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HomeMy WebLinkAbout0115 LUMBERT MILL ROAD - Health 115 LUMBERT MILL RD, CENTERVILLE A= 168 046 I F1t wd UPC 12 43 No,5T-OR HASTINGS, Ml 0 i Commonwealth of Massachusetts Title 5 Official Inspection Form r o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 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: A. General Information When filling out forms on the I�/n computer,use 1. Inspector: only the tab key to move your PatrickT. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name P.O. Box 371 Company Address Sandwich MA 02563 ' City/Town State Zip Code 508-888-6055 SI 12843 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: --� C"D ® Passes ❑ Conditionally Passes ❑ Fails - ❑ Needs Further Evaluation by the Local Approving Authority : December 15,2010 inspector's signature Date t 14 • " 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. L/v A t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewag isposal System•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cunt.) 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: 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 Qf the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined° ,/N, ND)for the following statements. If"not determined," please explain. j` The septic tank is metal and over 20 years olor the septic tank(whether metal or not) is structurally unsound, exhibits substantial in?ration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is placed with a complying septic tank as approved by the Board of Health. / "A metal septic tank will pass inspe fon if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan is less than 20 years old is available. ❑ Y ❑ N ❑ D (Explain below): t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 every page. City/Town 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 I Ith): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled pi 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): t C) Further Evaluation is/Requi the Board of Health: ❑ Conditions exist whicher evaluation by the Board of Health in order to determine if the system is failing toc health, safety or the environment. 1. System will pass 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•09JO8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..�'` 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 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 orption system (SAS) and the SAS is within 100 feet of a surface water supply or ributary to a surface water supply. ❑ The system has a septic tank and AS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water supply ell**. Method used to determine disc ce: **This system passes if the w I water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t at no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6°below invert or available volume is less than %day flow t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 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" s°or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is wi in 400 feet of a surface drinking water supply ❑ ❑ the system i within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the syste is located in a nitrogen sensitive area (Interim Wellhead Protection Area—I PA) or a mapped Zone 11 of a public water supply well If you have answered "yes" o any question in Section E the system is considered a significant threat, or answered "yes"in Se 'on D above the large system has failed. The owner or operator of any large system considered a si ificant 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 Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 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 GPD t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2009=323 GPD* g ( y g (gl�))' 2010=338 GPD Detail: *High water usage during summer months due to irrigation. Sump pump? ❑ Yes 0 No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 C/Title Gallons per day(gpd) Basis of design flow(seatslp Grease trap present? ❑ Yes ❑ No Industrial waste holding tank ❑ Yes ❑ No Non-sanitary waste discharghem? ❑ Yes ❑ No Water meter readings, 'if ava t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 every page. Cityrrown 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: Ready Rooter records: Pumped 05/28/09. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed (if known) and source of information: System installed as"emergency"repair December 14, 1999. Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 210"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: 1 V X 5.5'X 5' 1500 gallons Sludge depth: 2" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information uired for r Centerville MA 02632 December 14,2010 every page. c4frown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 37" Scum thickness 2.511 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? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Risers bring covers within 6"of grade. Grease Trap (locate on site plan): Depth below grade: f 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= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 every page. Citylrown 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: El concrete ❑ metal ❑ fib lass ❑ 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•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 every page. c4rrown state Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, one outlet. No solids carryover. No sign of high water staining over outlet invert. Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump c/er, dition 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 Forth:Subsurface Sewage Disposal System•Page 12 of'12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "Y 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 every page. Cityrrown State Zip Code Bate of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-60'L X 4'W X 2'D ❑ 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.): Camera used to inspect and locate trench. No sign of past hydraulic failure. Hand probing found dry sandy soil w/stone. No sign of ponding. Cesspools (cesspool must be pumped as part of'nspection) (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 i/ow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .' 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name required f forormation Centerville MA 02632 December 14, 2010 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,/ofulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 14 of 14 }� Commonwealth of Massachusetts aulWo- Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name in0rmatiort is required for Centerville MA 02632 December 14,2010 every page. Cityrrown state Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A:�= �` A3= a3 r M 36 Q 3 t5ins•08/OB Title 5 OfficW trrepecdw Form:Subsurraoe Sewage Disposal System•Page 15 of 15 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 29+- 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. December 27, 1999 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Emergency repair data shows adj. ground water at elv= 11.8(1999). Base of SAS at elv=41+-. Accessed local ground water contours and topo mapping. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 115 Lumbert Mill Road Property Address Guy Reidell Owner Owner's Name information is required for Centerville MA 02632 December 14, 2010 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 TOWN OF BA^R INSTABLE LOCATION < < L JVK B&Z 1Zk( 1®l, SEWAGE # VILLAGE � \erg„ \c ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. C o yv 4(,}8_ '6 Ito SEPTIC TANK CAPACITY ISO O G e�f. LEACHING FACILITY: (type) ten C H (size) �X-J'r�� NO. OF BEDROOMS 3 BUILDER OR OWNER J P Mes ?Q oct-1 PERMITDATE: H C- it�' COMPLIANCE DATE: YZ Separation Distance Between the: Maximum,Adjusted Groundwater Table and 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 r 09 61 , o TOWN OF BARNSTABLE LOCATION k�,SEWAGE# VILLAGE Ce ,ay L,l P ASSESSOR'S MAP&PARCEL 16 INSTALLER'S NAME&PHONE NO. God- SEPTIC TANK CAPACITY 1 ©O o r � ' LEACHING FACILITY. (type) (size) <00 X "Y X o� NO.OF BEDROOMS n OWNER PERMIT DATE: COMPLIANCE DATE: CJ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 3 Cf 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�R_ p!" N3= 23 c-f3 O O �3 = �� No. • arm f rT 1 Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: kl Yes PUBLIC'HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for ats pogar *pgtem Congtruction permit Application for a Permit to Construct( )Repair(VUpgrade( )Abandon( ) 11 Complete System ❑Individual Components Location Address or Lot No. S ), M'a Fa a M; Owner's Name,Address and Tel.N . 'I�EAIco� Assessor's Map/Parcel - Os C p3,6Ss" Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Q R-0o,-&,,v1 ws Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re airs or Alterations(Answer when applicable) V (-f cJ_Vty &V s��. r-Cs s o 8(l lSOo C �. 3'(6 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 by this oard of/ alth. Signed Date D eC. 71999 Application Approved by Date � = A Application Disapproved for the ollowing reasons Permit No. Date Issued No. // a1 "".'- ` Fee r © _+ - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: / ' - Yes , PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppffcatfon for Mi!5poml *pgtern Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. , S L v rt1$c a l-1a l Owner's Name,Address and Tel.No. I, Cenk. Z{ tktS —\-*,cr)`Co1_ Assessor's Map/Parcel / \b 0 hcAooty`A r\ ft c !a 0$:\cr.,G oa.bSS Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. lose;k1 0 Type of Building: Dwelling No.of Bedrooms 3 Lot Size.— sq.ft. Garbage Grinder( ) Other Type of Bding No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank " Type of S.A.S. Description of Soil a Nature of Repairs or+Ailterations(Answer when applicable)V 0 2 ('A 3 e _�C. 11 ,s,^t�c c c s S, 0 o(1 o k J O O C7111. a.11'\ t 1 S i-.lj�tt ��:� ��� 1 — e t1c�Trc^c w (1� C-�O �t �'r 1���� STone 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 issu d by this oard o alth. Signed Date J)eC. 7 199 � Application Approved by 'S'�►�, � Date / Application Disapproved for the following reasons p Permit No. / - a. Date Issued THE COMMONWEALTH OF MASSACHUSETTS t BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that tare On-site Sewage Disposal System Constructed(' )$epaired(3"")Upgraded( ) Abandoned( )by ` at 1 1 S_ L v �3 e r i h k( - CP A`Te r,, ` c Chas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - dated Installer Designer t The issuance of this permit shall not be construed as a guarantee that the system will functiorys designed. Date Q�" Inspector C/7 No.�^ G --------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS Of 6po0ar 4p9;tem Construction Permit Permission is hereby granted to Construct( )Repair ✓)Upgrade( )Abandon( ) System located at 1/Sr L 11 m&,27 /7, l y rr,,y7r1o�,t1, and as described in the above j- :.lication for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the follctkvmg local provisions or special conditions. Provided:Construction must be� ompleted within three years of-the date of this permit. Date: - / Approved by 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, Co(zo 01 , hereby certify that the application for disposal works construction permit signed by me dated CC concerning the property located at t 1 S U L-�,"ec-1 �,� �I�o�- Ce lr�eti;l�e 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. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There 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 Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed 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 GIS information) (2�.Q B) G.W. Elevation 10 +the MAX. High G.W. Adjustment. "8 _ �l DIFFERENCE BETWEEN A and B SIGNED : DATE: -PeC' ? � [Sketch proposed plan of system on back]. q:health folder:cen A Oo /500 6H/ u %• I i I i TOWN OF BARRNSTABLE LOCATION �ruy►ti�cr'� ��11 1®� SEWAGE # c/ VILLWE ��Q� \e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. c0 s�-��e��v Mpy '— (c S �C'N SEPTIC TANK CAPACITY /SO O G M, LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER J ei �� 04-1 PERMIT DATE:k*1`C i i COMPLIANCE DATE:- Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 S Q3 �A2�ct� `Z� 6e 39 ` - z 5 e e 1� C21�/ cam`a Ax; l l , i COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFF s DEPARTMENT OF ENVIRONMENTAL PRO TIO ONE WINTER STREET. BOSTON. MA 02108 617-292-55 ' 1 .: m N p IS"9'q WILLIAM F.WELD �`r � �j //��4��,,� TRL7DIY? OXE Governor '�lfpp ' cretany ARGEO PAUL CELLUCCI A I B..ySTRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E Qy Commissioner PART A CERTIFICATION Property Address: 115 Lumbert Mill Rd Centervillgddress of Owner: James Peacock Date of Inspection:id "�L/'" (If different) 100 Meadowlark Ln Name of Inspector: Wm E Robinson Sr osterville MA 02655 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Servi e Mailing Address: PO Box 1 089., QPnt-Pryj11e,__MA 02632 Telephone Number, 50 8 7 7�,_R 7 7 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 _ Co5ditionally Passes T >4eds Further Evaluation By the Local Approving Authority fails Inspector's Signature: Date: �� - -L��• The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. IN CTION SUMMARY: Check A, B, C, Or D: A] SYS EM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMME TS: BI SYSTE 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. Indicate s, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. 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 conforming septic tank as approved by the Board of Health.' (revised 04/25/97) Page 1 of 10 T DEP on the World Wide Web: http:Uwww.magnet.state.ma.us/dep e'j Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t J Q PART A t , a` CERTIFICATION (continued) Proper4 tAddr`ess: .11�5 Lumbert Mill Rd., Centerville Owner:�;�,'., Pe'2�c o C k Date of Inspection: /0w 41 9 B1 SYSTEM CONDITIONALLY PASSES (continued) 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 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 C1 FURTH R EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the ublic health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE YSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENV RONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to 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 ess than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 115 Lumbert Mill Rd, CentervildA Owner: Peacock Date of Inspection: i-1 Q D] SYSTEM FAILS: You must indicate ei;!;er "Yes" or "No" as to each of the following: rL✓$ I have determined that the system violates one or more of the following failure criteria as defined 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 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. — Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LA GE SYSTEM FAILS: You m st indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic health and safety and the environment because one or more of the following conditions exist: Yes o 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) The ow er or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 115 Lumbert Mill Rd. Centerville Owner: Peacock Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. 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. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up.- The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C L SYSTEM INFORMATION Property Address: 115 Lumbert Mill Rd., Centerville Owner: Peacock Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 34 0 e.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: i�+ Garbage grinder (yes or no):,eLjO Laundry connected to system (yes or no)y—� Seasonal use (yes or no): yli t) Water meter readings, if available (last two (2) year usage (gpd): 1st limos ' 98 — 29, 000ar Sump Pump (yes or no):Jv 1997 — 103 , 0009 1996 - 111 , 000g Last date of occupancy:, 7 -c l—f 6 COMMERCIAUI NDUSTRIAL: Type o establishment: Design low: gallons/day Grease t ap present: (yes or no)_ Industria Waste Holding Tank present: (yes or no)_ Non-san ary waste discharged to the Title 5 system: (yes or no)_ Water ter readings, if available: Last dat of occupancy: OTH (Describe) Last a occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /L- ZA System pumped as part of inspection: (yes or no) �10 If yes, volume pumped: 6U gallons Reason for pumping: TYPE OF SYSTEM �ptic tank/distribution box/soil absorption system f/ Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: ,Sewage odors detected when arriving at the site: (yes or no)/& (revised 04/25/97) Page 5 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Lumbert Mill Rd., Centerville Owner: Peacock Date of Inspection: /0 d-,ZL 4-/-,4 BUU,,FING SEWER: (Local on site plan) Depth low grade: Material f construction: _cast iron _40 PVC_other (explain) Distance rom private water supply well or suction line Diamete Comm ts: (condition of joints, venting, evidence of leakage, etc.) SEPTIC ANK:_ _ (locate o site plan) Depth be w grade: Material o construction: _concrete _metal _Fibergl s _Polyethylene _other(explain) If tank is m tal, list age _ Is age confirmed by Ce ficate of Compliance _(Yes/No) Dimension Sludge de the Distance rom top of sludge to b/let ttm f outlet ee or baffle: Scum thic ness Distance om top of scum to tr baffle: Distance f om bottom of scum et tee or baffle: How dim lions were determiComments (recomme dation for pumping, t and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, vidence of leakage, GREASE TRA (locate on site Ian) Depth below ade: Material of co struction: _concrete _metal _Fiberglass Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffl . Distance from bott m of scum to bottom of outlet t or baffle: Date of last pumpi g: Comments: (recommendatio for pumping, condition o inlet and out tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid c f leakage, etc.) (revised 04/25/91) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Lumbert Mill Rd., .Cnterville Owner: Peacock Date of Inspection: /()"',a 4/— TI T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (Iota on site plan) Depth low grade: Materia of construction: _concrete _metal _Fiberglass _Polyethylene .—other(explain)Dime Is' ns: Capaci gallons Design low: gallons/day Alarm I vel: Alarm in working order_Yes; _ No Date o previous pumping: Comm ts: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIB TION BOX:_ (locate on site plan) Depth o liquid level above outlet invert: ' Commen (note if le el and distribution is equal, evidenc of solids carryover, evidence of leakage into or out of box, etc.) 1 PUMP CHA BER:_ (locate on sit plan) Pumps in w rking order: (Yes or No) —/ Alarms in w irking order (Yes or No) Comments: (note conditi of pump chamber, fndition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Lumbert Mill Rd., Centerville Owner: Peacock Date of Inspection: 4 -3 SOIL BSORPTION SYSTEM (SAS):_ (locate site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not dete mined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: ° Depth of solids layer: L/— $ Depth of scum layer: '3 5' ' Dimensions of cesspool: G Materials of construct ion:6A_ s:� s Indication of groundwater: A, inflow (cesspool must be pumped as part of inspection)?G Comments: (note condition of soil, ns of hydraulicfailure, level of,Pondi* g, condition of vegetation, etc.) 4— b �/r PRIVY: (locate on site Ian) Materials of c struction: Dimensions: Depth of solid Comments: (note condition f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Lumbert Mill Rd., Centerville Owner: Peacock Date of Inspection: V— �f f SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) 0V � Gl (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) / Property Address: 115 Lumbert Mill Rd., Centerville Owner: Peacock Date of Inspection: Depth to Groundwater J�- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions „ Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe inyour own words how you established the High Groundwater Elevation. Must be completed) (revised 04/25/97) ?age 10 of 10