HomeMy WebLinkAbout0080 LUMBERT MILL ROAD - Health 80 Lumbert Mill Road
Centerville
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist.at the end of the form.
Important:When filling out A. General Information *54
forms on the I 1
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
n City/Town State Zip Code
(508)428-4028 S14454
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. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system: 1
C
® Passes ❑ Conditionally Passes ❑ Falls O
❑ Needs Further Evaluation by the Local Approving Authority ; ca
. .x `n
c
10/16/2009
Insp tor's Signature Date 3a.
CP7
The system inspector shall submit a copy of this inspection report to the Appro ing Authorty(Bbtbrd
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.
D i
t5ins•09108 Title 5 Official Inspection Form:Subsu ace Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
B System Conditional) Passes:
Y Y
❑ 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
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. Cityrrown State Zip Code Date 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 ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail"unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen'sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. Cityrrown 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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic stem consists of a 1500 gallon tank D-B x n tw p y g o and o drywells.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M ,•''r 80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
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:
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is Centerville Ma. 02632 10/16/2009
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System installed in 1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
'
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallon
Sludge depth:
3"
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 117
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
u r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,. 80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No
evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 117
I
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.Dry wells were empty at time of inspection.No stain line
observed.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
�. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
Map Page 1 of 2
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Commonwealth of Massachusetts
(z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of Leaching 15'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form `
Q
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 80 Lumbert Mill Rd.
Property Address
Estate of Robert& Helen McCutcheon
Owner Owner's Name
information is required for Centerville Ma. 02632 10/16/2009
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Completeltems 1,2,and 3.Also complete A..Sign ure
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C Date of Deliv
■ Attach this card to.the back of the mailpiece, J ����
or on the front if space permits.
Is delivery address different from item 1? ❑Yes
1. Article Addressed�to(� If YES,enter delivery address below: ❑ No
r_ j 3. Service Type
ill q N� 3 f Certified Mail ❑ Express Mail
❑ Registered In Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number -" --_ - - -
(Transfer from service label) I4 i i It 7 0 0 5 1116`0 0 p 0191 2 2 6t7 Hi c 'JAI
PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-15401
I
UNITED STATES POSTAL SERVICE Fj0Wra—ssMk,
A17 {l'4AY' .K ID' P 3
• Sender: Please print your name, address, and ZIP box ••�` �'
1 j
((/ Town of Barnstable
e Health Division
\ Fo 200 Main Street
Hyannis,MA 02601
J
Certified Mail#7005 1160 0000 0191 2267
�pFz Tp�ti Town of Barnstable
Y 2 Regulatory Services
+ nARNSTABL"
y MASS. o Thomas F. Geiler,Director
ap 16g9.
ArF°MA�A' Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
May 3, 2007
Linda McCutcheon
55 Kensington Lane
Bedford, NH 03110
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 80 Lumbert Mill Road Centerville, was inspected
on May 2, 2007 by Meredith Morgan, Health Inspector for the Town of Barnstable. This
inspection was conducted on the basis of the rental registration in accordance with
Chapter 170 of the Town of Barnstable Code.
The following violations of the Town of Barnstable Code were observed:
170-10—Smoke Detectors and Carbon Monoxide Alarms. No smoke detector
provided in basement.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by installing smoke detector in basement in accordance
with Mass State Fire Codes.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days after the date the order is served.
QAOrder letters\Housing violations\Rental ordinance\80 Lumbert Mill Road.doc
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD Or HEALTH
ET dean, R.S., CHO
Director of Public Health
Town of Barnstable
Cc: Meredith Morgan, Health Inspector
Evan Perry, Tenant
Q:\Order letters\Housing violations\Rental ordinance\80 Lumbert Mill Road.doc
FORM30 C&W HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF.JiEALTH
CITY/TOWN
o EPARTMENT
DRESS
ELEPHONE
Address 00 �UF'l �J' 1"►I V� ��-(jl • _ Occupaq uC(� V✓
Floor Apartment o. No. of Occupants
No.of Habitable Rooms No.Sleeping ROOmS�
No. dwelling or rooming units No.Stori
Name and address of owner �2fU � w
`vR�e1mwks Reg. Vio.03110
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress: and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation.-
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing, Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2 j�
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities SinkIXE
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION.WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. (See Over)
"THIS INS ECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTI RP Fly."
INSPECTOR TITLE V N
DATE �/ /v TIME (9 00
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
iF
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410,251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through,(0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
Town of Barnstable
SOP THE r0�
Regulatory Services
* IIARNS'rAF3LE. - Thomas F. Geiler,Director
9 AMASS.
039. Public Health Division
Arfb MAt A.
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
May 3, 2007
Attn: COMM Fire
Health Inspector Meredith E. Morgan conducted a rental inspection in accordance with
Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary
Code, 105 CMR 410.482, the Health Department is required to notify the Fire
Department if there is a smoke detector violation, or possible smoke detector violation.
The following property had possible smoke detector(and\or CO detector) violation(s):
80 Lumbert Mill.Rd. Assessors Map-Parcel: (168-105):
Smoke detector lacking in basement.
Me'r'jediifi E. Morgan -Health Inspector
Q:\Order letters\Housing violations\Rental ordinance\\Fire Violations\FIRE TEMPLATE.doc
f
b
Town of Barnstable
P
Regulatory Services Department
BARNS-TABLE, '
AS - Public Health Division
AjFO MAC A 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
April 23, 2007
Evan Perry
80 Lumbert Mill Road
Centerville, MA 02632
RE: Rental Inspection for the Town of Barnstable Code Chapter 170 - Rental Properties.
Dear Evan:
In accordance with Chapter 170 of the Town of Barnstable Code, we would like
to schedule an inspection of the rental property located at 80 Lumbert Mill Road.
Inspections are held Monday through Friday between LOAM and 2:15PM, as well as
evenings from 5PM to 7PM and Sundays from LOAM— 1PM. Please call me directly to
schedule this inspection.
Should you have any questions regarding this inspection, please do not hesitate to
call the Town of Barnstable Health Department.
Respectfully,
Caitie Barrett
Division Assistant
Rental Program Coordinator
508-862-4072
Parcel Detail Page 1 of 3
BARN,rk lli
+•1 zr
Logged In As: Parcel Detail Wednesday, I`
Parcel Lookup
Parcel Info
Parcel ID 168-105 _ I Developer LOT 13
Lot --- —------- - - -
Location 80 LUMBERT MILL ROAD Pri Frontage 141
Sec Road BRETWOOD LANE i'� Sec 130
- -- - -- - Frontage
village CENTERVILLE I Fire District C-O-MM
Sewer Acct Road Index 0933
Interactive
Map
Owner Info
owner MCCUTCHEON, ROBERT B & HELEN Gy Co-owner C/O MCCUTCHEON, LINDA, EXE
Streets 55 KENSINGTON LN Street2
y p I Country I US
city BEDFORD State NH zip 03110
Land Info
Acres 0.41 use 'Single le Fam MDL-01 zoning RC Nghbd 0106
ji
Topography Road
Utilities Location
Construction Info
Building 1 of 1
Year Roof Ext
2000 Bowstring Trus Wall +Wood Shingle
Built Struct _ _ -- ----- -----
Effect Roof AC
Area 1668 1 Cover.Asph/F GIs/Cmp Type,Central 1
Style Cape Cod � wall Plastered Rooms;2 Bedrooms
Model Residential I Int Carpet ^� Bath ,2 Full
_ Floor __- RMS
Grade Custom Minus Heat Hot Air , Total 15 Rooms
Type Rooms -----
http://issgl/intranet/propdata/ParcelDetail.aspx?ID=11022 5/2/2007
Parcel Detail Page 2 of 3
;;xWPK>
1A
Stories 1 Story-F A l Heat Gas Found- I rAT 2 GAR
.------ --- — Fuel ' ation .. BAs:
2 BMT
20
'$G'
Permit History
Issue Date Purpose Permit# Amount Insp Date Comrr
12/30/1999 New Dwelling 43308 $97,915 1/11/2001 12:00:00 AM
Visit Histor
y
Date Who Purpose
2/12/2007 12:00:00 AM Jeannette Kirwan In Office Review
1/11/2001 12:00:00 AM Martin Flynn Meas/Listed
4/27/2000 12:00:00 AM Martin Flynn Bldg Permit N/C
- Sales History
Line Sale Date Owner Book/Page Sale P
1 11/30/1999 MCCUTCHEON, ROBERT B & HELEN G 12694/213
2 SAYIAN, KIRK 2470/8
- Assessment History
Save# Year Building Value XF Value OB Value Land Value Total Parc(
1 2007 $208,900 $2,900 $0 $169,800
2 2006 $213,000 $2,900 $0 $174,800
3 2005 $202,600 $3,000 $0 $139,600
4 2004 $186,500 $3,000 $0 $104,700
5 2003 $143,400 $3,000 $0 $46,400
6 2002 $143,400 $3,000 $0 $46,400
7 2001 $0 $0 $0 $46,400
8 2000 $0 $0 $0 $35,500
9 1999 $0 $0 $0 $35,500
10 1998 $0 $0 $0 $35,500
11 1997 $0 $0 $0 $31,900
12 1996 $0 $0 $0 $31,900
13 1995 $0 $0 $0 $31,900
14 1994 $0 $0 $0 $22,300
http://issql/Intranet/propdata/ParcelDetail.aspx?ID=11022 5/2/2007
Parcel Detail Page 3 of 3
15 1993 $0 $0 $0 $22,300
16 1992 $0 $0 $0 $24,800
17 1991 $0 $0 $0 $56,700
18 1990 $0 $0 $0 $56,700
19 1989 $0 $0 $0 $56,700
20 1988 $0 $0 $0 $21,700
21 1987 $0 $0 $0 $21,700
22 1986 $0 $0 $0 $21,700
Photos
http://issgl/intranet/propdata/ParcelDetail.aspx?ID=11022 5/2/2007
• r
DATE 5/10/06
PROPERTY ADDRESS 80 Lumbert Mill Road
Centerville
MA 02632
On the above date, the septic system at the address above was
Inspected.
This system consists of the following: 6 9J
1.� 1-1500 gaiioa septic taak.i 7
2., 1-D.ista-igut.ioa Box., <_
3.t 2-560 gaUon 2ea6h.iag cham&eaz.-
Based on inspection, I certify the following conditions: ; ry
4., 7hiz iz a 7�. .ee Pave .s12et.-c zy s emo
5.1 Septic zystem .is .in paopea wo2k•ing o2dea at the p/tezeat t 'me.,
-- R1
A,��4—
SIGNATUR
Name: Robert A. Paolini
Company: Joseph P. Macomber & Son Inc .
Address: P. 0. Box 66
Centerville, Mass 02632
Phone: 508-775-3338 or 508-775-6412
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775.6412
•
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—.NOT.FORVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PARTA
CERTIFICATION
Property Address: • 80 Lumbert Mill Road
Centerville MA 0263.2
Owner's Name: Est of Robert & Helen McCutcheon .
Owner's Address: Same
Date of Inspection: -s 10 10
Name of Inspector:(please print) Rob ert A Pao.lini
Company Name: _�_.P_ flucom.&e2,9 .S:o.n Inc. A.
Mailing Address:
en env. e, N477..02632
Telephone Number: 00 8-7. 7 5_3 3 3 8
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 to-Section.15:340 of Title 5(310 CMR M000). The system:
XXX Passes
Conditionally Passes
Deeds Further Evaluation by the Local Approving Authority
ils
Inspector's Signature:
Date: v140 11(0
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.
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 diffeeut
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTIONYORM—.NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �
PART A
CERTIFICATION(continued)
Property Address: 80 Lumbert Mill Road
centefV1115 MA U26iz
Owner: Estate of Robe�rt He en McCutcheon
Date of Inspection: 5 10 0 6
Inspection Summary: Chock A,B,C,D or.E/ALWAYS�eomplete all of Section D
A. System Passes:y£S
NO I have not found any information which indieates'ihat any of the failure criteria described in 3 10 CMR
15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
Se/zt.ic .system W_*.s .in /2ao.Nea woak.iag oadea at the j2ae,6en.t t.iM.�
B. System Conditionally Passes:
NO 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 aporovedjby the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following satements.If"not determined"please
explain.
NO The septic tank is metal and.over 20 years old*or the septic tank(whether metal or:not)is,�structurally
unsound,exhibits substantial,infiltration or exfiltration or tank failure-;is imminent:System will pass inspection if the
existing tank is replaced with a complying septic tank,as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection-.if(with
approval of Board of Health)!
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
NO The system required pumping more than 4 times a year due to broken or obstructed pipe(s)..The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 80 Lumbert Mill Road
Centerville MA 02632
Owner:. Estate of Robert & Helen McCutcheon
Date of Inspection: 5/1 0/0.6
C. Further Evaluation is Required by.the Board of Health:
NO 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:
no Cesspool or privy is within 50 feet of a surface water
_&p 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'SgVI*er;if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
no The system has aseptic 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.
n° The•system-has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
n o The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well.
P P. PP Y
n o 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 v.i-3eLa e
"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
I
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A .
CERTIFICATION(continued)
Property Address: 80 Lumbert 'Mill Road
Centerville MA 02632
Owner: Estate of Robert & Helen McCutcheon
Date of Inspection: 5/1 0/0 6
D. System Failure Criteria applicable to all systems: .
You must indicate"yes".or"no"to each of the following:for all inspections:
Yes No
X Backup of sewage,into facility or system component due.to 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'%.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
X Any portion of the SAS,cesspool or privy is below high ground water elevation,
7 Any portion of cesspool or privy is within 100 feet of a surface wgter supply.or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a:publicwell..
X Any portion of a cesspool or privy is within 50 feet of a privat6gWater 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: [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 forip.]
NO (Yes/No)The system fails.I have determined that one or mor6bf 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•
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)
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
If you have answered"yes"to any question in Section E the system is considered a significantthreat,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.
4
Page 5of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 80 Lumber.t Mill Road
Cen ryi11P MA 0_632
Owner: Estate of Robert & Helen McCutcheon
Date of Inspection: 5/1 o/o F
Check if the following have been done.You must indicate"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 Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available cote as N/A)
a•
X _ Was the facility or dwelling inspected for signs of sewage back
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS,located on site?
X 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?
X. _ 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
X Existing information.For example,a plan at.the Board of.Health.
X _ 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(3)(b)]
5
Page 6 of 11
OFFI:CIA.L INSPECTION FARM--NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE SEWAGE.DISP.OSAL:SYSTEM.,INSPECTION FORM �
PART C
SYSTEM INFORMATION
Property Address: 80 Lumbert Mill Road
Centerville MA 02632
Owner: Estate of Rnbpr - x. mal en McCutcheon
Date of Inspection:5 110/0 F
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CNM 15.203(for example: 110 gpd x#of bedr6oms).'3 3 0.
Number of current residents: 3
Does residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no):p= [if yes separate In required]
Laundry system inspected(yes or no): n oo
Seasonal use?(yes orno):no 2004_.34, 000 gaeioaz q1 -9.3:, 15
Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 5_2 4; 0 0 0 ga 2 o n G%D=6.5 , 7 5
Sump Pump(yes or-no): rz o
Last date of occupancy: R 2 e-3 e a t
COMMERCIAV&bUSTRUL NIA
Type of estab lint:
Design flow on 310.CMR 15.203): gpd
Basis of dtsi*n"flow(seats/persons/sgft,etc.):.
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system-(yes or no)._
Water-meter readings,if available:
Last date of occupancy/use: .
OTHER(describe):
GENERAL INFORMATION
Pumping Records NCR
Source of information:
Was system pumped as part of the inspection(yes or no): q ee.6
If yes,volume pumped: 15 0 0 gallons--How was quantity pumped determined? m e a s uaed
Reason for pumping: heavy z o i id z m a.ia i- 12 u m R
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
T 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)
_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):—
6
Page 7ofII
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 80 Lumbert Mill Road
Centerville MA 02632
Owner: Estate of Robert & Helen McCutcheon
Date of Inspection: 5 1)x 0 0 6
BUILDING SEWER(locate on site plan)
Depth below grade. 2 4"
Materials of construction:_cast iron _40 PVC X_other(explain):
Distance from private water supply well or suction line: 2 0 f
Comments(on condition of joints,venting,evidence of leakage,etc.):
ao:intz appeaa tight.., vented thorough house vent
SEPTIC TANK:LS(locate on site plan)' 1500 ga i i o n s
Depth below grade: 1 8"
Material of construction:X_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Complianee(yet or no):_.(attach a copy of
certificate)
Dimensions: 10' 6"X5 ' 8"X5 ' 8"
Sludge depth:_,. 4"
Distance from top of sludge to bottom of outlet tee.or baffle: 2"
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 0
Distance from bottom of scum to bottom of outlet tee or baffle: 'n o n e
How were dimensions determined: m e a s u 2 e d
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,.evidence of.leakage,etc.):
eam42 9 out
tarik 1.3 2ud u2ai y .sound.,
GREASE TRAP: NO(locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Gaease tzap not paesent
t
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: 80 Lumbert Mill Road
CPntt_ryi 1 1 P MA 02632
Owner: FctatA of Robert" & Helen McCutcheon
Date of Inspection: 4.1 0.40 6
TIGHT or HOLDING TANK:NO (tank must be pumped at time of inspection)(locate on site.pian)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes.or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
1-ight os hoid.ing. ianks aae no.t /2ae6ent
DISTRIBUTION BOX:I/�� (if present must be opened)(locate on sitd,,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 .is ieve.2., .11as 1 Qateltai., No zi ns ol zo.eid caza oven., No .2 ak ge
.trz 0)1 ou o 90x.'
PUMP CHAMBER:NO (locate on site plan). .
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
um,2 c h a m ez is n o 4 RaPAPnf
J
8
I
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION(continued)
Property Address: 80 Lumbert Mill Road
Centerville MA 02632
Owner: Estate of .Robert & Helen McCutcheon
Date of Inspection: ,[1 0/06
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located .6ee /cage 10.,
Type
leaching pits,number:_
leaching chambers,number: Z
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,
ftc.):
oamy to m.ed.ium zand., No z ignz o� �a i�u�e,5 .S`o i 2� ate day.,
o zzgnz oZ /2on .ing. ege a .--on .c s noama
CESSPOOLS:NO (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:or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Ce.6,3/2oo2z. ate not /2a.ebent
PRIVY: NO (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/t.ivy is not /22eseat
. f
9
i
Page 10 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: 80 Lumbert Mill Road
Centerville MA 02632
Owner: Estate of Robert & Helen McCutcheon
Date of Inspection: 5/1 0/0 6
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...
a.
1 ,
r
n
10
Page 11 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION•FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .80 Lumbert Mi 1 1 Road
Centcryi 1 .1 a MA n2632
Owner: Estate of Robert & Helen McCutcheon
Date of Inspection:S/1 n/n
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:.
-NO Obtained from system design plans on record-If checked,date of design plan reviewed:
me Observed site(abutting property/observation hole within 150,feet of SAS)
Checked with local-Board-of Health-explain:rz s i.i.2i Cn n d
no Checked:with local excavators,installers-(attach documentation)
Accessed USGS database=explain4;t;Cp:�o wn.,to znis is l ie.,,me.-u,3
• M
:w
You must describe how you established the high ground water elevation:
Ilhed. : Cape Cod Comm.i ion tdatea 7agie Codtouah And %u92.ie Uatea Sup�2y
ldeii head pzotectiqa neap ma Se t 1995
Glate2 aehouaceh o f,,1 ice cane cod comm.ih.ion.-
Leaching
Pit fleet
Groundwater Feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical.separation distance between the bottom 6-
of the leaching pit and the adjusted groundwater table is
' feet:
' 11
lip ."Wpww
OP B ABLE WPD aF usAITn
_gUnBURFACR SEVA09 I)j$POSA4 AYSTPM INSPECTION FEMH - PART D CERTIFICATION
-M WWI
,.•..•..
'-T"''•°'"' "„'�`*"'"'�"•�,�..�.�•• •�**'�-,cam ' -TYPE On PRINT 01,906Y—
PRO.PERTY INSPI•;CTIs0
STREET ADDRESS 80 :Lumbert Mill Road Centerville 02632'
A•SS•ESSORS MAP, BLOCK AND -PARCCL
OWNSR'a NAME Estate-----of----Aobert & Hr�l An pjgrjj c�hgnn -
PART''D CHfirx1FI0AT30N ,
NAME -OF INSPECTOR
Ro 6.e.at A.a.o tin•, '
oze8h P.� Macon&eti Son Ina
COMPANY NAME --.--- —
Box 66 " 'Czn4t,%vj_0_0z Oa.�b'.02632 '
COMPANY ApDRgSS sc�f Tow -or C1W. • a rp
COMPANY TEEXPHONE t 508. 07.5 - 3338 .FAX . ('.508',1190 = f578
70
CERT-171CATION. STATEMENT
I -certify that I have persoaal,'ly Ans-peated .the sewage diopopa"1. system at
this nddress and that' tii:e• information reported .is true,. eoo0ra-te•0 and
omplete as of the time a sinspeetion.s• The i>lsgePti.on was per•Formed and any
recommendations regarding upgrade•, -maintenance,* abd rep4.1r •are• eongis-tent
witli my trainiklg and exP.erience in the ppoper function- and maintenance of on-
site sewage disposal. systa.ms
Check one., '
XXXX Systeal PASS*D
The inspection wh ic.h -I have .conducted has .*t- found any information
which Indicates that the system' fails to adewately. protect .public
health or the env i,.ropmen t as defined DI .310 CMR. 15 3'0.3•1 -Any failure
criteria Dot --evaluated are as stated in the FAILURE' CRI't'LRIA ;section o•f
this form.
System FAILED*
The inspection which I have corcl�ted -has .found that the System fails to
protect the public 1lealth end the env4roji' - in acoo'rdanoB with Ti,t1e
6 , 310 CMR 15 . 303, and as -specifically noted an -PART' C -. FAILURE
CRITERIA of this inspec'ti.on- .forms '
Inspector. tignature' Date
ne' co
of this sett,,f icatior must •b8 rovided :to :the .9WNSK•1 ih� BUYER'
where appli.oablf) and the DPARD OP' HEA Tile
* if the inspection FAIL-E.D., %hb .owned' .qr 9perator eyetem.
within one year of the date of the inspection, unless. al-Iowed qr' regi $,reed -
n t.harw{se as urovided iT ;JO CHR 15 ,306 ,. � ,
Towno Barnstable I>rl
Department of health,Safely, and Environmental Services
�WErth Public Health Division
Q 367 Main Street,Ilymmis MA 02601
uAMr9I'A lll$ • �
rED►IAt� Dale Scheduled l,r �_ 'I'jnle Fee Pd.� .
Soil ,Suitabilip)assessment fin- Se► age Disposal
'0' Performed Ily: q WitncsScd B
LOCATION & .mI1,Ii;AL INrORlY1A`I`ION v_
r<
Location Address ���i�/����7�,�jJ Uwncr's Name
Address --
Assessor's Map/Parcel: p� tsT,` 6 Engineer's Naine YAOUICeeSv"
NIiW CONSTRUCTIONG J REPAIR -Telephone N
i L/ _
Land Use Lt100 J 4 Slopes(°o) 0— Surface Stones
Distances from: Open Water Body — Il Possible Wet Area R Drinking Water Well ft
Drainage Way Il Property Line • i Il Other Il
SKI;TC11: (Slrcel name,dimensions of lot,exact locations of test holes&perc tests,locale wetlands in proximity to holes)
/07- $ '
�, as
C
a
I'aicnl material(geologic) Depth to Bedrock
Depth to Groundwater: Standing Willer in I tole: Weeping from Ili(Pace N <
Estimated Seasonal I ligh Groundwater �✓ __
DETERMINATION VOIZ SEASONAI. IIIGI0VAT1-P,IZ.`I'ABLL
Method Used:
Depth Observed standing in obs.hole: ill. Depth to soil mottles:
Depth to weeping frmn side of obs.hol in. Groundwater Adjustment Il.
Index Well ll _ Readinp Dale: _ _-. Indcx Wecll Ievcl Adj.factor..— Adj.Groundwater Level
PLRCOLAITION'I'ES'P life 11-17 Time IAI'
Observation
I Jule II _ 'I ime at 9"
``
Depth of Pere "I"uQ 3C Time at 6"
YY 3®
Start Prc-soak Time n •OCf Time(9"-6")
y0
I-nd Prc-snaky
Rate Min./Inch
Site Suitability Assessment: Site Passed i� Site Failed: Addilional Tcstiog Needed(1'/N)
Original: Public Ilcallh Division Observation Hole Data To Ile Completed on Ilacl( j
Copy: Applicant
1)EFT 013SERVA`I'ION 110LL LOG Ilolc It .
Dcfnh from Soil Ilorizon Soil Texlurc Steil Color Soil Other
Surface(ill) (USDA) (Munsclf) Mollling (Structure,Stories,ISouldcres.
0 3 a o►@6-tNt�-
3 7 -
A
L
- -- ---- -- sa `ayR' -� -=- ----- --�e 1�C- -- -
- — --- ----------- - --- -s D--
Nd r0�1wA v,,cx3�
DEAT OBSERVATION 110LE LOG Bole it �
Depth Irony Soil I lorizorl Soil,texture Soil Color Soil Other
Surface(in.) (USDA) (Nd(lriscil) Molding (Structure,Sloncs, Ilouldcres.
-- — Consislcnc�,_o(imveh
it
sj z 16YA5-it
—Z- S )�
6� S --- --- - ---- - - - -
C - _ e D'�
--- -- --c � �mow, -
-13a AS'Y'7-L/
DEEP OBSERVATION-IIOLIe, LOG'. Hole It
Depth from Soil Ilorizon Soil'Iexlure Soil Color Soil 011ie[
Surface(in.) (USDA) (C funscll) f'lollling (Slrucrurc,Sloncs, Ilouldcres.
4q(itavcl)
i
i
DEEP. OBSLRVATION HOLE, LOG Itole it
Depllr from Soil Ilorizon Soil'lexime Soil Color Soil Olhcr
Surface(in.) (USDA) (Mansell) Moilling (Structure,Sloncs,Ifouldcres.
— —_-- — (.:o0 isle[cy,1o_(il;lvel)
I i
Floyd lilsill—al ce R�te_111a1Z;
Above 500 year flood boundary No Yes L�
Wilhin 500 year boundary No i/' Yes
Within 100 year flood boundary No V Yes
llel>lli of Nallul_ally Occurring Pervious Materiel
ROCS at least four feet of nalurally occurring pervious material exist in all areas observed throughout the
area proposed For the soil absorption system'? _ r,
—
r--- -----
If not, what is the depth of naturally occurring pervious ntatol ial?
Certification
1 certify that oll,/�OIL/ / ((late) I have passed the soil evaluator exaniinalion approved by the
Deparlmenl of Enviromiticnlal Protection and Ihat (Ile above analysis was perfornlecl,by me consislelll with
the Ierluired (raining, expertise and expelience cscribed in 310 CM 15.017.
Signature — ---- -- Dale 1 7/7g
TOWN OF BARNSTABLE
LOCATION 0 � ` /� ' SEWA. E #
VILLAGE LdP A�t'ell,C/vlf ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. ft k-; 019Z'%
SEPTIC TANK CAPACITY 1 �®
i
LEACHING FACILITY: (type) Z ®�gQ�`v� ��� (size) f aZ. A of y
NO. OF BEDROOMS 3
BUILDER OR OWNERPiL���1
PERMITDATE: 7"Z 7` COMPLIANCE DATE: ����;Z 000 A.
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 leeaachiin facility). Feet
Furnished by �'�' ' �l` X
2 L
e
n
3 0 0r
r
Q�j t
No. l� , FEE
Board of Health, 9AA( stm L I-e- - MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(4<Repair( ) Upgrade( ) Abandon( ) - complete System ❑Individual Components
Location 80 Lo v,.,,�e v-T /j i u f0oqj> Owner's Name SA M CS /j uR d
Map/Parcel# 1(o g /o,1-- Address
Lot# I O S Telephone#
Installer's Name erl�p 4J Al eoeA7 Designer's Name A N Llle_�C_ Su yr V02' e-U✓I SQI-T44�
Address Address
yog N I�vST`R Rod R,S�uS /`'il
Telephone# Telephone# /-/ ppS"
Type of Building Lot Size 7 7 sq.it.
Dwelling-No.of Bedrooms 3 Garbage grinwo
Other-Type of Building No.of persons Showers ( ),Cafeteria( )
Other Fixtures
Design Flow (min.required)
3 3O gpd Calculated design flow 330 Design flow provided 397 gpd
Plan: Date 11— /p q -I Number of sheets Revision Date
Title S/ + s e-WCx,-1 e- 014 to
Description ofSoil(s) 'cam 1v " !
Soil Evaluator Form No. (D� Name of Soil Evaluat(pruce Gh u@� �/R ate of Evaluation `I'1 7-99
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to Anooplace a em in operation until a Certificate of Compli a has been issued by the Board of Health.
Signed Date ; ��l0o
N X0. FEE /(f v�
C®MMONWF-ALT14 ®F MASSAC14USETTS ✓
1 ! Board of Health, IyA��s 1 ►'✓ �`e MA. L
e APPLICATIONFOP, DISPOSAL SYSTEM CONSTRUCTIONPERMIT "{
14,
Application for a Permit to Construct(<Repair( ) Upgrade( ) Abandon( ) ]'Complete System ❑Individual Components
Location- 8O L. ,r��e�T /-�1 LL Rd eq Owner's Name 5A M ES /y UP t7
Map/Parcel# '(o g 0 S'r Address
i
+} Lot# f O S Telephone#
Installer's Name D�41- C,D4S7� Designer's Name R N �VQ�j �U"1 Sv[ R1�1
Address Address 908 N lbuS'M M �oN
R04P �P_ S m
Telephone# i Telephone#
Type of Building �` Lot Size / 7) / 7 fi sq.ft.
w
Dwelling-No.of Bedrooms 3 Garbage grin (
Other-Type of Building No.of persons Showers ( ),Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 30 gpd Calculated
^^d�esign flow 33 o Design flow provided 3 417 gpd ,
Plan: Date Number of sheets !T Revision Date
_x
Title S f` C+ S e_wc-.9 e
V Y
Description of Soil(s) Set 0 14 1j ' 1
Soil Evaluator Form No. 60 a Name of Soil Evaluat y«�- U Rlp ��� ate of Evaluation q
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposaf System in accordance with the provisions of TITLE 5 and
further agrees to no o place a sys em in o eration until a Certificate of Compli ce has been issued by the Board of Health.
/
Signed �h9 Date �!Zb1KO _
1�SgGtlkYtPS ✓Y t r fj 7 F (r'd..J� , /�J —
Y I,
No. ���� COMMONWEALTH OF MASSAC14USETTS FEE
Board of Health, 1�+9 RN�T�+ L� MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) iWomplete Systemf.'.
The undersigned h
preby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by: ol-
at &0 LV I K 6e rT' M I L.I— R0.4 i
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 7/c''��� dated Approved Design Flow 3_ 7 (gpd)
Installer / C 4 /)
Designer: Dater
The issuance ofthis permit shall not be construed as a guarantee that the system will functio as designed. --,�-,77
.l No. %f— �7� FEE /Oe)%
Board of Health, W RVi ST 1`B LE , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 8� LUw��j e iT f`1 I LL QU � �+ as described in the application for
Disposal System Construction Permit No. /.3 dated /2 -/y-
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 'mZ7 -0 Board of Health V,
-
i TIM
1 _ Q
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IV
ew ~
.e' 40•� 1 'Y
1 '
f 10
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i
TOWN OF BARNSTABLE p
LOCATION fo � � � �I, � SEWAGE # 21 4413
( //
VILLAGE � 2U/p?�l`f1rl ASSESSOR'S MAP & LOT !e_ Z_
INSTALLER'S NAME &PHONE NO. � �
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)
-? .(size) !
NO. OF BEDROOMS 3 k
W
BUILDER OR OWNER AG(-qTL�L" �l r
PERMITDATE: COMPLIANCE DATE: —� � coo
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leachin Facility. Fee
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 leachin facilityy).�-�►-c Feet
Furnished by
/7,6
a .
J
1 £ i
a
7 Z
Y �NOTA. THERE J E NO FLOOD ZONE CHANGES R7THIN 100' OF Lor BARNSTABLE
: F ,
/0000,
ol
f y`
L / �EL� p0� E o
/ ��� '`� �, ` R USA
14
jD
E 101 Lew �o LOCUS
DES P / 1 t moms
V, � / 8
�A0 P 107• ~,
0
EDTP
BENCHMARK Q5 N 5' S. AS/LOT 133
mp OP C S
ELEV.= 100.0'ASS EDJ ✓' ° �'� ,
C B. r ° x�
rn N { LOCUS MAP
cs�
'tK •lp0 ° ^: DEED REF 24 7%08
° '#, ASSESSORS MAP.- 168, LOT 105
N ° SIT 26' �, _ PLAN REF 30115
-,� ZONING.• "RC"
y o+ va N ' -- . FLOOD ZONE. �.C,,.
r
12 O �- o COMMUNITY PANELI 250001 0016 D
\ 0' \> DATED.• 7102192
�\ C.Rjop SITE AND SEWAGE PLAN
AS/LOT 105 PROPOSED
\ AREA=17,944fSQ.FT. 3-BEDROOM
HOUSE \ PROJECT L OCA T/ON
\ T.O.F.=101' T 80 LUMBERT MILL ROAD
�\ S 0, CENTERVILLE, MASS
.
S.APPL/CANT -
% HY
N `9 DAMES MURP
o
Vol,
YANKEE SURVEY CONSUL TANTS
V P.O. BOX 265
gaY°SE / o UNIT 5, 408 INDUSTRY ROAD
Y 6 MARS
TONS MILLS, MA. 02648
1' PH.(508)428-0055 - FAX(508)420-5553
\ s61
AS/LOT 104 SCALE.• 1"= 20' FA TE.• 11 729:9LJ.
9
y REV 111912000 REV
MHB JOB NO. 52165A SHEET 1 OF 2
::
`' •. .-� ire
1
7OP OF FOUNDATION
20, ,AIIN.
E 1 10' MIN. CONCRETE COVERS 4" SCHEDULE 40 P.V.C.
i A(IN.. PITCH 1/8 PER FT. 2"LAYER OF
Z.
,. 1/8 l/2~
CONCRETE COVER WASHED STONE
Z. " " /MAX --�- " EL=101. 0
4' CAST IRON PIPE 9„
(OR EQUA6j MINIMUM CLEAN SAND
PITCH 1/4 PER FT. MIN.
10 FLOW LINE , EL=97. 0
1 10 w w
INVERT M11V 14 `" f20'� o00 00000000000 080000
np INVERT LEVEL 000 0 00000000000 0Oo
EL.=-9-8-�__ CAS 8 SUM 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 -
o 0 CO0 0 0 0 0 0 0.0 0
INVERT BREEZE EL.=��i0 INVERT INVERT 00 0 -
EL._�� 5 EL.=-72� EL._����_ 4' (2) 500 CAL LEACHM CHAAMERS
(W BE PLACED ON ff" BASE) DISTRIBUTION EL.
A/ECHANICALGY COAfPACTED OR B' OP SMNE BOX
ALLONS TO BE WATER TESTED 128' X 25' TRENCH M"A77ON
SEPTIC TANK IF MORE THAN ONE OUTLET
PLACE ON s S70NE 3/4' ?O 1-1/2' SOIL ABSORPTION
PROFILE OF
DOUBLE WAWASHEDSTONE SYSTEM (SAS
SEWAGE DISPOSAL SYSTEM BOT7IDM OF TEST HOLE OR USGS PROBABLE' WATER TABLE ELEV.=_89____
NO OBSERVED WATER TABLE 0.07/99) ELEV.=89
NOT TO SCALE OBSERVATION HOLE 1 ELEV.= 100_-5
PERCOLATION RATE �5 _'3 MIN./ INCH AT _4�"' INCHES OBSERVATION HOLE 2 ELEv=_101_
DEPTH HOR�Z TEXTURE COLOR OTT. OTHER DEPTH ORIZ TEXTURE COLOR MOTT. OTHER
O-3" O ORGANIC 0-3" 0 ORGANIC
3-9" A SANDY!IWAM IOYR 5-3 3-9" A SANDY LOAM IOYR 5-
NERAL NOTES 9'-36" B LOAMYtSAND IOYR 5-6 9"-36" B LOAMY SAND 10YR 5-
GE
6"-138' Cl MEDIUM SAND 2.5Y 7-4 PERK. 36"-138 Cl MEDIUM SAND 2.5Y 7-4 PERK
1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO DER
TITLE 5 AND THE TOWN OF -BARN�'TARLE____ RULES AND NO WATER ENCOUNTERED NO WATER ENCOUNTERED
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. � SOIL TEST
2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO #'
WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" 1111719.9 SOIL TEST DONE BY BRUCE G. MURPHY' R S.
SANITARY SYSTEM SHALL BE CAPABLE OF DATE OF SOIL `TEST
3) ALL COMPONENTS OF THE S ;{
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN WITNESSED BYE ED EARRY
10 FT. OF DRI VES OR PARKING AREAS. H-20 LOADING SHALL BE P# 960z DESIGN CALCULATIONS.'
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. TOP LOAD NUMBER OF BEDROOMS . . . . . . . . 3
4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL 5 INFILTRATO]gw WITH GARBAGE DISPOSAL . . . . . . . . . NO
BE MORTERED IN PLACE. ' STONE SIDES AND ENDS TOTAL ESTIMATED FLOW
4
5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH , . :.� 110__GAL/BR/DAY x 3___ BR) 330 GAL/DAY
DEEDED OR•, ZONING REGULATIONS. OWNER/APPLICANT IS TO Il' X 38 ( - -
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. :;{ REQUIRED SEPTIC TANK CAPACITY 1500 GAL
6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VATION CONTRACTOR "_
IS TO CALL "DIG- SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS - SOIL CLASSIFICATION . 1
DESIGN PERCOLATION RATE 5 MIN./IN.
PRIOR TO COMMENCING WORK ON SITE. "� ' EFFLUENT LOADING RATE . . . . . 74 CAL/DAY/S.F.
?� CONTRACTOR. IS" TO VERIFY GRADES AND ELEVATIONS AS WELL AS 381 GAL DAY
OR TO COMMENCING WORK ON SITE. LEACHING CAPACITY (AREA X RATE) 381 /
SITE CONDITIONS ,PRI " " _ RESERVE LEACHING CAPACITY . GAL/DAY
8) PARCEL IS IN FLOOD ZONE__C___-_• ',
105 (38X11.�74)f(38+38f11 f11X 74)
9) LOT LS SHOWN ON ASSESSORS MAP ___Ise_ AS PARCEL _____-- y ,g SHEET 2 OF 2 JOB NUMBER__ 5216b_______