HomeMy WebLinkAbout0189 LONG BEACH ROAD - Health 189 Longbeach Road
Centerville
A=205-033
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Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r , 189 Long Beach Road
Property Address
Witco ,LLC
Owner Owner's Name
information is required for every Centerville MA 02632 10/1/14
page. City/Town " State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Informi a on
filling out forms �
on the computer,
use only the tab 1. Inspector: V v3
key to move your
cursor-do not James Ford
use the return Name of Inspector f.
key. I
rae Company Name
P.O. Box 49 _
Company Address
Osterville MA 02655
CitylTown State Zip Code
I 508-862-9400 S 12482
Telephone Number License Number
B. Certification
I certify that I have personally, i`ispected the sewage disposal system at this address and that the
information reported below isltrue, 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 1 3 0 CMR 15.000 . The system:
( ) Y
Z Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Furth r Evaluation by the Local Approving Authority
10/22/14
Ins is Signature Date
The tem inspector shlai`submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within �0 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 descrideg conditions at the time of inspection and under the conditions of use
at that time. This inspectlon does not address how the system will perform in the future under
the same or different conditions of use.
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t5ins°3/13 - Title 5 Official Inspection For :Su urface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official , Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 189 Long Beach Road
Property Address
Witco LLC
Owner Owner's Name
information is required for every Centerville MA 02632 10/1/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.);.
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 oir.in;310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally P�aSses:
❑ 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 es" '''no" or"not.
y 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 thatJ11e tank is less than 20 years old is available.
❑ Y ❑ Nil, {_� ND (Explain below):
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
i
Commonwealth of Massachusetts
Title 5 Official' Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
189 Long Beach Road
Property Address
Witco LLC
Owner Owner's Name
information is
required for every Centerville MA 02632 10/1/14
page. Cityrrown _� State Zip Code Date of Inspection
B. Certification (cont:)`
❑ Pump Chamber pumps4erms not operational. System will pass with Board of Health approval if
pumps/alarms are reppi0d.
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.,ploe(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):
ti '
ElThe 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 isire,moved ❑ Y ❑ N FIND (Explain below):
i
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.te protect public health, safety or the environment.
1. System will pass artless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the.s ystem is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cess ool or 'riv is within 50 feet of a surf P P y ace water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•.Page 3 of 17
i A
Commonwealth of Massachusetts
: Title 5 Official` inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f.,
189 Long Beach Road
Property Address
Witco LLC
Owner Owner's Name
information is
required for every Centerville MA 02632 10/1/14
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.),, :
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environn nt:.
❑ The system has a sOptic 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 aseptic 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: �..
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D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes', or"No" to each of the following for all inspections:
Yes No
❑ ® Backu.p.(jf sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® DisehaFge or ponding of effluent to the surface of the ground or surface waters
due.to:an'overloaded or clogged SAS or cesspool
❑ ® Staticii,iquid level in the distribution box above outlet invert due to an overloaded
or cloogged SAS or cesspool
i❑ ® Liquid;depth in cesspool is less than 6" below invert or available volume is less
thari`'/�.day flow
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
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Commonwealth of Mas`sac usetts
Title 5 Officia' Inspection Form
Subsurface Sewage Disposlai System Form - Not for Voluntary Assessments
189 Long Beach Road f;1:
Property Address
Witco LLC
Owner Owner's Name
information is Centerville
required for every MA 02632 10/1114
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.).';
Yes No
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obst.rudted pipe(s). Number of times pumped:
i . .
❑ ® Any!portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any'Ip"Rqrtion of cesspool or privy is within 100 feet of a surface water supply or
tribut0y to a surface water supply.
I`
❑ ® Any!polrt on 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
laborate'ry,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-
10,0.000pd.
❑ ® Thetsystem 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
nece5 .ary to correct the failure.
E) Large Systems: To be do;nsidered 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. I ?
Yes No
i.
❑ ❑ the system is within 400 feet of a surface drinking water supply
t
❑ ❑ 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'';tro any question in Section E the system is considered a significant threat,
or answered "yes" in Sectiph 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; 10 CMR 15.304. The system owner should contact the appropriate
regional office of the Depar(rnent.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
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Commonwealth of Massachusetts
Title 5 Officia, Inspection Form
Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments
189 Long Beach Road
Property Address
Witco LLC
Owner Owner's Name
information is required for every Centerville ' MA 02632 10/1/14
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
;I
❑ ® Were 6ny of the system components pumped out in the previous two weeks?
® ❑ Has tl�e system received normal flows in the previous two week period?
❑ ® Have 4arge 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 thefacility 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 siie 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 (des,ign): 5 Number of bedrooms (actual): 5
DESIGN flow based on 31b CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Ipi.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
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Commonwealth of Massachusetts
Title 5 Officilh Inspection Form
Subsurface Sewage Disposal ; ystem Form -Not for Voluntary Assessments
189 Long Beach Road
Property Address
Witco LLC
Owner Owner's Name
required for
is every
Centerville
required for eve MA 02632 10/1/14
page. CitylTown ; State Zip Code Date of Inspection
D. System Informatf
Description: t,
i'
Number of current resider! 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate SO�age system?(Include laundry system inspection
information in this report.)' ' ❑ Yes ® No
Laundry system inspected? : ❑ Yes ® No
' t
Seasonal use?
❑ Yes ® No
Water meter readings, if a'y5ilable (last 2 years usage (gpd)):
Detail:
unavailable
Sump pump?
I. ❑ Yes ® No
Last date of occupancy: unknown
Date
Commercial/Industrial FI Conditions:
Type of Establishment:
Design flow(based on 310 CNIR 15.203):
Gallons per day(gpd)
Basis of design flow(seat/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
i S li
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� . Commonwealth of Massachusetts
v Title 5 Offici Inspection Form
a Subsurface Sewage Dispo' I system Form - Not for Voluntary y Assessments
:E
189 Lon Beach Road
Property Address
Witco LLC ' ,4
Owner Owner's Name
information is , r
required for every Centerville 4 MA 02632 10/1/14
page. City/Town
State Zip Code Date of Inspection
D. System Informat%o,n (cont.)
Last date of occupancy/us5
Date
Other(describe below):
' f
4
General Information
Pumping Records: `. .
j dumped in 2010 -
Source of information: per owner
Was system pumped as part of the inspection?
i. ElYes No
If yes, volume pumped:
I t gallons
How was quantity pumped determined?
i
Reason for pumping: y:
k
Type of System: 6i
® 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/Ptternative 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
t
❑ Tight tank,Attach a copy of the DEP approval.
❑ Other(describe):
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
" Title Offici ,llnspection Form
y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`t 189 Long Beach Road ,
Property Address ,
Witco LLC
Owner Owner's Name
information is
required for every Centerville MA 02632 10/1/14
page. City/Town
State Zip Code Date of Inspection
D. System InformatIO-A (cont.)
l!.
Approximate age of all components, date installed (if known)and source of information:
installed on 8/18/1981 - er as-'built
• a
Were sewage odors detected when arriving at the site? ❑ Yes ® No
,.
Building Sewer(locate dIn site plan):
Depth below grader
tl i„ •
?' feet
Material of construction:
❑ cast iron ® 41OPVC
❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition cf:jpir)ts, venting, evidence of leakage, etc.):
ii
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Septic Tank (locate on site Olan):
Depth below grade: l 21"
feet
Material of construction:
® concrete ❑ .0tal ❑fiberglass ❑ polyethylene ❑ other ex lain
� P )
•
E• ,,� l
If tank is metal, list age:
'. years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal.
Sludge depth: " 2
15ins•3/13 {, Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 17
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z Commonwealth of Massachusetts
Title 5 Officiall Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Ali
189 Long Beach Road
Property Address
Witco LLC ':
Owner Owner's Name
information is
required for every Centerville MA 02632 10/1/14
page. City/Town State
Zip Code Date of inspection-
D. System Informatrca'n (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 33
Scum thickness 2
i li •+ 6
Distance from top of scum to:top of outlet tee or baffle
Distance from bottom of scn .to bottom of outlet tee or baffle 13
How were dimensions dete'mined? measure
i
Comments (on pumping r0.
ecommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tees were present. There%were no sign of leakage Steel cover was to grade
r
u
Grease Trap (locate on size-
plan):
4
Depth below grade:
feet
Material of construction: '
❑ concrete ❑ me&el:. ❑fiberglass ❑ polyethylene
❑ other(explain):
Dimensions: `
Scum thickness
Distance from top of scum:10 top of outlet tee or baffle
Distance from bottom of scum to.bottom of outlet tee or baffle
u
Date of last pumping:
j ;r Date
l5ins•3/13 ) Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 10 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Dis osal System m
' f p . .y em Form Not for Voluntary Assessments
® `r 189 Long Beach Road
Property Address
Owner Witco LLC
'
information is Owner's Name
required for every Centerville MA 02632
page. City/Town I 10/1/14
State Zip Code Date of Inspection
D. System Inform °Y ati6h (con
t.)
t.
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: j
❑ concrete ❑ m,gt�l . ❑ fiberglass ❑ of
N/a e" P yethylene Elother(explain):
Dimensions:
Capacity:
gallons
Design Flow: ;t
i gallons per day
Alarm present:
P _ ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
i
Date of last pumping:
Date
Comments (condition of alarm.and float switches, etc.):
, .
'Attach copy of current pumping contract(required). Is copy attached?
l ❑ Yes ❑ No
l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
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Commonwealth of Massachusetts
M Title 5 Officia[ Inspection Form
Subsurface Sewage Dispo's'al System Form - Not for Voluntary Assessments
^a a 189 Long Beach Road
Property Address
Witco LLC
Owner Owner's Name
information is i
required for every Centerville MA
02632 page. City/Town 10/1/14
State Zip Code Date of Inspection
D. System Informat�®n (cont.)
Distribution Box(if presehi.must be opened) (locate on site plan):
Depth of liquid level above�dtatlet invert n/a
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, an
evidence of leakage into or;but of box, etc.): Y
4
1
Pump Chamber(locate Ohl site plan):
Pumps in working order:
❑ Yes ❑ Noy
Alarms in working order: i ❑ Yes ❑ No'
Comments (note conditioh;pf pump chamber, condition of pumps and appurtenances, etc.):
1
If pumps or alarms are no in working order, system is a conditional
tional pass.
Soil Absorption System (,SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
s;
Commonwealth of Ma 'sac
husetts
,.
v Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
189 Long Beach Road
Property Address
Witco LLC
Owner Owner's Name
information is
required for every Centerville MA
page. Cityl I own 0263_ 1011114
State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pis number: 1- 1000 gal.
❑ leaching chambers number:
i
❑ leaching ga"enes number:
I
❑ leaching trJodhes
number, length:
❑ leaching fields
number, dimensions:
'i
❑ 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.):
The pit was dry and clean.iThe scum line was 2.5' up from the bottom. There was no sign of failure.
Steel cover was to grade. Tlhe bottom to grade was 8'
`Y
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Cesspools (cesspool must'he'pumped as part of inspection) (locate on site plan):
It
Number and configuration
Depth—top of liquid to inletnvert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool k
Materials of construction
Indication of groundwater in6w
❑ Yes ❑ No
l5ins'•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
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Commonwealth of Massachusetts
4 Title 5 Officit Inspection Form
Subsurface Sewage Dispo8a'I System Form - Not fo
r Voluntary Assessments
189 Lon Beach Road
l r
B e .
Property Address i
Witco LLC '
Owner Owner's Name r
information is
required for every Centerville MA 02632 page. City/Iown 10/1/14
State Zip Code Date of Inspection
D. System Informatip (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
' a
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.): l
N/a
t
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t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
•• Commonwealth of Mastachusetts
Title 5 Official, Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�a. •'" 189 Long Beach Road
Property Address
Witco LLC
Owner Owner's Name
information is
required for every Centerville MA 02632 10/1/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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13 g,
a ao 14�. 3
3 -3 3 .
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15ins•3/13 �� •
I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
;i
Commonwealth of Massachusetts
Y Title 5 Official' Inspection Form
Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments
`�a• 189 Long Beach Road
Property Address
Witco LLC
Owner Owner's Name
information is
required for every Centerville " MA 02632
page. City/I own , l State 10/1/14
Zip Code Date of Inspection
D. System Information (cont.)
5
F
Site Exam:
❑ Check Slope }'
❑ Surface water ;
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 14' +/-
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 focal Board of Health - explain:
Topo and water contours map
is
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USES database-explain:
;r
You must describe how you established the high ground water elevation:
wl
see above
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4;
Before filing this Inspection.Report, please see Report Completeness Checklist on next page.
l5ins•3113
i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
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;.. Commonwealth of Massachusetts
Title 5 Officinal Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°r 189 Lona Beach Road
Property Address
Owner
Witco LLC
'
information is Owner s Name '
required for every Centerville MA
page. City/Iown ------- 026__32 10/1/14
State Zip Code Date of Inspection
E. Report Completer .ess Checklist
® Inspection SummaryIA, B, C, D, or E checked
rl f'
® Inspection SummaryD'(System Failure Criteria Applicable to All Systems)completed
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® System Information—F:Estimated depth to high groundwater
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® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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15ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
1'
LOCATION SEWAGE PERMIT NO.
VILLAGE
I N S T A LLER'S NAME i ADDRESS
3UILDEIII OR OWNER
DATE PERMIT ISSUED �zk�
DATE COMPLIANCE ISSUED �J�g�
of
o, Aek PnPLil
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..............1.QWJ. .......OF..... �L.1' . `LLhkl ................................
Appliration for lliipnsal Works Tonstrnrtinn j1prmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ,4 an Individual Sewage Disposal
System at:
.......... ...............................................................................::..:..............
Locati n-Address r Lot No.
.......&IcQoja.................•---------= ------..i : -...r��.1.1 .............---------------...._................
Owner - ddress
a -----......(J.t,P.Y1.2 Cvl LAY.. . 11,.. �'.� ------- �r_I.�11.1 Ate.... ----------- ------------
Installer Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms....... ................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
0.' Other fixtures ----------------------------•••. .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area..._................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.....................................•..
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•-------•-------------------------------•---------------..........-----------....------------....•--........................................................
0 Description of Soil...........
x
°'
U Nature of Repairs or Alterations—Answer wben applicable.... -,)6_6f.1... �____�aa,1s�__________________________________
Agreement: , . i
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued by the board of health.
ff l
Signed L0`� = d �'1- 6 ....... ......
/ Date.
Application Approved By......... ��..!...,�/ -•------------------- ......
Application Disapproved for the following reasons------------------------------------------------------------------------ --------------------------------=------
.............................................=...........................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
A
c-
No......................... ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
j ?.
............ .Cnd:A ....OF...... ... .r.,. � .: . ..::%r _: *..................................
Appliratiun for DiupuoFal Works Tonstrur#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (a—) an Individual Sewage Disposal
System at
1
S p p�-�
fl I<C :L+. 'd!." .. ice.A�L... .. �+ L...Ar a- _ .
.......... .... .................. ......_.__...._._._.._._...._._._.............._.
Locati n-Address or Lot No.
.....G „t�% € yc :frA# •.................................................
__.
—«. r� . f Owner ` r 1Address
Installer Address
UType of Building Size Lot.......................... S. q. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures •------------------------------• .
W Design Flow............................................gallons per person per day. Total daily flow-----_......................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width.........._..... Diameter................ Depth........
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------_------------- Diameter................_... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
G=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-•••-••••--------------------••••--•-••--............................•-•----•-•-•------........................................._...................----••---
0 Description-of Soil.............................................................................................................................................-•.......••-• •••-•.•.....
x -/yY4'/��},,. /cam Cs.. _ _pal, . /- c.l & . � /��/
••--•-•............ .---- ......................... y:...........................................................----•---• — ` ----
.............................................................................................................................................f----.._................_...._................_...........
U Nature of Repairs or Alterations—Answer en applicable__%_'. {g-�......_............... ...................................
• y n f
--------------------•---------•---...-•---•-•••-•-•-••---•------ ....... c.7.....re-----i-s/f :a
Agreement: 1
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
...� 1
Signed...•` Vf- • f..3, 1�.+.
..--• .. ....----•-
I a Date /
ApplicationApproved By..- ................................................ •-•--. ..................... ................. ...................
Date
Application Disapproved for the following reasons:.............................................•...................._..._......-_...._....._...................._.
..-•------•..................•-•----•-------•------------•-•--.......------------•--------...-----------.._....-----------------------------------------------•-•---------------•--------••-••-----------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................." 1.....O F../:' �. .'?�! 'r f✓ .. .....................................
Trrtif iratr of Tomplianrr
THIS—IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�')
by............ �..�_�..... ..lJ� ,� ..-•-1` I�".J _.................•----------•----------•---........--•--•-•--.........................-- ...--
+�f]y r'j ► I Installer
at .--••---- -•------- --- --- -------- --------- --------- -------•- ------ ....._... ._..---..............................................-----•----------•-----
has been installed in accordance with the provisions of��-LE c 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit l o.---� __�G..,................. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.---••..................P... ...................................... Inspector..-•-- ----------..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1
10.
`/ .......... . x,✓ �,....
FEE ..... .i....
�io�rol�,durko �ono#rynr�Uan rr�ttt/�•'
Permission is hereby granted_..-- ---•..... .. ..... ......... .......s'-� -------•• -............................................................
to Construct ( ), or Repair—(—) an Individual Sewage Disposal System
at No.... k-�"?t--.•1�7f.! . s f,!/;, �,+
y _ ...................................................` �c �...
w ..................... ...
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
,� ��
............. ........ Board of Health
DATE----- > ��� ---•--•-•...................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
a
�*THETO
S
• BARNSTABLE, o /�"/��q ,f� . •
00 i6S9,
0 MAY k•
367 MAIN STREET
HYANNIS, MASSACHUSETTS 02601
TOWN OF BARNSTABLE - EMERGENCY ORDER FOR WORK
UNDER MASS. G. L. Ch. 131 Sec. 40 AND TOWN OF BARNSTABLE BY-LAW ARTICLE XXVIII
To: Joseph P. Macomber & Son, Inc.
Centerville, Mass. 02632
Project Location: Lot 6 Long Beach Road
Centerville, Mass.
Regarding: Dudley F. Wade
Date: August 17, 1981
Pursuant to the authority of G. L. Ch. 131 sec. 40 and Article 28 of the Town
of Barnstable By-Laws, emergency work necessitated by the collapse of an
existing cesspool, is hereby permitted.
A new system may be installed, provided a limit of work of 50 feet is maintained
from the top of the retaining wall adjacent to Long Beach; and the installation
is performed in accordance with and under the strict supervision of the Barnstable,
Board of Health.
Signed
Chairman, Conservation Commis n
cc; Board of Health
LOCATION S E W A E PERMIT NO.
VILLAGE
I N S T A LLER'S NAME i ADDRESS
o
R UILDE R OR OWNER
• �� � f �wG � cr? c� /:�a.t� . �' -rrt� i'c;2i; � l l�
DATE PERMIT ISSUED J
DATE C 0 M P L I A N C E ISSUED
t
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informational purposes and cost estimating only and to show design a• 13 February 2015
options when presented. Al dimensions to be field verified by SLME: 1/4'-1'-0'
contractor. oEva n-:Tom Moloney
oEva TE—Brenda Mearo
.EC'nitL:
No.
Floor Plan
sra[i xuxeER: A01
A.02
Bothwell
Residence
Centerville, Ma.
Floor Plan
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CEnEPK rM1ES
----------—.__.--_.-------—-----—-----—.------------' .___--------._-_..-_.---------"—..-.---_.--__--
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-------------
Existinq Second Floor Plan
Note.Drawings are not for construction.Drawings are for
Informational purposes and cost estimating only and to show design
options when presented. All dimensions to be field verified by
contractor.
o.E 13 February 2015
aEscr.nm:Tom Moloney
oEvcr.rz:W:Brenda Alearo
vQET one
Existing
Floor Plan
—E1 w1eEx A.01
A.03
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Residence j
Centerville, Ma.
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N2te1 Drawings are not for construction.Drawings are for
infonnalional purposes and cost estimating only and to show design D•< 13 February 2015
options when presented. All dimensions to be field verified by YKE 1/4--1'-0-
contractor.
ms..-Tom Moloney
-xE rz.Y:Brenda Meara -
- SxECT TICS:
New
Floor Ran
van nwaza A.01
A.04
i
i
107 1%a h strsiet -
'Shapd.MA0263S
1.�,3.•lc .�'-j..i i -107 BEACH STREET ProjectBO7HWELL Alterations ;
DENNIS•MA 02638 Project N0: P73 Bothwell
-19 _ Bothwell
S 1(•Z. �� % I '�--.:`� WB.iw. (t.. i 1.508-3aS-8682 Date: 14 February 2015 —_
GENERAL DESCRTYXEM D.axgz --Tom teilnnay Residence j
9i4645 Centerville, Ma.
Na t a, 2 ma Remodeling
ry Stang shingle G Shake /P t Roci Winger.
__ _ major KanW 1_ng f-.r Enlarged'b Wca rs'varvaya -
��nirteas ww i _1 'Lo ti �HHELL, /89 rcnq Eaan1 Road. Cxa.y»lle, MAII: 'Oa .—..a �n 0E91G8 NOTES: Before&After
. e ... 2 = - P g 9-e Elecadons
Y ,J �� SK_2 t a B fS._ uvbin .A G a'Poly..ansts a lea orkusi
3# ti _ • Q 1 grid .d 2 pa r f 1.75^ 5' L1. ^_., TAD n'Fr ale
� .�e�l Snow ..i S`,-'!- dow Sol balcony abo 1 -t for Stair'loca Lion'
3 ea ;
S NIINNG JUNK; y '/ it Dobl:a4iung Haadai 2/2 81 1O SP7 u/ 1/2 CM flitch plate. j
Pr der 2 Yang studs i.'1'Jack stud ... 9
02 Trans-Headers; 2 2 (i.XD SP'F x! 1/2 CD+t :'li tch ata runCE.EPK x01Ek
the full length. Provide 212^z 4^KD-SPF null jack Studs and -
.' 1 � I w .�
- � 2 Y:ng studs _
'I f3 DCOa. _d '*ie Qn
f s Sting wo lD Steal Deaa / oi.of a a D-F- Zack posts
- 1- 2 375- 3 s" Ll' members. F.Y.#4 9 . 1 ne d 33/3 - o sped2 ,
of,-see i
r II I E C f5 -Partit-'.n Support., 3 2 x._ pilaster th 2 3 stud..all
E sti g Heed nvs d .-,e arcs veiify aaf.:sdta '<1r¢^present.
— ..I I K N / - F non cant headarc - !7 bal a ?
4'8 p,r-h,Wall Seeder,'' w6x25.atoc beam N/pair of 6 d^D-Fir'Jack I
i I sc' KITOI v ` ?
L� I - ./ ?nar: Solid block to beasr co -be xo optics ra i d.rl:a'
LL f• b 10^ fl. c bol -hit upgrades a that Less _ ti
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49 t n teoppr_y. a 1- wade/ r s- k2 as5acia.s^ef ad-dn
P.,lu2P_•ovida�3.king studs,6 2 Jack etude
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-;.. 312 frog .46 y ad path t Sean/cal Ghi location -
3
.0,,4117,0 ' .The.scot 'f oo i2^z 5^a ate.-3?F 3 12•,o/e1",111 b4 ss NEW ENGLAND LIFESTYLES DESIGN
. _ when inset Stai—y to grade is zerioved '
#14 Rea 'east an G vvr p P.ug 3 is t o f floor joist _ Hirghsm,MA, f
r.: 3 3/Bion !.^zv 1 k5a 5 S �d 12 Pl tie.offyant
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D, ,L w,e 13 February 2011
Ind
� r EEi AN ONY A4D 11 H�1
.. ". � ,
47. \/ _ _ xso.rcw:Tom Moloney
. tcvo,1Eu::Brendo Neoro
Sections-
auPc sort Wi-dow Schedule
swaPc
s,rtE1^waEa A.01
C
x A.09
New Buildin Section ® Stoif
3 1/. 1'd
t
a.
Bothwell Fn
Residence
r�
Centerville, Ma. m
1�
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Floor Plan
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ININ B0°"` LIVING .SMS�E NEW EN6LAND LTFESr&E5 DESUN _
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(-, /4-�w First Floor Plan
Note:Drawings are not for construction.Drawings are For
informational purposes and cost estimating only and to show design am: 13 February 2015
options when presented. All dimensions to be field verified by
oDntractor. t/4'=t'-o'
oo..a..:Tom Maloney
xsa-•.rE...:Brenda Mearo
y.CCr DRE:
N—
Floor Flan
s U'.caeca. AO1 -
A.02
s
Bothwell
Residence
Centerville, Ma.
Floor Plan
Existing
P
iC S� WE& -
...................................
. . .,.__...._.__._..__._....._R. . - -
8ED 00 ._...
8EDROOM
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BATH
I BATH NEON ENGLAND UFESMES DE516N
I - HALE - Hingham.MA.
CL
I
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-
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i. — - --- - -- - -- -. - --•.; : , . BEDROOM .__._... ---__..._ ... -..
cvaa .
1 1 1 +
I
IIEMSp�i
le 1Existiny Second Floor Plan
1/4 -r—0'
Note:Drawings are not for oxlstructiom Drawings are for
Informational purposes and cost esdmating only and to show design
options when presented.All dimensions to be field verified by
contractor.
01M 13 February 2015
.— 1/4*-1'-0*
ug.m—Tom Maloney
OELCM 2��'.Brenda Meara
—Cr tiRE:
Existing
Floor Plan
v:EE'—9Eo' AOt
A. 03