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HomeMy WebLinkAbout0039 LUMBERT MILL ROAD - Health 39 LUMI3ERT S MILL RD., CNTRVILLE A = 168015L17 I OCT i UPC 12543 No. 5.. 3...„LOR HASTINGS, MN i I I �I By Aid Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is required for CENTERVILLE MA 02632 every page. City/Town State Zip Code Date Date of 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. ImporWhen A• General Information When filling out / forms the I (J computer,use 1. Inspector: only the tab key to move your D cursor-do not OUGLAS A BROWN use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name t� P.O. BOX 145 Company Address CE NTERVI LLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number _ B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection ' was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ) t ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/3/10 nspe s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Jy 39 LUMBERT MILL RD Properly Address ISAACS Owner information is Owner's Name required for CENTERVILLE MA 02632 6/3/10 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM MEETS MINIMUM PASSING REQUIREMENTS AT THIS TIME, S.A.S APPEARS TO BE DRY BUT THERE WERE NO OBSERVATION PORTS TO OPEN SO I HAND AUGERED BESIDE THE S.A.S AND DID NOT FIND ANY SIGNS OF FAILURE, TANK NEEDS PUMPING, I CAN NOT PREDICT THE FUTURE PERFORMANCE OF THIS SYSTEM B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'y 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 b every page. Ctty/Town State Zip Code Dateate of of Inspection B. Certification (Cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Ur` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Properly Address ISAACS Owner Owner's Name information is required for CENTERVILLE MA 02632 6/3/10 every page. Cltyfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins•09/08 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �Y 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. Cltyrrown State Date of Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered'yes"to any question in Section E the system is considered a significant threat, or answered'yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09M Title 5 official Inspection Farm:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a� 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page. Cltyrro im 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ME Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page. Cltylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO SEPTIC PERMITSYSTEM CONSISTS OF A 1500 GALLON TANK, D-BOX,AND, 6 HI CAP INFILTRATORS IN A 10X40X2 AREA Number of current residents: 0 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 years usage(gpd)): 142.25 GPD Detail: 142.25 GPD WAS THE AVERAGE WATER USAGE OVER THE PAST 4 YEARS Sump pump? ❑ Yes ® No Last date of occupancy: 2009 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NO PUMPING RECORDS SINCE 2000 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form-Not for Vol untary Junta Assessm ents ments 39 LUMBERT MILL RD Property Address I SAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page. Ctty/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: ACCORDING TO SEPTIC PERMIT SYSTEM WAS INSTALLED IN AUGUST OF 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3 FT 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: Sludge depth: HEAVY t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page. Cdyrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK NEEDS PUMPING 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 t5ms•091M Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page. City/Town Date of State Zip Code Date of Inspection. D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene y El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes El No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '~ 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. Cltyrrown State Zip Code Date Date of of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL, RECOMMEND INSTALLING RISER, DEFINATE SOLID CARRY-OVER PROBABLY DUE TO LACK OF MAINTENANCE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NO OBSERVATION PORT, I DID HAND AUGER BESIDE S.A.S AND FOUND NO SIGNS OF HYDRAULIC FAILURE AT THIS TIME t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °Y 39 LUMBERT MILL RD Properly Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page. Ct mown State Zip Code Date of Inspection D. system Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6-HI CAP INFILTRATORS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): JUDGING FROM MY HAND AUGERING BESIDE THE S.A.S I SEE NO SIGNS OF HYDRAULIC FAILURE AT THIS TIME BUT CAN-NOT PREDICT FUTURE PERFORMANCE 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 t5ins•0.9/08 Title 5 Official insp ection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commo nwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page, id r-own State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page. Clty1rown 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 t5ins•09/W Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 6/3/10 every page. Cltyrr.wn State Zip Code Date of Inspection D. System information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5 FT 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: 2000 TITLE5 CODE Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 LUMBERT MILL RD Property Address ISAACS Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. Cdy/town State Zip Code Date ate of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Health Complaints 03-Feb-06 Time: 9:30:00 AM Date: 1/23/2006 Complaint Number: 18632 Referred To: DONNA MIORANDI Taken By: ELLEN WADLINGTON Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: ILLEGAL OPERATIONS Business Name: Number: 67 Street: LUMBERT MILL ROAD Village: CENTERVILLE Assessors Map_Parcel: Complaint Description: multiple families noted living in house; lots of boards piled beside fence; lots of plastic trash barrels upside down; lawn mowers inside and outside building; suspected illegal use of premises (Jack Fitzgerald, Building Dept. has pictures). Actions Taken/Results: Health Complaints 03-Feb-06 Investigation Date: 1/23/2006 Investigation Time: 2 4e _ .JalJF F AV a r - Wr � - d ,�Ywrr ,d � AV Awo W. Air 4101 A � - ro 49 xr LN LN ti, k , y r M It - owl ., Ave .�idtiM r _ Y fI f • y t • v lip!O r ppl� Ru IF"k3 v 1. one" ..., - .+X r� 7Alf., 4- ; Ac. Aw ip 'm4 �r l F- t . r j! Fi OF � y • . �iA! _ • 4 ! A ` A f� � I wu. � qw fir t now Ilwll•. n , �. .0pt L. _ T a + l at ..W i a � y}y s e t� y , , - 3 . a - U My 1,.a t 77 • ._ — . L And �- '^ _ - �y9 Ryxz- JAN 7 2006 i ai �+or Al law— r r. + r M• ��r_� T• 'r ,,��:. Ida •� ' _ 4 .. 1p F y _ y� a :. tr .i Y. j• -�i IC A%' amLX- .; ILA AL h ■ r �j A Health Complaints 24-Jan-06 Time: 9:30:00 AM Date: 1/23/2006 Complaint Number: 18632 Referred To: DONNA MIORANDI Taken By: ELLEN WADLINGTON J Complaint Type: NUISANCE CONTROL REG. 1 RUBQISFj Article X Detail: ILLEGAL OPERATIONS Business Name: R:- N er: 67 Street: LUMBERT MILL ROAD Village: CENTERVILLE Assessors Map_Parcel: Complainant's Name: LOIS LOMBA Address: Telephone Number: x 4772 Complaint Description: multiple families noted living in house; lots of boards piled beside fence; lots of plastic trash barrels upside down; lawn mowers inside and _._..outside,building; suspected illegal use of premises (Jack Fitzgerald, Building Dept. has pictures). A Actions Taken/Results: DZM investigated#67 only to find out that#67 is the complainant, Mr. James Kelly. Talked to him regarding the problems at length. He is complaining about #39 Lumbert Mill Road, Centerville. He states there are 10 men living there and they work all night coming and going with noisy cars and loads of lumber. He also states that they micturate in the backyard. After talking with Mr. Kelly DZM went to the correct house of the complaint and started taking pictures. I was then invited inside by two women. One of them being a daughter named Atila Coelho, cell phone (508_367-4131. She was most cooperative and stated that her parents bought the house in October 2004 as a 5 bedroom house. She states that there are only 5 people living there. DZM walked through the house 1 4 r - v Health Complaints 24-Jan-06 and there are two bedrooms on the main floor with another room as a potential bedroom being used as an ofice and two completed bedrooms in the basement.Thel assessor's has it listed as a 3 bedroom house and there are no permits to go from 3 to 4 or 5 bedrooms for that matter. Previous septic inspections and permits have it stated as a 4 bedroom . On another note, the vans shall be removed in a week and they ask for a month for the unusable debris to be removed. Investigation Date: Investigation Time: 2 J *a #t •t Id NMI r r " r a r N t, r 4 ` w. r tip jo • V �► ` ,� 04 ANOM ti g .. �'- r { L . a.. l • a x �9 Y ION E� WOW - � r IN, - - At IF 0-1 a or 'r. ft r5w = t fill '-� jilo co } 4 F ram: a O.. 04 aaw - JON 23 2006 L Page 1 of 3 u THE I ieJle � Logged In As: Parcel Detail Monday, January 23 2006 Parcel Lookup Parcel Info Parcel ID 1168-015 Developer Lot 1-LOFT 17 I Location 139 LUMBERT MILL ROAD J Y I Pri Frontage!147 ,I Sec Road FZTUMN DRIVE ^� ^�! Sec Frontage,201- 7 I Village[CENTERVILLE Fire District;C-O MM Sewer Acct I Road Index 10933 I Owner Info Owner COEL O H , G EN A R & MARIDELIA Co-owner f O I streets 39 LUMBERT MILL RD Street2 CityrCENTERVILLE I StatejMA zip 02632 Country ;USA "nd Info Acres�0.34 I use FSingle Fam MDd zoning I RC I Nghbd 0106 Topography[R011ing Road Paved Utilities Public Water,Gas,Septic Location Construction Info Building 1 of 1 Year Roof AC file://C:\DOCUME-I\miorandd\LOCALS-I\Temp\AET5WQU3.htm 1/23/2006 Page 2 of 3 Built 1963 Struct Gable/Hip TypeI None Effect 2074 Roof[As GIs/Cm Bed Area Rooms 3 Bedrooms Cover iff- Bath Style Cape Cod wall Drywall Rooms I s y Model Residential �— Total 7 Rooms ( Rooms= _ Int Bath Grade[Average Floor! Style Stories t 1 1 2 Stories ( KitchenStyle Ext[Wood Shin le Heat Bath Hardwood 4M Wall ` g Fuel Split Heat(Hot W tera Found- Gas Type° ation i Permit History Issue Date Purpose Permit# Amount Insp Date Comments 11/16/2005 New Roof 88432 $1,500 2/2/2005 Out Building 82024 L� Visit History Date Who Purpose 4/1/2005 12:00:00 AM Gary Brennan Meas/Est 9/27/1999 12:00:00 AM Donna Dacey Meas/Listed 6/25/1998 12:00:00 AM Lloyd Kurtz Mea./List Bldg Permit Only Sales History Line Sale Date Owner Book/Page Sale Price 1 10/1/2004 COELHO, AGENOR & MARIDELIA C174569 $385,000 2 10/9/2001 TALMAGE, RICHARD GEORGE C163029 $100 3 7/30/2001 RALEIGH, LORRAINE M & STEPHEN V C162298 $0 4 4/23/1999 RALEIGH, LORRAINE M TR 152817 $0 5 8/15/1994 RALEIGH, LORRAINE TR C134698 $57,000 6 10/15/1990 GARDEN MANAGEMENT CO INC C121674 $94,500 file://C:\DOCUME-1\miorandd\LOCALS-1\Temp\AET5WQU3.htm 1/23/2006 Page 3 of 3 7 7/15/1986 WITT, BETSY J C107443 $152,000 8 9/15/1984 SHIELDS, R SR&R JR TRS ETAL C98052 $90,000 9 5/15/1983 SHIELDS, ROBERT M SR C92018 $71,400 10 8/15/1979 MACALLISTER, PHILIP C $42,900 11 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2006 $164,400 $10,800 $0 $169,400 $344,600 2 2005 $156,900 $5,800 $0 $135,100 $297,800 3 2004 $124,900 $5,800 $0 $101,300 $232,000 4 2003 $121,800 $5,800 $0 $44,600 $172,200 5 2002 $121,800 $5,800 $0 $44,600 $172,200 6 2001 $121,800 $5,900 $0 $44,600 $172,300 7 2000 $96,200 $5,600 $0 $33,500 $135,300 8 1999 $96,200 $5,600 $0 $33,500 $135,300 9 1998 $96,200 $6,400 $0 $33,500 $136,100 10 1997 $101,200 $0 $0 $30,100 $131,300 11 1996 $101,200 $0 $0 $30,100 $131,300 12 1995 $101,200 $0 $0 $30,100 $131,300 13 1994 $99,100 $0 $0 $21,100 $120,200 14 1993 $99,100 $0 $0 $21,100 $120,200 15 1992 $112,800 $0 $0 $23,400 $136,200 16 1991 $118,100 $0 $0 $53,600 $171,700 17 1990 $118,100 $0 $0 $53,600 $171,700 18 1989 $118,100 $0 $0 $53,600 $171,700 19 1988 $85,100 $0 $0 $23,700 $108,800 20 1987 $85,100 $0 $0 $23,700 $108,800 21 1986 $85,100 $0 $0 $23,700 $108,800 22 1985 $0 $0 $0 $0 $0 Photos file://C:\DOCUME-1\miorandd\LOCALS-1\Temp\AET5WQU3.htm 1/23/2006 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED LHHEAL 0 2004 RNSTABLE TITLES DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 39 Lumbert Mill Road - _ ^ ons 1ARCEL O1 Owner's Name: Steve Raleigh O Owner's Address: Date of Inspection: Name of Inspector:(please print) Wi 11 tam E_ •Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1 089 Centerville, MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 tion 15.340 of Title 5(310 CZAR 15.000). The system: 2Speasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth-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 ent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of I I r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 Lumbert Mill Road Marstons Mills Owner. Date of Inspection: — —® Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 0 B. stem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaire .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If`not determined"please explain. Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,hhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A metal a tic tank wi p 11 pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating at the tank is less than 20 years old is available. ND expla' Ob.,ervation 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 o Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expl e system required pumping more than 4 times a year due-to broken or obsawed pipe(s).The system will pass in ection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is roved ND ex lain: PZ&3ofII OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 Lumbert Mill Road Marstons Mills Owner: Steve Ralei h Date of Inspection: 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 fail' to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b)that the s stem 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. Sys em will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system 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 sur cc 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 front 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 and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 Lumbert Mill Road Marstons Mills Owner: Steve- Raleigh Date of Inspection: —0 D. System Failure Criteria applicable to all systems: You ust indicate"yes".or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outiet 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 Va day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Numbcr 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 I 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 coliform bacteria and volatile organic compounds indicates that the H•cll is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 prim,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)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: T be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gp Yo must indicate either"yes"or"no"to each of the following: on a following criteria apply to large systems in addition to the criteria above) 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 f 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 immer or operator of arty large system considered a ignificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR .304.The system o%%wr should contact the appropriate regional office of the Department. 4 I Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 Lumbert Mill Road Marstons Mills Owner: Steve Raleigh Date of Inspection: •-1-1 C3 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pu ping information was provided by the owner,occupant,or Board of Health - _V Were an of the system components pumped out in the previous two Y Y P P P P weeks 7 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) v Was the facility or dwelling inspected for signs of sewage back up? signs of break out? Was the site inspected for si — g 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: Yes no — A,,.Axisting 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 i unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 Lumbert Mill Road Marstons Mills Owner: Steve Raleigh Date of Inspection: 7—1— ?-6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): lJ Number of current residents: d Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):/ O[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): O Water meter readings,if available(last 2 years usage(gpd)): 2003 — 54 000 Sump pump(yes or no)-A10 2002 — 94, 000 Last date of occupancy: . COMMERCle NDUSTRIAL Type of establnt: Design flow( on 310 CMR 15.203): gpd Basis of desig (seatslpersons/sgft,etc.): Grease trap pr (yes or no):_ Industrial wasding tank present(yes or no):Non-sanitary discharged to the Title 5 system(yes or no):Water meter rgs,if available: Last date of oncy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of a inspection(yes or no): If yes,volume pumped:__gallons•-How was quantity pumped determined? Reason f r pumping: TYP OF SYSTEM OF tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):1--e) 6 I �I'agc 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Lumbert Mill Road_ Mars ons Mi s Owner: Steve Raleigh Date of Inspection: BUILDING SE'YE (locate on site plan) Depth below grade Materials of cons ction:_cast iron ___40 PVC_other(explain): Distance Gom pr' ate water supply well or suction line: Comments(on ondition ofjoutts,venting,evidence of leakage,etc.): SEPTICt/ TASK._(locale on site plan) Depth below grade: /67 Material of construction: t/concrete metal_fiberglass_polyethylene other(explain) — If tank is metal list age:_ Is are confirmed-by a Certificate of Compliance(yes or no): certificate) _(attach a copy of Dimensions:_ `u 4 G ,I- v Sludge depth: 0 1 Distance Gom top of sludge to bottom of outlet tee or baffle: 70 Scum thickness:�_ t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom outlet tee or Jae: How were dimensions determined: y�-�✓ ta,or ) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: (locate on site plan) Depth below grade: Material of eonstru (ion:_concrete metal fiberglass_polyethylene,other (explain): — — Dimensions: Scum thickness: Distance from t p of scum to top of outlet tee or baffle: Distance Gom ottom of scum to bottom of outlet tee or baffle: Date of last p mping: Comments n pumping recommendations,inlet and outlet Ice or baffle condition,structural integrity,liquid levels as related t outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 . umb rt Mi 11 Road marstans Mi11s Owner: Date of Inspection: TIGHT or HOL G TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grad ; Material of const ction: concrete metal fiberglass polyethylene other(explain). Dimensions: Capacity. gallons Design Flow: allons/day Alarm present es or no): Alarm level: Alarm in working order(yes or no): Date of last p mping: Comments( ondition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): dz4j G PUMP CHA111DER: (locate on site plan) Pumps in working ord (yes or no): Alarms in working der(yes or no): Comments(note ondition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Lumbert Mill Road Marstons Mills Owner: Steve Raleigh Date of Inspection: '-A 7—O - SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,ezcavation'not required) If SAS not located explain why: Type aching pits,number:— leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (ces pool must be pumped as part of inspection)(locate on site plan) Number and configurati n: Depth—top of liquid to let invert: Depth of solids layer: Depth of scum layer: Dimensions of cessp ol: Materials of constru tion: Indication of groun water inflow(yes or no): Comments(note c ndition of soil,signs of hydraulic failure,level of ponding,condition of.vegetation,etc.): PRIVY: (locate on site plan) Materials o construction: Dimension Depth of s lids: Comment (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Lumbert Mill Road Marstons Mills Owner: Steve Ralei h Date of Inspection: O 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. � y p e I i Ail A 7 a P"Q 10 i Page l i of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Lumbert Mill Road Marstons Mills Owner. Steve Ralei h Date of Inspection: ,�d SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: 11 No. C?C���c/ ® (8 Fee THE COMMONWEALTH OF MMASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYicatiou for Migpogar *pgtem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / �-' �11 r , Own�errs�N Ad ess and Tel.�No. ,�,/„ ��— [� T Ad y /vim gP Assessor's Map/Parcel G.e�jL�o,�i1/e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(141�p Other Type of Building 11GP No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ,le gallons per day. Calculated daily flow `® gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. /b,kv Description of Soil Nature of Repairs or Alterations(Answer when applicable) rhL/e- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this B d o Health. Signed Date Application Approved by Date Z�l Application Disapproved for the following reasons Permit No. 0?1—,q Date Issued /Jn l 6 s y« No cif/, �V ) - Fee Entered in computer: THE COMMONWEALTrALaE.kASSACHUSETTS Yes PUBLIC HEALITH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for �Digozal bpgtem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. n / LlAf heel. "—"0/��/ Owner's N Ad ss and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. to1. � Co -�3 n Type of Building: Dwelling No.of Bedrooms 7 Lot Size sq.ft. Garbage Grinder(_45:�p Other Type of Building _ e_ice No. of Persons Showers( ) Cafeteria( ) Other Fixtures /1/ Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title i Size of Septic Tank 15WIle Type of S.A.S. /f X W,-KZ_ Description of Soil Nature of Repairs or Alterations(Answer when applicable) I/' /mil/ Date last inspected: Agreement: �• The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this B d o Health. - Signed Date Application Approved by IZA - Date Application Disapproved fok-the following reasons t Permit No. U'y Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Diosal System Constructed( )Repaired(✓Upgraded( ) Abandoned( )by �r Z"o C©�l 57, at b/N1 "C2 7- ew, 1' N/'o t47'1�Ul has ben constrWrIZ400 to accordance with the provisions of Title 5 and the for Disposal System Construction Permit No� 'Y&S dated Installer Designer The issuance of s1halll,n4t be construed as a guarantee that the sys cdon al d ed/ / Date Inspector v✓i t/F'�f// l`�-/ ------/--------------------f--Q'----------- No. �(� ! >�(/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS dig ogaY *potent Conotruction Permit Permission is hereby granted t9 Construct( )Repair(! )Upgra e( Abandon( ). System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction mu t be completed within three years of the date of t ' je��it. Date: �� Approved by_/V x-- . r. �r 1/6f9'9 • NOTICE: This Form Is To Be'Used For the Repair Of Failed Se "tic Systems Only: - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMPT(WITHOUT DESIGNED PLANS) L /1 ki-7 v G0r/06/Aereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 3 LU�'1r�1�1�✓ meets all of the following criteria: �✓ The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. V/'��he— he soil is classified as CLASS I and the percolation rate is less than or equal to minutes per inc!L are no wetlands within 100 feet of the procosed s=tic s✓stem V/7rhe,-are no wells private ells within 1�40 feet of the proposed septic System There is no increase in flow and/or change in use proposed ere are no variances requested or needed The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Ftimptcr method when applicable) l� If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed p� leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GLS information) Bj G.W.Elevation _+the MA.Y.High G.W.Adjustment. _ /3 31 DIFFERENCE BETWEEN A and B ► �J SIGNED : DATE: (Sketch proposed plan of system on bad]. \d 7 "^1 A Qy TOWN OF BARNSTABLE , LOCATION'b a"` SEWAGE # VILLAGE A��� SOR'S MAP & LOT jiL 1.5! INSTALLER'S NAME&PHONE NO. A012--01 �2 e52:/ljS1'- 7 71 fi?J,0 SEPTIC TANK CAPACITY I �C6® 6df LEACHING FACILITY: (type) �°14 2yajl, Aff.. DI-L`tftva e) /®X qo,& 2-' NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Jzzlgo Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by P4®04' ®� 13 J �� TOWN OF BtARNSTABLE LOCATION 7 7 G � �� / �G�- SEWAGE # 2"4 5 VILLAGE �u � _ASSESSOR'S MAP & LOT IZ!5 G � INSTALLER'S NAME&PHONE NO. ��.r^/`O�*��/`) C !�i°S�` 7/ _Z322 SEPTIC TANK CAPACITY I < 0 'd� _ w/ a I LEACHING FACILITY: ( pe) 6l iayl, ' ��tltra size) —�( �lU1C NO. OF BEDROOMS BUILDER OR OWNER , / /"o ` PERMITDATE: :ay COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by VIV LIP 5 3 �C�Ala " 3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY CORE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 8 9 Property Address: 39 LUMBERTS MILL RD. CENTERVILLE' V Name of Owner LORRAINE RALEIGH \0 Address of Owner: 19 MARY DUNN WAY HYANNIS MA.02601 B� Date of Inspection: 5121/99 Ica Name of Inspector:(Please Print)JOHN GRACI ✓(fin, I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) �� 1 1 1999 Company Name: n/a �'4 � NStgq� Mailing Address n/a r �T Telephone Number: n/a s y ',U CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: _ Passes The inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is Needs Further Ev luation By the Local Approving Authority performing at the time of the inspection.My Inspection does X Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:6/25/99 The System Inspector sh I submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM FAILS TITLE V INSPECTION.THE LIQUID LEVEL IN BOTH CESSPOOLS IS PONDING TO THE SURFACE. THEY ARE PAST THE EFFECTIVE DEPTH OF LEACHING.SYSTEM FAILS. revised 9/2/98 Page 1 of 11 Y , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:6121/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: n/a B. SYSTEM CONDITIONALLY PASSES: nla 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n(a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:5/21/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER n1a revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:6/21/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:6/21/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:6/21/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-44Q g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 440 Number of current residents:4 Garbage grinder(yes or no):MQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):-W Seasonal use(yes or no):JM Water meter readings,if available(last two year's usage(gpd): nta Sump Pump(yes or no): MQ Last date of occupancy: D& COMMERCIAL/INDUSTRIAL Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):JSLQ Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) nLa Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS PUMPED 6 WEEKS AGO BY ROBINSON,BOTH TANKS System pumped as part of inspection:(yes or no):NO If yes,volume pumped Wa_ gallons Reason for pumping: nta TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 19601S Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2198 Page 6 of 11 i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:6/21/99 BUILDING SEWER: (Locate on site plan) Depth below grade: nla Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: n& Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) Iva SEPTIC TANK: X (locate on site plan) Depth below grade: n& Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) IILa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NIQ WA Dimensions: ONE BLOCK CESSPOOL Sludge depth: nta Distance from top of sludge to bottom of outlet tee or baffle: Wa Scum thickness:_nLa Distance from top of scum to top of outlet tee or baffle: OVER Distance from bottom of scum to bottom of outlet tee or baffle: n& How dimensions were determined: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE CESSPOOL IS PONDING TO THE SURFACE,THE OVERFLOW CESSPOOL IS IN HYDRAULIC FAILURE, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: Wa Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:jVA Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping:. nLa Comments.- (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Wa revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:6/21/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n& Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) DLa Dimensions: D& Capacity: nta gallons Design flow: DLa gallons/day Alarm present: NQ Alarm level:jiLa- Alarm in working order:Yes_No_: DLO Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n& DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa PUMP CHAMBER: MO (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:5/21/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: Wa leaching chambers,number: _Va leaching galleries,number: _nLa leaching trenches,number,length: nta leaching fields,number,dimensions: nLa overflow cesspool,number: ONE Alternative system: n& Name of Technology: ji& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE OVERFLOW CESSPOOL IS PAST THE EFFECTIVE DEPTH OFLEACHING,SYSTEM FAILS LIQUID LEVEL WAS OVER PIPE IN THE PIT CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: n& Depth of solids layer: Wit Depth of scum layer. a& Dimensions of cesspool: nta Materials of construction: n& Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection)nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n1a PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:nta Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:6/21199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a d - G revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 LUMBERTS MILL RD.CENTERVILLE Owner: LORRAINE RALEIGH Date of Inspection:6/21/99 NRCS Report name: Wa Soil Type: Wit Typical depth to groundwater: Wa USGS Date website visited: n& Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers _ Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) n/a revised 9/2/98 Page 11 of 11 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Southeast Regional Office WHUM F. Wild Oorwna • , Daniel 8.WoMb psi, oomerwer»f i � s��: ' �•,yx-,:x¢x�Z��.,x a �, Y f February 2 5, 1994 s ,}°:; Mr, Eric Stungeon REt EARNSTA$LE Dime Savings Bank 39 Lumbert .Mill ,Road East Tower-EAB Plaza NOTICE° OF RESPONSIBILITY 11th Floor _ �. M:G:L: { Chapter.21E. Uniondale, New York 01556 c 30 CMR 40.Ob0 " . , Tracking Number:-4 6049 URGENT LEGAL MATTER: PROMPT ACTION NSCE88ARY w CERTIFIED MAIL: RETURN RECEIPT REQUESTED t r NOTICE ,6 'RE8PON8"IBILITY M.G.L. a. 21E, 310 CMR 40.0600 t Dear Mr. Stungeorts , ,,.. . , , F The Department of Environmental Protection (thee "Department") received oral notification on October 10, 1989 that there is or has been a release of oil at the above referenced property which requires one or more response actions. The Department has received a report entitled "Property, 39 Lumbert Mill Road, Barnstable, MA, Spill/Leak Incident-Basement AST" dated February 25, 1992, and prepared by Mason Associates Environmental Services, Inc. , which indicates that a release of °oil, �and/or hazardous material has occurred at the location referenced 'above: The term "release" refers to both a recent, sudden spill of oil and/or hazardous material or "historical" contamination that is identified through some level of investigation. � a �L.IF°�,t•�st 1C"iE�,'�°t.55 t�,ek�� �E,sY i, �a.� 4��.��. ref+.�`'-„� r";+VP� .xif+r�.�_Accordingly, there Department hash reas'ong to'g bel°lever th>�tthe property, or portions thereof; is a disposal site as defined in the Massachusetts Oil and Hazardous Materials Release Prevention and Response Act, M.G.L. c. 21E, and the Massachusetts Contingency Plan (the "MCP") , 310 CMR 40.0000. The cleanup of disposal sites is governed by M.G.L. c. 21 E and the MCP. The purpose of this notice is to inform you of your legal responsibilities under State law for assessing and/or remediating the release at this property. For purposes of this Notice of 20 Rivenidi Drl" 6 LAWAIW,IMisaachu/itts 02347 FAX(M)0474 1 i Telephone (508) "6-27 INC !4r tv, . b,. 4- TWI '2 erg � � "+� s • � w Y Y Responsibility, the terms and phrases 'he ahallhavthe meaning ascribed to such terms and phrases by the MCP'uriid the context clearly indicates otherwise. .... STAtUTORY LIABILITIES The Department has reason to believe that you (as used in this letter, "you" refers to PRP) are a Potentially Responsible Party (a n n PRP ) with liability under M.G.L. c. 21E s. 5, for response action costs. Section 5 makes the . following parties liable - to- the Commonwealth of Massachusetts: current owners or operators of a site where oil or hazardous materials are located; any person who owned or operated a site at the time hazardous material was stored or disposed of; any person who arranged for the transport, disposal, storage or treatment of hazardous material to or at a site; any person who transported hazardous material to a transport, disposal, storage or treatment site from which there is or has been a release or threat of release of such material; and any person who otherwise caused or is legally responsible for a release or threat of release of oil or hazardous material at a site. This liability is M§trict";l "iftingTit is not based on fault, rather it is based solely on your status as an owner, operator, generator, transporter or disposer. It is also "joint and* several", meaning that you may be liable for all response action costs incurred at the site, regardless of the existence of any other liable parties. A � ,' Tea, The MCP requires °res bnsble arties -to stake necessary P P y response actions at properties where there is or has been a release and/or threat of release of oil and/or hazardous material. If you do not take the necessary response actions, or fail to perform them in an appropriate and timely manner, the Department is authorized by M.G.L. c. 21E to perform the work. By taking such actions, you can avoid liability for response action costs incurred by the Department in performing these actions and any sanctions which may be imposed for failure to perform response actions under the MCP. You may be liable for up all-jreSponse action costs incurred by the Department. Response action costs include, without limitation, thencost of direct hours spent by Department employees arranging for1response actions or overseeing work performed by persons other than the Department or its contractors, expenses incurrediby the Department in support of those direct hours, and payments to` the Department's contractors. (For more detail on cost liability, see 310 CMR 40.1200: Cost Recovery. ) c l,y. The Department may -Ai assess4.=interest?on costs incurred at the rate of twelve percent (12%) , compounded annually. To secure 41 * '4 -3= payment of this debt, the Commonwealth may place liens on all of your property in the Commonwealth. To recover the debt, the Commonwealth may foreclose on these liens or the Attorney General may bring legal action against you. In addition to your liability for up to three (3) times all response action costs incurred by the Department, you may also be liable to the Commonwealth for damages to natural resources caused by the release. Civil and criminal liability may also be imposed under M.G.L. c. 21E, § 11, and civil administrative penalties may be imposed under M.G.L. c. 21A, § 16, for each violation of M.G.L. c. 21E, the MCP or any order, permit or approval issued thereunder. ACTIONS UNDERTAKEN TO DATE AT THE SITE Information on file with the Department indicates that the following actions have been performed to date at this site: 1. Soil vapor survey of (an oil release from the) feed and return lines associated with 275 gallon #2 fuel oil above ground storage tank (AST) performed on May 6, 1991; 2. Concrete was removed f rom the basement f loor and f ive (5) cubic yards of contaminated soil was excavated; 3. Total Petroleum Hydrocarbons (TPH) at 2 feet was 2700 ppm and 4-700 ppm at 5 feet. The soil boring sample at 18 feet contained 860 ppm TPH; and 4. A monitoring well was installed outside of the building at a presumed downgradient location. Groundwater analysis results were all below reportable levels (BRL) . NECESSARY RESPONSE ACTIONS AND APPLICABLE DEADLINES This site shall not be deemed to have had all the necessary and required response actions taken for it unless and until all substantial hazards presented by the release and/or threat of release have been eliminated and a level of No Significant Risk exists or has been achieved in compliance with M.G.L. c. 21E and the MCP. The MCP requires persons undertaking response actions at a site to submit to the Department a Response Action Outcome Statement prepared by a Licensed Site Professional upon determining that a level of No Significant Risk already exists or has been achieved at the site. -4 a- Unless otherwise provided by the Department, a responsible party has one year from the initial date notice of a release or threat of release is provided to the Department pursuant to 310 CMR 40. 0300 or from the date the Department issues to him or her a Notice of Responsibility, whichever occurs earlier, to submit to the Department either a completed Tier Classification Submittal and, if appropriate, a completed Tier I Permit Application, or a Response Action Outcome Statement. The deadline for these submittals for this site is February 25, 1995. This deadline constitutes an enforceable Interim Deadline established pursuant to 310 CMR 40.0000. In addition, the MCP requires persons undertaking response actions to perform Immediate Response Actions in response to sudden releases, Imminent Hazards and Conditions of Substantial Release Migration. Such persons must continue to evaluate the need for Immediate Response Actions and notify the Department immediately if such a need exists. The encourages Department parties with liabilities under P g M.G.L. c. 21E to take prompt action in response to releases and threats of release of oil and hazardous materials. By taking prompt action, you may significantly lower your cleanup costs and avoid the imposition of, or reduce the amount of, certain permit and annual compliance assurance fees payable under 310 CMR 4.00 (e.g. , no annual compliance and assurance fee is due for Response Action Outcome Statements submitted to the Department within 120 days of the initial date of release notification) . PROCEDURES TO FOLLOW TO UNDERTAKE RESPONSE ACTIONS You must employ or engage a Licensed Site Professional to manage, supervise or actually perform the necessary response actions at this site. You may obtain a list of the names and addresses of these licensed professionals from the Board of Registration of Hazardous Waste Site Cleanup Professionals at (617- 556-1145) . You should notify the Department in writing no later than 5:00 p.m. on March 25, 1994, if you intend to undertake response actions at this disposal site. If you fail to provide a response to this notice as requested, or fail to undertake the necessary response actions in accordance with the MCP, the Department may perform the necessary response actions and take appropriate legal action againTt you. -5- If you have any further questions, please contact Julie Hutcheson at the letterhead address or at 508-946-2852. All future correspondence communications regarding the site should reference the following Release Tracking Number: 4-6049. Very truly yours, ?'La- Richard F. Packard, Chief Emergency .Response Section P/JH/re CERTIFIED MAIL #P 337 625 781 RETURN RECEIPT REQUESTED cc: Barnstable Fire Department 3249 Main Street Barnstable, MA 02630 Board of Health P.O. Box 534 Hyannis, MA 02601 DEP-SERO, Data Entry 1 t' Centerville-Osterville-Marstons Mills Fire Department Incident Report ' Alarm # [ FA-0520 ] v .G Type of Call [ Investigation (Oil spill) j Date [ 10-9-89 ] a, 6 Location [ 39 Lumbert' s Mill Road Centerville ] Time Rec'd [ 1405 ] a4 [ ] On Air [ 1408 ] uX: Cq � 1414 a o Reported By [ Tele. No[ ] On Loc. [ ] W N •ri A Address [ ] In Service [ 1428 ] � o0 .n v Station Response Still 1 301 2 3 Weather [ clear ] Alarm 1 2 3 Wind [ NW ] at [0-1T U O r-I 0o¢ Dispatcher [ Leary. ] Zone of Call [2-1 ] b N [ u •�+ Comments ) m w [ o '-i 4J HU Z Buildings - Type of Occupancy [ ] 0 r Owner [ ] Address [ ]Tele. No[ ] > �I ro0 b' Tenant [ ) Address [ ]Tele. No[ ] Equipment, Description [ ] W aLocation of Equipment [ ] s � a Year [ ] Make [ ] w Model [ ] Serial No. [- ] Year [ ] Make [ ] Model [ ] o -1 Color [ ] Vin. [ .] -W U 0 .c Owner [ Address [ ] v / Class [ ] Area/Size [ ] Cost [ ] Vehicle Response [ ] State Notified [ ] cn -- -------------------------------------------- ______________ U 4-j U rz Alarm Classification/Code [ ] Form 62 Left [ ] o Called or Notified By [ ] Tele.# [ ] LBrief narative required all calls (Page Q) over C-O-MM Form 199 I ( TOWN OF(B NS IT(A�B,1,PT LOGATIJP% v"` , \�,i� 1 ° 11 `\4-� SEWAGE # VILLAGE �o y�l� ASSESSOR'S MAP`&VL T 21- L' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �)ko C*- cv-sseo O I LEACHING FACILITY: (ty ) Q�&Cx �C L?'& n0-4— (size) NO.OF BEDROOMS n r BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by G� 7D - Ov 0-o . s ' Page 2 J Alarm # [ ] Date [ )171rf41 b [ ] N / Y Report By [ - ] Date [ ] List items that need follo - ip [ — J Other agencies notified Name [ ] Tele. No.. [ ] By [ J Chief [ ] Date [ -' J 1 i CEN'TERVIL.L,E-os-rER4)IL.L..E--MAF 61'r-)NS MILLS FIRE DEPARPIENT OIL/HAZARDOUS MATERIAL RELEASE LOCAT I ON. 3TREET ODDRESS OF V I L L()G E.- DATE: TIME OF RELA-if-V-SE.": orecewv -dw .x7/e- & TIME OF F. D. NOTIFICATION: _ PRODUCT RELEAsE:,D-. .--.* ELB�*A lin' '-ED CAJANTITY-. CORREC"'rIVE ACTION IF NOTIFICATION: NATIONAL. RESPONSE CE-NTER r. I NO f-, 'i DATE-......_.___.._ -1,1 I)CEUE I I YES L I NO OA Tl;;.40 T I t 0 1 L SP I Lf C C)----C)R D I N A T Qf E V4` NO DATE , BOARO OF HEALTH U w.-I" YES r I NO DATE,#,./�`� T p- i ME li HARBOR MASTER I I Y E S I ww'-NO DATE. T I Mf.::,' OTHER Af'3F--NC-JES ----------- ........ COMMENTS. Le co,..r —17 FtE PORTED D A T E py. v FIr:. Vili ITE PY 'E CO D-PAR MENT YEI L-OW DEQE PINf-,` DOARD Ol:7 HEM A1 TH --O--MM FORM #58 ♦: 's i i i � ` � - 0u1i ^ ^=, �~ � 00 '�tD PAR Real Estate System - General Property Inquiry Help Parcel Id: 168 015- - Account No: 93491 Parent: Location: 39 LUMBERT MILL RID CENT Neighborhood: 38AC Fire Dist: CO Devel Lot: 17 LC31043-A Lot Size: . 34 Acres Current Own: GARDEN MANAGEMENT CO INC State Class: 101 EAB PLAZA EAST TOWER No. Bldgs: 1 Area: 2310 Year Added: - LJN IONDALE 9 NY 11556 Deed Date: -Th0Soerence: C121674 January 1st: GARDEN MANAGEMENT CO INC Deed MMDD: 1090 Deed 'Ref'.' C121674 Comments: Values: Land: 21100 Buildings: 99100 Extra Features: Road System: 108 Index: 56 (AUTUMN DRIVE ) Frntg: 147 Index: 933 (LUMBERT MILL ROAD ) Frntg: 207 Control Info: Last Auto Upd: 091292 Status: C Last TACS Update: 051491 Land Reviewed By: Date: 0000 Bldgs Reviewed By: Date: 0000 Tax Title: Account: Taken: Account Status: Hold Status: Cancel Press XMT for more data Next screen PAR Action � Owners Name Road Index Road Name Parcel Number 168 017 ~ t *************** -COMM. JOURNAL- ******************* DATE AUG-25-2010 ***** TIME 12:27 ******** MODE = MEMORY TRANSMISSION START=RUG-25 12:26 END=AUG-25 12:27 FILE NO.=319 STN COMM. ONE-TOUCH/ STATION NRME/TEL NO. PAGES DURATION NO. ABBR NO. 001 OK $ 918662391050 0041004 00:01:31 BARNSTRBLE HEALTH ************************************ -BARNSTRBLE HLTH - ***** - 5088624713- ********* TOWN OF BARNSTABLE Health Division—200 Main Street-Hyannis,MA 02601 FAX Dato: 8 � /o ; atnxsTAM-K rtnM• Number of pages including cover sheet: To � )From: �Jly /Ih?y� Town of Barnstable Elealtlt Division Mail to: 200 Main Street Phone: �a 3�� - Hyannis,ILIA 02601 Fax phone: g12=� 3�-�p�� Phone_ CC: Fax phone: 508-790-6304 REMARKS: ❑ Urgent ❑ For your review ❑ Reply ASAP ❑ Please comment o� TOWN OF BARNSTABLE Health Division— 200 Main Street - Hyannis, MA 02601 F'THE FAX : . "�� Date. 85yzo - -1 • BARNSTABLE, • 9 MLASS• g Number of pages including cover sheet: 1639. �0 p To From: bpd(m A- From: of Barnstable Health Division Mail to: 200 Main Street Phone:0'3�6 2 O Z/ Hyannis,MA 02601 Fax phone: 8' — 39 —�pJ�°� Phone: CC: + Fax phone: 508-790-6304 REMARKS: ❑ Urgent ❑ For your review ❑ Reply ASAP ❑ Please comment F� l � Centerville-Osterville-Marstons Mills Fire Department Incident Report Alarm # [ FA-0520 ] .G Type of Call [ Investigation (Oil spill) ] Date [ 10-9-89 J Location [ 39 Lumbert' s Mill Road Centerville ] Time Rec'd [ 1405 ] v [ ] On Air [ 1408 ] N o Reported By [ Tele. No[ ] On L6c. [ 1414 ] •r-1 N Q Address [ ) In Service [ 1428 ] Station Response Still 1 301 2 3 Weather [ clear ] a U) Alarm 1 2 3 Wind [ NW ] at [0=1� cu o Dispatcher [ Leary ] Zone of Call [2-1 J o b U r Comments4-4 [ J as � •� [ ] o E' co z o Buildings - Type of Occupancy [ ] � �- Owner [ ] Address [ ]Tele. No[ ] > �clj o Tenant [ ] Address ( ]Tele. No[ ] U H � Equipment, Description [ ] Location of Equipment [ ] R G o Year [ ] Make [ ] W¢ Model [ ] Serial No. �4 a) Year [ ] Make ( ] Model [ ] o U Color [ ] Vin. [ ] Owner [ Address [ ] v [ Class [ ] Area/Size [ ] Cost [ ] Vehicle Response [ P ] State Notified [ ] ------------------------------------------------------- '0 F- Alarm Classification/Code [ ]0 Form 62 Left [ ] o � Called or Notified. By [ ] Tele.# [ ] i i Brief narative required all calls (Page 2) over C-O-MM Form 19 FjK �� Page 2 Alarm # [ ] Date [ V ] of— a� J [ gA , �60w m ` f ,/ /� ova,* ] [ J H � r / � Report By [ ] Date [ ] List items that need follo - ip Other agencies notified Name [ ] Tele. No. [ [ ] By [ J J ,I Chief [ ) Date [ $5 No oil x '_WuyS t�E y w' Cf;.N14.,RV I_f..!«..E. OSTL F>.VILL E -"ARS OWS . M7l r..IS FIRE D PAR TONT .. LOCATIONg Kam STREET i'-?Dd.1R!:::S13 CW FZEL_.EAl.,E. xyke 1;rl�...!_.t"�8,31�..v ._. +�.L.���_i.�v�♦�� tJ� �� tt y ;� � { E k,i#� ��!`% 7��'4�3n^��` r r 1.i°7t=. d.1F ('+:E:.i..E"r'r�3E «. _! ,�' ^. /,��'- ,�� ,r',� o ° rr,/7�.1�%'�%.,�,,�;•�.�,.�� r�,, N . a DATE t TIME F t n D }O I 11 A I ON a . Ag 0' PRODUCT } p`l 1.:Cy 1 11;:� 1 �1 t�llF�9�17<7 T�n_'�,�j�e�r.�'`.D� i t� i E fl; ! C h .. CORRECTIVE ACTION IF AN4'w } Aw- �Y ,_.,e.�d.�i�.+ .«..f?�fa"..t�'&'G...::.�� .._:�.x.*srG.«..«./.t�"S�«.., t1.2t�!'�.�+,»..f�� .fx�5�"'•¢+c,d�«7` ..,��stra��`��t��"���" ;>'� ~��r �`,��": i QL- t . !'lt:1 T Y1:w-101NEL RESPONSE r r�l"I E r ! . YE-<<. N t. 1:I t�( I I YES�:, (: 1 i#'! I)�`r"(I� � � r-11311:� OIL i. r or� , .1'E.�� 1. 1 �+11.! U*A`!`El����✓, �� ! �I�il r� Y�������'q���« T-.10ARD OF HEALTH TH Loge YES ' I r i�� . 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