 .—.. No. �U��"�—� ---- — �--.—.— .—.. .—. ---_----.—.---.—. .Fee
THE COMMONWEALTH OF MASSACHUSETTS -
'� PUBLIC HEALTH DIVISION tBARNSTABLE, MASSACHUSETTS
k ; aigoal �&pwm Construction Permit ,
Permission is hereby granted to Const U grade ( ) Abandon ( ) \
System located ata„ -
Wrt�
i, 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 pe��Int.--
Date Approved by
i
2sz ^.loj
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 John Septic
D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (564Govemor ARGEO PAUL CELLUCCILt.Governor SUBSURFACE SEWAGE DISPORT ASYSTEM INSPECTION FORMu��'CERTIFICATION LAkcstDc .love fA� 19g?Property Address: 126 Lvkvlt�4r East Centerville Address of Owner:Date of inspection: 11l8l97 (If difTerent) ,Name of Inspector: John Graci Richard Jean:Box 192 Osterville Ma.026 ,
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X_ Passes This Inspection Is based on criteria defined In Title V
_ Congubmit
sSeS code 310 CMR 16303.My findings are of how the system is
performing at the time of the Inspection.My inspection does
_ Neevaluation By the Local Approving Authority notImpyanywarrantyorguaranteeofthelongevityofthe
Fellsepuesystemand any of Its components useful life.
Inspector's Signature: Date: 1119197
The System Inspector shallpy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no, or not determined(Y, N. or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection V the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04127197)
One Winter Street • Boston,Massachusetts 02108 9 FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 126 Lake Shore Or East Centerville
Owner: Richard Jean:Box 102 Osterville Ma.02655
Date of Inspection:1119197
_ Sewage backup or.breakout or hioh.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Cj 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 the public health, safety and the environment.
1j SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revleed 04n7197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 126 Lake Shore Dr East Centerville
Owner: Richard Jean:Box 102 Osterville Ma.02655
Date of Inspection:1118197
D]SYSTEM FAILS(continued)
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).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed 10 be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 0427)97)
SUBSURFACE SEWAG
E DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 126 Lake Shore Dr East Centerville
Owner: Richard Jean:Box 192 Osterville Ma.02655
Date of Inspection:111E197
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
,c_ _ Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this
inspection.
x — As built plans have been obtained and examined. Note if they are not available with NIA.
x The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is
— — unacceptable)[15.302(3)(b)]
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 126 Lake Shore Or East Centerville
Owner: Richard Jean:Box 192 Osterville Ma.02655
Date of Inspection:1U8197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 0
Garbage grinder(yes or no): Yea
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last two(2)year usage(gpd):
Na
Sump Pump(yes or no): No
Last date of occupancy:9 months ago
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow.0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nla
Last date of occupancy: nla
OTHER:(Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last year.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nla
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components.date installed(if known)and source information:
April 19%
Sewage odors detected when arriving at the site:(yes or no) No
(revised 04127)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 126 Lake Shore Dr East Centerville
Owner: Richard Jean:Box 192 Osterville Ma 02655
Date of Inspection:1118197
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 6"
Material of construction:_concreate_m eta l_FRP_Polyethylene—other(explain)
If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: 1.10'VI-15'7"W5'e"Plastictank
Sludge depth:1"
Distance from top of sludge to bottom of outlet tee or baffle: 2e•'
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:o
How dimensions were determined: Measured
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
Septie tank and all components ere structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rva
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle.rda
Distance from bottom of scum to bottom of outlet tee or baffle: rda
Date of last pumping;,,.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2'
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line?ow^
Diameter: 4"
gvemments: (conditions of joints, venting,evidence of leakage, etc.)
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 125 Lake Shore Dr East Centerville
Owner: Richard Jean:Box 192 Osterville Ma.02655
Date of Inspection:11r9197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rva
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nfa
Capacity: We gallons
Design flow: nfa gallons/day
Alarm levei:_nfa Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nfa
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: Liquid levelwilhbottomarpipe
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
The Dbox Is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Yea
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
nfa
(revised WNW)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 126 Lake Shore Dr East Centerville
Owner: Richard Jean:Box 102 Osterville Ma.02655
Date of Inspection:1118197
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
We
Type:
leaching pits, number: We
leaching chambers, number:a'ehembers
leaching galleries, number: We
leaching trenches, number,length: nla
leaching fields,number, dimensions:rda
overflow cesspool, number:rda
Alternate system: rda Name of Technology:_rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Sas Is functioning properly.
CESSPOOLS:
(locate on site plan)
Number and configuration: We
Depth-top of liquid to inlet invert: rda
Depth of solids layer: nla
Depth of scum layer: rda
Dimensions of cesspool: nla
Materials of construction: rda
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
PRIVY:
(locate on site plan)
Materials of construction: nla Dimensions: rda
Depth of solids: nla
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
Ne
(revised 04127)9T)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
126 Lake Shore Dr East Centerville
Richard Jean:Box 192 Osterville Ma.02655
1118197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
1 A(
[A
AA q S
hb Ti
A( T �
Lob
�. b3
Page ! of 10
(revleed 04)27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
126 Lake Shore Dr East Centerville
Richard Jean:Box 192 Osterville Ma.02655
1 tf8f97
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be Completed)
USGS Maps and Chots .
page 10 of 30
(revised 0027187)
TOWN OF BARNSTABLE
LOCATION , P- (, -,> ,�k �-- SEWAGE
VILLAGE y, //�� ASSESSOR'S MAP & LOT4�7z:�� �
INSTALLER'S NAME 6a PHONE NO. ?0� S 6 w- 1 7 5""`?-7 7
SEPTIC TANK CAPACITY / el y
LEACHING FACILITY:(type) Ll 7 (size) C- 3 V
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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ASSESSORS MAP NO:_
PARCEL NO- �I�
No...C>r-- ^. 30 . 00
� .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diopoottl Worko Ton,6trnrtion lirrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
l..2.6...Lakeside....E? Cer� erY ll.................. ....•--------•-•------•••--------•-•-•---------------------------•--------------•----•---•---•----
- .. ..
John Tyburski eatio„-Address 7 Spring House Ke'Hamden MA 01036
......................--.......................................................................... •-•---------------------••---•-•---------•-----•-•••-•-----------•------------. ....
Owner Address
a W._E.-- Robinson---Septic.... ery ce--••------••-• P_,0......Box__.1.089-...Cknter. ille---MA..................
Installer Address
Type of Building 3 Size Lot............................Sq. feet
Dwelling—No. of Bedrooms......................_...._._..._--.-_--.Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a'' Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity---- .......gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit._..--------_---.--. Depth to ground water........................
a ...............................................................•----•-•---------••-----•••----------.........................................................
0 Description of Soil----------------sand----------------------------------------------------------
V ------------------------------------------------••--•----------•-•-•-••----------...----------------------•-•----------••-----------•••-•-------•-•---...••---------•--•••--•-••-....---•--•...........
W
------ -----------------------------------------------------------------------------------------------------------------------------------------------------•-•----•------
U Natur Repairs or Alterations—Answer when applicable...--Pump & fill Old cesspools, install
1 00 gal septic tank_,____d-box_._&___pre
_cast at.Qnezacked.-leachf.i.eld......................
--
Agr�Kent:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed .................................... .. ..... ............................. . ................................:......
Dare
Application Approved By ........... ............................. .�. u" 90
Date
Application Disapproved for the following reasons- ------------- ---- --------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- ........................................
_ q. Date
Permit No. ---------- cJ " ----------------- Issued �� 1 Q^f ...................
Dace
F>s.... 0:.00.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. TOWN OF BARNSTABLE
Appliratiou for Di-nVagal Works Tomitrurtinn rrruttt
> Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
....3 26 Lakeside E. Centerv_ 11e................. p ....
....................d.--...E..•...••---
John Tyburski°Cat.°"-Address 7 Spring House Ad'otI�amden MA 01036
.................._.......................................................................... ---------•--------------------._......-••....-••---------..........-•-•-----•-- ...... -.....
Owner Address
a "I.E.-..Rob inson...Septic...Service------------- P-O...... ox----1.089__.Ccnterviiie... k...
--.._...--••---
Installer Address
UType of Building 3 Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...................................._......Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------....... Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------- ------------------------------•---•-----------•..............
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity......._....gallons Length---------------- Width................ Diameter..._ .......... Depth................
x Disposal Trench—No. .................... Width.................... Total Length..........__.....-.- Total leaching area....................sq. ft.
Seepage Pit No-------------_----- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( . ) Dosing tank ( )
Percolation Test Results Performed by.......-.................................................................. Date......................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water...._........._.........
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
9 •----•-•-•-•-----------------------•-----•-•------•----•-•----------•---------......-------•--•-•--•.........................................................
0 Description of Soil.................Saxld.....................................................................
V .......................................••--....------•-•------------•-•-•----.....---------•---•-----•------------------•----•---------------•------------••••-------------....-•--••-------•---•--•---•.
W
------------------------------------------------------------------------------- ----------------•------...-----------------.---- -------•-.....--------•-••--•-•----••-•--•--------•----•......---•-
U Naturgod Repairs or Alterations—Answer when applicable.-.-Pump & fill old cesspools, install.
!;to 0� oa....septic iranl�, d-box precaS.t._stone9ACk d I-eack f.ie�. ..................
Ag�re�ment:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed .... ..................... ...... ......................... . ........ .................................
Dace
Application Approved BY -------- - �2 vow .. .... ..f. ...-:.��.j
. �............................................................................ Dace
Application Disapproved for the following reasons: - ../ ....................................... ......... ........ . -.. ....... -- ----
......................................................................................................... ............................................................................................... ........................................
Date
Permit No. c
- .........t..................... Issued ----------- )- ...�. ----------
Date "-�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:TOWN OF BARNSTABLE
(ItTertifirate of Q-111ontylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X )a
W.E. Robinson._Sept -G. .Serviee--------------------------------....------------------------------------------- ----------------- ----------------------
bY .....
tostauet
126 Lakeside E. Centerville
at ........ ..........................................................------------------------------------------------ -------....----------...------ ---....---------.......---------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ------.q.-tj". .. .__. __ dated .-------......................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
��
DATE . < ........ .........�`"''' ,��� - Inspector .. _ �. . .x..��Z :-�
---------------------- --- ---------------------------.---_— --I:fl-f------
Tybur.ski THE COMMONWEALTH OF MASSACHUSETTS )0 7
BOARD OF HEALTH
�`�^ � TOWN OF BARNSTABLE 30. 00
NO.-�r-•�•••-.:.� FEE........................
�i�pn�ttl urk� �un�tr�rtilan �.ermit
W.E. Robinson Se tic Service
Permission is hereby granted- -•--._..... -- •. --•---------- ---- ---- •. ---------------
to Construct � ) or Repair ( X) an Individual Sewage Disposal System
i26 akeside E. Centeryil_ie---••-------------------- ----------------------....----...------------------------------------.----•-------.
at No.. ...••-•-----•---•-- ._... _
Street
as shown on the application for Disposal Works Construction Permit No.75_ _=.3ll Dated.......J.-...(�_�.-•Q
r DATE...................Q2- -�F =0 `� -•------------------------------
Board of Health
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
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