HomeMy WebLinkAbout0062 LONG BEACH ROAD - Health 62 song Beach Road
Centerville
A= 206 -010
c
Commonwealth of Massachusetts �oU- 0-70
Title 5 Official Inspection Form
- Fa, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name /
information is Centerville V Ma 02632 12/22/2020
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 614
on the computer,
use only the tab Chad Hathaway
key to move your Name of Inspector
cursor-do not Hathaway Septic Inspections
use the return key. Company Name
P.O.Box
151
rab Company Address
Forestdale Ma 02644
City/Town State Zip Code
auun 774 274 2581 12866
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
12/22/2020
Inspector's Signature Date
The system inspectors I submit-a copy of this inspection report to the Approving Authority(Board
of Health or DEP)wit 0-days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
cam, Commonwealth of Massachusetts
i - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•� 62 Long Beach Rd
Property Address
Roncone
Owner Owners Name
information is required for every Centerville Ma 02632 12/22/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This inspection is not a guaranteeand applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described components. This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
Information on care and do's and don't's can be found at town health dept or mass.gov
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system,,upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�� as Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is Centerville Ma 02632 12/22/2020
required for every
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
16.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page•3 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Ihspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owners Name
information is required for every Centerville Ma 02632 12/22/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
6-P; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has,the system received normal flows in the previous.two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Y
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: seasonal
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: seasonal
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit r s n p e e t. El Yes ❑ No
I
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: pumped oct. 2020
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: maint.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
i
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy j
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1981. Dbox looks newer
Were sewage odors detected when arriving at the site. El Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.3'
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.):
none
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
1� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2"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:
8'x5' 1000 gal
Sludge depth: 1,,
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
tape and sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tee inlet and concrete baffle outlet. no major decay present.level at bottom of outlet
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑. Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Dbox clear of carry overs. no major decay or leaks. at working level
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
t
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
E
® leaching fields number, dimensions: 12x18
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
probed field no saturation or wet soils
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
t Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y 62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A � QS
� � g
0 �
J�ive�j U 3
b �
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V � 62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 8
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
system is on elevated area of property. shot transit elevations. bottom of field is 4.5'above high
coastal high water line on waterside of property
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.cloc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
62 Long Beach Rd
Property Address
Roncone
Owner Owner's Name
information is required for every Centerville Ma 02632 12/22/2020
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Commonwealth of Massachusetts
.W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector: _
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return ��11
key. Capewide Enterprises,LLC M
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
�qq
certify that I have personally inspected the sewage disposal system at this address and that the c:
information reported below is true, accurate and complete as of the time of the inspection. The--Jnspection
was performed based on my training and experience in the proper function and maintenance gf;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: Co
c
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/02/2007
I n s p or'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.
62 long beach rd.•118/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
- W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
B) System Conditionally Passes:
El One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound-, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that-the tank is less than 20 years old is available.
ND Explain:
J
❑ 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
❑ obstruction is removed
62 long beach rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
.W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments
^M • 62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is.leveled or replaced
ND Explain:
❑ The system required pumping more than-4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
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
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.
62 long beach rd.•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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
El ® 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 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
62 long beach rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
k/
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑' ® 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.
62 long beach rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is Centerville Ma. 02632 8/02/2007
required 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?
® ❑ 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)]
62 long beach rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7M1,
62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x.#of bedrooms): 330
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 2005: 80,000
g ( y g (gpd)): 2006: 32,000
Sump pump? ❑ Yes ❑ No
Last date of occupancy:
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:
Last date of occupancy/use: Date
Other(describe):
62 long beach rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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)
El maintenance
technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
12 long beach rd.•011106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°wM 62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC 20 PVC
® other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
2"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ,❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 8'6"x4'10"x57'
211
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness 0
10.1
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Measured
62 long beach rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every 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.):
Pump tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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):
62 long beach rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
62 long beach rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 18'x12'x1' -
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.Stone in leachfield was dry at
time of inspection.
I
62 long beach rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
62 long beach rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
f
0
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town . State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
I:
F f i
S
62 long beach rd.-08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 15
r
, 1
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
62 Long Beach Rd.
Property Address
Gene McQuade
Owner Owner's Name
information is required for Centerville Ma. 02632 8/02/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
> 5'
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
AS-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used:Gaherty and Miller Model 12[16[94 Ground Water Elevations. Used:USGS Observation Well
Data June 1992. Used:Technical Bulletin 92-000-01 Plate#2 annual ranges of ground water
elevations. Front of property is raised 4'above road.Bottom of Leachfield is 20" down.Dug test
hole at road level encountered ground water at 3'.System has 5' seperation.
62 long beach rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
i
,} 3261 Main Street
Route,6A
Barnstable Village MA
02630
September 5, 1986
Barnstable Conservation Commission
'down Hall
Main Street
Hyannis, MA 02601
RE: Landscaping and Building Demolition 617 362 8133
Lots 62 & 76 Long Beach Poad, Centerville_
(Assessors Map 206 , lots 9 & 10)
(Our file 3-1929 . 01)
Dear Commissioners:
Attached, in accordance with our discussionsof September 3 , 1986
is a Request for Determination of Applicability for Landscaping
and removal of an existing qarage at the above captioned site.
Work proposed includes the followincr tasks :
1) removal of the existingr fence and shrubs along the
property line between the two lots
2) removal of the existing garage and slab on lot #76
3) removal of brick barbaue grills on each lot
4) construction of new latice work fence and hedges along
the proposed easement line between the lots
5) relocation of the two stone driveways
6) additional shrub and lawn plantings as shown on the project
plans.
Although all work proposed is within a 100 yr coastal flood. plain
and on the developed portion of Long Beach, a barrier beach, all
work is within previously altered. and developed areas . No grade
-chancres in excess of }6" are proposed. Demolition materials and
Engineers debris will be removed to an area not subject to regulation under
Surveyors State or Local Wetlands Statues.
4
Scientists Should you have any questions, please do not hesitate to contact
Architects
our office.
Landscaoe Very truly yours,
Architects BSC,/CAPF. COD SURVEY CONSULTFNTS health Dept.
Planners
I qu
Arlene P1. Wilson --= ���
Manager Environmental_ Sciences
AW: rh SEP i,2 19 ,
Cape Cod Survey Consultants
u
y -
Form 1
DEQE FOS No.
(To be provided by DEQE)
OEM
cityfrown_('a tl t P rs 7 i l l P
Commonwealth
s of Massachusetts Applicant Po b e r t Shields Jr.
4
Request for a Determination of Applicability
Massachusetts Wetlands Protection Act, G.L. ,c. 131, §40.
and Town of Barnstable Art, ' 27 ,
1. I,the undersigned,hereby request that the 13a rn s nhl¢
Conservation Commission make a determination as to whether the area,described below,or wprk to be
performed on said area,also described below,Is subject to the jurisdiction of the Wetlands Protection
Act,G.L. c. 131, §40.
2. The area is described as follows.(Use maps or plans,if necessary,to provide a description and the
location of the area subject to this request.)
Lot 9 & lOr. Pssessors Mao 206 CL Ct P 40.113A & 2.9224A)
62 & 76 Long Beach- Rd. Centerville
CSee attached locus plans)
The two abutting lots are on the northerly side of the road
in the developed section of the Barrier Beach Fach. lot
is and has been fully Oeve.loped for some time i4ith a year
round house, septic system utilities, landscaping and
other amenities. Both lots are in a coastal Flood Plain,
3. The work in said area is described below.(Use additional paper,if necessary,to describe the
proposed work.)
Demolition of an existing garage at 476;
. Removal of existing fence and hedge along lot line.
. Relocation of stone. drive. on lot V 6
• Re.location .of_ paved drive on lot 62
• Removal of brick- barb-cue grills on each. lot
• Construction of new fence along easement line
Landscaping approximately as shown on attached landscape plans
• Grade changes in work- areas limited to + 6" of existing grade
to accomod.ate construction of plant beds and driveway grading
1-1
a I
4. The owner(s)of the area,if not the person making this request,has been given written notification of this
request on •(date)
The name(s)and address(es)of the owner(s):
Owner/applicant
Robert Shields Jr.
C/O The Shields Company
132 Airport Poad
Hyannis, MA 02601
5. 1 have filed a complete copy of this request with the appropriate regional office of the Massachusetts
Department of Environmental Quality Engineering on 9/12/8 6 (date)
Northeast Southeast
323 New Boston Street Lakeville Hospital
Woburn,MA 01801 Lakeville,MA 02346
Central Western
5 Grove Street Public Health Center
orcester,MA 01605 University of Massachusetts
Amherst,MA 01003
6. 1 understand that notification of this request will be placed in a local newspaper at my expense in accor-
dance with Section 10.05(3)(b) 1 of the regulations by the Conservation Commission and that I will be
billed accordingly.
Agent: BSC/Cape. Cod ev Consultants
Signature apse
Arlene ^" Wilson
Address 3261 P?ain 'Street Tel. 362-8.133
Barnstable Village, , A 02630_
* Please bill ourne.r for legal advertising
1-2
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N ../'��... `!� t Fps.... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
1,..w...... .................OF.....
Appliratiun for Uispuua1 Workii Tunitrnrtiun ramit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
, —------`=----•----------------------------------•---..--------- .... . vd.. OT..._.�b..._......._. - ..........
Location Address or No.
................G.. �o>z, - �''� -•• P. ......�1'
W Own Y Address
Installer Address
Pq
d Type of Building Size Lot.. ,i..................Sq. feet
Dwelling—No. of Bedrooms... .....................................Expansion Attic (lVa) Garbage Grinder (ives)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ............................ .
W Design Flow......... —-----.._----------------gallons per person pey day. Total daiV flow............................................gallons.
WSeptic Tank—Liquid capacityOd�-..gallons Length__ '6'. Width... .__°.. Diameter---------------- Depth................
x Disposal Trench—No. ../................. Width..12-.......... Total Length....//........ Total leaching area....................sq. ft.
Seepage Pit No-_----------------- iameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( DosingitI/C ( ) I-
`" Percolation Test Results Performed b ._ ! - i9LQ✓ cfONs /6 '�
a Y yet Date-------�..--
Test Pit No. 1..�7...._._minutes per inch Depth of Test Pit...4.1.......... Depth to ground water____ ��_..........
f=, Test Pit No. 2................minutes per inch Depth of Test Pit--- q........... Depth to ground water----�_1�...._....._..____
p4
O Description of Soil.-- ; `1---------�?9 .i 4!1 still..--...----•---•-••------------•= -
U ----•-•----------------- •----/---'-------... ----d--/ur-j-• -'-In�l>----•-•-------•-•-------------------------•-•-----.---.---•----------•-•------..--.---- ---------------
-•......................•--•----------••--•-•-•--........----•-•-•------•----•-------•----------••-------•-------•-...._..-------- -------••_•----------••--•--•-•..............................
U Natur of Repairs or Alterations—Answer when applicable- �6 j v G fsr� ... 115%
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT i,,�. 5 of the State Sanitary Code— T ndersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeWithe board ofhealth.
Si ned---------- ......../�' !ti '. /�.._....
Dat
Application Approved By..- � ' /,i' ----------.
------------------
Date
Application Disapproved for the following reasons:--- --------------------•-----------------------------••----•---•--•---------------..•.-----------------------_
-•--------.---•-•----------------•----------•---.--------------------•--•-•--•---•---------•---------•--------------•--------------------------------------------------- ...............................
Date
PermitNo.......................................................... Issued.......................................................
Date
r
yNp ]ass.... ......................
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD�OF• HEALTH
............OF....... ................................................................................
Applirtttion for Dhiposttl Works Tonotrurtiun remit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
10116
Location-Address / y y�
ff`lIG L.0 LL/Z� /LU,f�CGGc��✓°/ � �� ✓i�)/'✓ �'/ 7�
_..... ............. ................................................. ........••-...........•-----......._........................... ................
Owner Address
W
Installer Address
U Type of Building Size Lot_._�Z.z _�---------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (��� Garbage Grinder
a'4 Other—T e of Building No. of persons............................ Showers
YP g ---•-----•----------•------- P ( ) — Cafeteria ( )
Otherfixtures -----------------------------------•--------------•---••-••--•--•----••••••-••-••••-•---••••-•••••--•-••-----•----.........••-•-.....-----•---••---•-
WDesign Flow........ 5..............................gallons per person pp day. Total da'ly �qpv_._....._...._-------,.......-.---........--gallons.
WSeptic Tank—Liquid*capacity'v! .gallons Length...:.. .... Width....... Diameter__________ ____ Depth................
x Disposal Trench—No. ...1............... Width... ............ Total Length..... ........ Total leaching area....................sq. ft.
Seepage Pit No------------------- -iameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( Dosin annkk
Percolation Test Results Performed bY---------- ........---••-------•-•-----�-;j- Date..................... -,..........
14 Test Pit No. I....,✓E'.:.....minutes per inch Depth of Test Pit...'
Depth to ground water..__. ' .y........__.
(T4 Test Pit No. 2../...........minutes per inch Depth of Test Pit.... ........... Depth to ground water....�J.........._.._
R; �'.----......-•.................................••---_..............................................................
Description of Soil.....�._•�.�........ Lor,h . �� <�/i_
................................
. .. rf% _.J..7r_✓........................................•._.............................................................
_ _ ..................................................... ........................................................e....._ ..___._ ..� _ ._... ........._
U Nature of Repairs or Alterations—Answer when applicable._ � 'J_---.�� ����-`J�-_-��U`--__-'-'uv`-< 3'i_:
-..................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIS 5 of the State Sanitary Code—he dersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee s the board of health.
Signed.......................................................................................
�?y. Date
Application Approved BY ............ . .__ .......
; ../...., .............f........................ ----• ...........
�✓ / Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------•••--•.... ••-•••--•---....._.
--•---•----------------------------•--------•-----••-----•-------------......--------.......--------...---•-•-••-•---•••-•••.--•-•--••-•••-••--•••-•-•••••---•-••••-•-•-•-•••-••------••-......•-•---•.
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
.............T..:......:...:............0F.......>^...:.:................ ..`.... ....................................
�prtifirttt�e of �uttt�rfittnrp
THIS IS TO CERTIF);,-That the Individual Sewage Disposal System constructed '('�) or Repaired ( )
by............................................ ...................................................................................................................................
Installer,•
------•-------------•---•--•----------•---------------------•--•-----•-•-•---••••••---•----••••-••--••-•••-----......••---•----•••.....••-•----•••-••--••--
has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit .............. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
2.3'B............ Inspector........... ..
DATE..... %' -----------------------------------•••--•-------••--•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......
No..-�.�-.�'.:.`�..`�s' FEE......... ..............
i �rrr ttl ks To trwtinn 'v"nutit
Permission is hereby granted7 t..l....V ---j.........................................................................
to Construct ('),,,or Repair- ( ) an Individual Sewage Disposal System
............................•--..................................................................................................................................
Street J
as shown on the application for Disposal Works Construction-Permit No.•W ....... Dated.....•..r./J�� /
... � /
/P
DATE............. .......... Board of Health
:.III••.. -•
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS »
� 3
I s
INC.
Co SHO,R'T`
RIMI° Box 757, East Dennis, Aiassachusetts.02641 (61.7)-385,2831
September 23, 1981
Barnstable Conservation Commission
Barnstable. Town Hall.,
Hyannis, MA 02601
RE: SUBJECT: S E 3 479/Barn. -#1 - 80'
Lot on Long Beach Road
Dear Gentlemen;
This is to certify that L inspected the construction of the foundation- -
for. the subject project during, construction. and that it was built
according, to:my-design and-in accordance with the State Building Code
and Chapter X Title 24 section 1910 of the National Flood Insurance
Program.
Also attached is an.as built location plan of. the foundation. and Septic.
System for your records.
Sincerely, :.:
/7
Craig R.-Short, P.E.
President
CRS: pls
r
ENGINEERING • DESIGNING,.• BUILDING
LOCATION �* (p2- SEWAGE PERMIT NO.
VILLAGE
Ll 1
I N S T A LLER'S NAME i ADDRESS
U I L D E R OR OWNER
D ATE PERMIT ISSUED _/�1- �
DATE COMPLIANCE ISSUED - 23-8/
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