HomeMy WebLinkAbout0400 LAKESIDE DRIVE WEST - Health 400 Lakeside Drive West
A= 232—023
Centerville
i
08 14 11:188 P.
Commonwealth of Massachusetts
IJTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Z
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is
required for every Centerville MA 02632 1-4-14
page. CityfTown 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.
Im out A.t:When A General Information
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use only the tab key to move your 1. Inspector:
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cursor-do not James D.Sears JAMES :m
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CapewideEnterprises,LLC
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Company Name ��•.• TI`R F�`'G�o`\�
153 Commercial St. ''o.���Hr ttNnrP ���\\\``
. � Company Address
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this adds ss and tf bt the-i
information reported below is true, accurate and complete as of the time of th spec6on:I'he inV is".4ection
was performed based on my training and experience in the proper function anO'rnaintenatice of on site
sewage disposal systems, I am a DEP approved system inspector pursuant to Section`95 340 of
Title 5(310 CMR 16.000).The system:
r
• �3 � �"MYY
Passes
❑ Conditionally Passes ❑ ;Fails �,a,;
❑ Needs Further Evaluation by the Local Approving Authority ,
1-6-14
pectoes Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
v 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.
15ins-W13 Title 5 ORiclal rnsp flFcrr:Subsurface Se Dis sal System•Page 1 of 17
ri
Jan 08 14 11:19a p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
" information is required for every Centerville MA 02632 1-4-14
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:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 3.10 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):
i
t5ins"3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
fan 08 1411:19a p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required:for every Centerville MA 02632 1.4--14
page. City/Town state Zip Code Date of Inspedlon
B. Certification (coat.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.);
❑ Observation of sewage.backup or break Dut 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):
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
t5ns-3/13 Title 5 Official Inspeclian Fornc Subsurface Sewage Disposal SWarn-Pape 3 of 17
I plan 08 14 11:19a p.4
Commonwealth of Massachusetts
Title 5 Official _Inspection Form
^ a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is
required for every Centerville MA 02632 1-4-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in end is less than 6"below invert or available volume is less
than 2 day flow �;TS
t51ns•3113
Title 5 Offidal Inspection forth:Subsurface sewage Olsposat System-Pape 4 of 17
del an 08 14 11:52a p.1
■
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owners Name
i tion s
required For every Centerville MA 02632 1-4-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
[❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ' ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
15ire-3113 rifle 5 Official inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Jan 08;1'4 11:52a p.2,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M_ /� 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
require Eifo is Centerville MA 02632 1-4-14
regliired for every
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
® ❑ 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?
4 ❑ ® 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
n DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
l5in3•3113 We 5 Official h3peclion Form:Subsurlece Sewage Disposal System•Page 6 cl 17
,Jan 08 1411:53a p.3
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 1-4-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal.Tank D. Box and two pit's.
Number of current residents: na
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(include laundry system inspection D Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)): 213-15,,00 Gal s
2013-15,000 Gal s
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Canons 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-3113 Title 5 Of5dal Inspection Form Subsurface Sewage Disposal System•Page 7 of 17
Jan 08 14 11:53a p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is Centerville MA 02632 1-4-14
required for every
page. City/Town Stale 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:
12-18-13
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):
15lns•3113 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System•Page 8 of 17
Jan 08 14 11:53a p.5
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
ynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632
page. City/Town State Zip Code pate of Inspection
D. System Information (cont.)
Approximate age of all components,date installed (if known)and source of information:
1982
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: _ fee
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.):
4" PVC SCH 40'.
Septic Tank (locate on site plan):
Depth below grade: 4
feet
Material of construction:
®concrete %` ❑ metal-,. ❑fiberglass ❑ polyethylene ❑ other(explain)
i
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
a Dimensions: 1600 Gal. Precast
- Sludge depth: No Sludge
t5ins•3113 Title 5 Official Inspection Form:Subsudece Sewage Disposal System.Page 9 of 17
Jan 08 14 1 1:54a p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 1-4-14
page. Cityrrown 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 No Sludge
Scum thickness No Scum.
Distance from top of scum to top of outlet tee or baffle No Scum
Distance from bottom of scum to bottom of outlet tee or baffle No Scum
How were dimensions determined? Asbuilt-Tape- Past Report
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.Tank and cover's at 4" below grade. In and out let tees_ No sign of
leakage. Note: Tank has been resealed 12-18-13.
y Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3113 - Title 5 Official In spection Form:Subsurface Sewage Disposal System-Page'10 of 17
,Jan 08 14 11:54a p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 1-4-14
page. Cityrrown 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•3113 TWO 5 Official Inspection Form:Subsurface Sawage Disposal System-Page 11 of 17
Jan 0$ 14 11:54a p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
> information is Centerville MA 02632 1.4-14
required for every
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 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"x21"-T below grade. Box is clean and solid w/two line's out.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes 0 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.
Soil Absorption System(SAS) (locate on site plan, excavation not required)
If SAS not located, explain why:
[Sins.3113 T&le 5 OflcW Inspection Form:Subsurface Sewmge Disposal System•Page 12 of 17 .
Jan 08 14 11:55a p.9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 1-4-14
page. City/Town State Zip Code Dale of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number.
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two precast pits. Both pits are 1' below grade. Pits are dry, wall's are clean like
new-
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
15im•3f 13 Tdle 5 Official Inspection Forth-Subsurface Sewage Disposal System-Page 13 of 17
•Jan 0$ 1411:55a p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 1-4-14
page. CitylTown 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.):
15ins.M3 Title 5 Oficial In
spection Form:Substrraoe Sewage Disposal System•Page'14 of 17
elan 08 1411:55a p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 1-4-14
page. Cityrrown 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
-D pC
s
5:1 =ao h
El 3
33'
38=�
3-s= s/'
. . I
t5ins•3113 Tine 5 Official Ins
pection Fame Subsurface Sewage Disposal 9ystam Page 15 of 17
Jan 08 14 11:56a p.12
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner. . Owner's Name
information is Centerville MA 02632 I A-14
required for every
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells N0
Estimated depth to high ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
9-16-8
If checked, date of design plan reviewed: Date 3
D
❑ 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:
T.H. Design on file 9-16-83. No G.W.at 10'. Bottom of pit's at 7'. Bottom of pit's 3'above T.H. lot
high.
Before filing this inspection Report, please see Report Completeness Checklist on next page.,
15ins"3113 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 16 of 17
,Jan 08 14 11:56a p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owners Name
information is Centerville MA 02632 1-4-14
required for every
page. CRylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official fispecWn Forni:SubsWam Sewage Disposal System•page 17 of 17
.o
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UFFICIAL USE
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so that we can return the card to you. B. Received by(Printed Name) C. Da of Del' ery
■ Attach this card to the back of the.mailpiece,
or on the front if space permits. ` X!f- Y-
D. Is delivery address different from item i? ❑Yes
1 Article Addressed to: If YES.enter delivery address below ❑ No
I
Y.A
Lynn--fl Ptak,"TR
112 Steno Ridge !
3. Service Type
'Rocky Hill, CT 06067 ❑Certified Mail ❑Express Mail
Y
F ❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery.?(Extra Fee) O Yes
2.Article Number ? ' �j tom. ,—!0000—
(Transfer from service label) Ft I im7 012 -1010 2851
1333
PS Form 3811. February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED,-STATES POSTAL,SERVICE, First-Class Mail
I Postage&Fees Paid
` USPS
I` Permit.No.G-10
Sender: Please print your name, address, and ZIP+4 in this box•
I�
Town of Barnstable
Public Health Division
200 Main Street
( Hyannis, MA 02601
lilh:l;sii;t111;1i1i°1i.�11111;1;'I�flil;li}tli:�i�I�llliii�;I};I
�'THE r�
Town of Barnstable Barnstable
Regulatory Services Department 'edcaCft
EA.RNSfABLE,
MAC Public Health Division
200 Main Street,Hyannis MA 02601 2007 .
Office: 508-8624644 Richard Scali,Interim Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2851`1333
November 25, 2013
Lynn H Ptak, TR
112 Steno Ridge
Rocky Hill, CT 06067
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 400 Lakeside Drive West, Centerville, MA was last
inspected on 10/30/2013 by Matthew Gilroy, a certified septic inspector for the State of
Massachusetts. `
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00)�due to the following:
• The septic tank is leaking and must be replaced.
• It is strongly recommended that either the garbage disposal be removed
or a new septic system be designed to accommodate the garbage disposal.
.You are ordered to repair or replace the septic system within Sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER O HE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\400 Lakeside Dr cent Nov 2013.doc
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak:
-Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
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,
use only the tab 1. Inspector:
-
key to move your
cursor-do not Matthew Gilfoy
I �
use the return
key. Name of Inspector
B&B Excavation, Inc:
Company Name
14 Teaberry Lane - - -
Company Address
Forestdale MA _ 02644
City/Town State Zip Code
(508)477-0653 S113640
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
❑ Passes Z Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/28/13
Inspector's Date
The system inspector all 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' nspection 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•3/1& Title 5 Official Inspe lion�'rm:Subsurface Sewage Disposal System Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N FIND (Explain below):
At time of inspection septic tank is leaking and must be replaced.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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 (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
�M 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
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
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 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
°M 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
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
El ® Pumping information was provided by the owner, occupant, or Board of Health
❑ Z 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
El ® 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): 630
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M s 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Feb 2013
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
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:
1982
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1'3"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: > 10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appears to be in working condition. No sign of leakage
Septic Tank(locate on site plan):
8"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No
Dimensions: 1500 gallon
Sludge depth: no sludge
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
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 no sludge
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle no scum
Distance from bottom of scum to bottom of outlet tee or baffle no scum
How were dimensions determined? k scour stick
Comments (on pumping recommendations, inlet d outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence oreakage, etc.):
At time of inspection septic tank is leaking and must be replaced.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
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.):
t
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
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 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box appears to be structurally sound. No sign of 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.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching is dry and appears to be in working order. No signs of hydraulic failure.
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
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M .'v 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
page. CityfTown 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
ID002
A Et AP-A(I
6
O ® 0
AI= 3�1 "
A2- 3g '
A3= -�421C
A�-J 33` 6 't
A5= .514 '
-81 :720 ,
B226 16 it
_93= 32`
'B4- 3g'6
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
. Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: > 120"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: 9/16/83
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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
A � Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 400 Lakeside Drive West
Property Address
Lynn Ptak
Owner Owner's Name
information is required for every Centerville MA 02632 10/24/13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Septic System Page 1 of 1
McKean, Thomas
From: Lynn Ptak[lynnptak@cox.net]
Sent: Wednesday, December 11, 2013 1:26 PM
To: McKean, Thomas
Subject: RE: Septic System
Mr. McKean,
As we discussed this morning, our house at,,-400°Lakeside'Drive Westin Centervillejs unoccupied, and we are
attempting to determine a more precise answer as to whether our septic tank can be repaired or will need to be
replaced. Could you please provide us with an additional sixty days to accomplish this? I would hope that it will
not be needed, but with bad weather and holidays approaching, I would not want to risk being in non-
compliance with your letter of November 25th.
t
Thank You,
Lynn &Stanley Ptak
From: McKean, Thomas [ma ilto:Thomas.McKean @town.barnstable.ma.us]
Sent: Wednesday, December 11, 2013 9:11 AM
To: lynnptak@cox.net
Subject: Septic System
•
12/11/2013
9
LO CATION H0050* SEW-AGE PERMIT NO.
15 LAx e 0 reel c 8Y-73
VILLAGE 1
INS_TA LLER'S NAME: i ADDRESS
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81U,11DE R OR OWNER
DA; T E PERMIT ISSU E:D
D-ATE COMPLIANCE , ISSUED -713 1 85
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH.
..................... . ..............OF..............................................
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at: +CuD
Alea
4es; . ..... ...........•------
Lo atioq- or Lot No.
.� --- Owner �Ad�es � �' ................
TTa�CC��
4t ,
( Q l6:v,,
w -----.`.�41.a:���............................ ......
..1....4Pse7�► r....
a Installer Address
T e of Building Size Lot�Z 5.2®....Sq. feet
Dwelling—No. of Bedrooms.._...�................................Expansion Attic ) Garbage Grinder {Ye$
04 Other—Type of Building _________________a.____-_•-. No. of persons-----6__.--__.__.__-____ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..................................
w .Design Flow.........��.......................gallons per person per day. Total daily flow____-_-M-.®.......................gallons.
WSeptic Tank—Liquid capacit/67 allons Length................ Width---------------- Diameter--------------_. Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Depth below inlet. . , .... Total leaching area.6�®...sq. ft.
Seepage Pit No..._�_...______. Diameter._1.�..� ,_.
Z Other Distribution box Dosing tank ( ),
'~ Percolation Test Results Performed by--- .•......................a;.--------------- Date..��*._a� f ct?ez
a
Test Pit No. 1....a......mmutes per inch Depth of Test Pit---`.RO..... Depth to ground water.-� ®....._._..
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
,.. e ..._.. o a ..--------•--•----------•---...._.
Description of Soil.O.-.ram �'4..1..... a ..... °' %'...
�. -----o...------ ....�� �.... ........ s�� 4 !""'�- ���----------•------------------------------------------
w
U Nature of Repairs or Alterations—Answer when applicable_______ ______ ______ .
-------••-------------------•---•--••------••------------------------------------------•------•-••-•----•-----•------------------------------------------------------------------------•-----........._.
Agreement:
The undersigned agrees to install the aforedescrib Indivi Sewage Disposal System in accord ce ith
the provisions of ITLi� 5 of the State Sanitary e r t r agrees not to place
operation until a Certificate of Compliance has b ' s t b ai of
P P
Signed. -• --------•---•• . ---- •....
i
-- -------------------------------
Date
Application Approved By.. ................•--•....... .......:..........•-••------------•- :__ �..
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------•-------------------------....--
.........-•••-••--•----••----•---•-•-•-•...•-------•••---•-•------••--•••----•-••----••----•-••-•----•--•-•----•----•-•--•••••-•••--------------------------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
,owl�
t c2_._
*No. ...._. FEs...... Q-.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 4
.................. OF.................. .................... .............................................
Appliration for Disposal Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct ()o or Repair ( ) an Individual Sewage Disposal'
System at:
Loc�•tionr Qd ess S + ..........
='lam.�. 1 � 1 1t� Dr t c�G€Vc i�i
..
or N
Owner .,. _"7.. .... ... .................._i
a `wylP U4 _��f. J S``�............................. �✓.t�!�. Li Ca 1 W4CI�!Ad&o......
Installer Address _
U Type of B ding _ Size Lot.'? ,. a0....Sq. feet
�. Dwelling—No. of Bedrooms...........................:...........Expansion Attic A) Garbage Grinder pfe)5
`4 Other—Type of Building .............. No. of persons a yp g -------------- p �-•----•---.--._.. Showers ( ) — Cafeteria ( )
dOther.fixtures --------------- ------•---•-------•---•-------•----••-•---•---------•--
W Design Flow.......... *57..................::..gallons per person per day. Total daily flow-------- .....................gallons.
WSeptic Tank—Liquid capacity/1'•- allons Length................ Width................ Diameter................ Depth................
x Disposal Trench No..................... Width.................... Total Length..................... Total leaching area..... ..._...sq. ft.
. Seepage Pit No......K:R.......... Diameter... Depth below inlet �e'� '__. Total leaching area..rQ:72.�'. ..sq. ft.
Z Other Distribution box Qf Dosing tanktt( )
Percolation Test Results Performed by----T�...44 ®5?`......................... Date...Oc-* act 1Rg�
!j ..... -
Test Pit No. 1.....�-----minutes per inch Depth of Test Pit.... Depth to ground water..�...._P_....._-
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------------- ------•----- -.•--•- ----.-----------•----
0 Description of S il.Q-1 '•3 ��__ �P►.W►_ .a _ ��... .�c�i i
ai ... .t k .�O_2eAo.' --- mac. ``�a --------------------------------------------------
w � - _
x •.................
U Nature.of:Repairs or Alterations—Answer when applicable...........................................:................................................... '
------------------------------•----------------------•----------------------•--------------------•--•_--.....---._..........
Agreement
The undersigned agrees.to install _the aforedescribe4 Indivi ewage Disposal System in accord/ a ith ...
the..provisions of TIrnm 5 of the State Sanitary e r agrees not to place
operation until a Certificate of Compliance has b d t b ar o health.
577
Signed•-- ----•- .....................................
Application Approved By •-�--- ----- = -----• ---- 2 e_
1
Application DisaPProved or the followin $'reasons:..........................
------•---•---•• ......... -•---- ............ •.
......................................... ...•-----•-•------.........••--------.......--•--••---••--•---•........-•-•-•-•-•-•------•-------•.....-•----------•---•-••--------- •.•...............
Date
PermitNo......................................................... Issueii_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................................OF..........................
Trrtifiratr of TontpliFaurr
THIS f�_7T_0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by....._.. ,< ..........................................•-••-•--------------•-------.....------------................-----------.......................: ..................
_ � ="-•..Installer �1 /�'
has been installed in accordance with the provisions of TIT F j of The State Sanitary Code as des ribed in the
application for Disposal Works Construction Permit No.....�w" __=
a dated � �'� ` �c �------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F NCTI N SATISFACTORY.
r
DATE..... ..... --- Inspector...---•-•. ...1..J
THE COMMON EALTH OF MASSACHUSETTS
, `' B D OF HEALTH ,
„s"b. —�"" ...............OF .............................. , ..
No... ..........? FEE.�a..............
Disposal Works Tonstrttrtion antit
Permissionis hereby granted..............................................................................................................................................
to Construct (`O or Repair ( ) an Individual Sewage Disposal System
atNo........1.9.•• ...... � �:3d _.. .t.::-----------------------------------•------------------..............................................
Street
as shown on the application for Disposal Works Construction Permit No...........
.......... Dated....... Yy.":'-•---.-....
------------•--•-----------------------------------------------•---.....------...-------•--..............
Board of Health
DATE.................................-..............................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
E.))%5 C Cape Cod Survey Consultants
3261 Main Street/Route 6A Barnstable Village, Massachusetts 02630 (617)362-8133
July 12, 1985
Barnstable Board of Health
Town Hall
Hyannis, MA 02601
RE: Subsurface Sewage Disposal System
Lot 19, Lakeside Drive
Centerville, MA
(Our File No. 03-1525.00 )
Members of the Board:
This letter is to inform you that the subsurface sewage disposal
system has been installed substantially as per plans by Norman
Grossman, P.E. , R.L.S. dated 9/16/83 both in location and
elevation based on an inspection by this firm on July 12, 1985.
However, the proposed grade over the system will have to be raised
one foot to allow for 12" minimum cover.
If there is any questions , please do not hesitate to contact me.
Very truly yours,
BSC/CAPE COD SURVEY CONSULTANTS
G1�8-4
Stephen A. Haas
cc: Peter Daigle & Co.
The BSC Group of Companies Planning Surveying Design Engineering
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