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HomeMy WebLinkAbout0137 LUMBERT MILL ROAD - Health FA= umbert Mill Rd le -020 S Ivi EA 0- 1 No. H163OR UPC 10259 smead.com • Made in USA zJ ��` Idu i�8 Commonwealth of Massachusetts Title 5 Official Inspection Form ' A Subsurface Sewage Disposal System Form -Not for Vol u ntary.Assessments . 137 Lumbert Mill Rd Property Address Nancy Karami . . Owner Owner's Name / information is Centerville f/ MA 02632 12-18-2020 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address East Falmouth MA• 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems:After conducting this inspection I have determined that the system: " 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12-18-2020 I ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 " Commonwealth of Massachusetts Title 5 Official Inspection Form t �01 Subsurface Sewage Disposal System Form -Not for Voluntary-Assessments 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary r Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: •System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced.or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y El ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts r,, Title 5 Official Inspection -Fora r ;al Subsurface Sewage Disposal System.Form -'.Not for Voluntary Assessments off' 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will -pass inspection if,(with approval of Board of Health): f r❑' broken pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below): obstruction is removed ❑ Y El ❑' 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 El ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if 'the system is'failing to protect public health, safety or the environment. ' a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, t safety and the environment: • t5insp.doc•rev.7/26/2018 Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 p Commonwealth of Massachusetts ;µ Title 5 Official Inspection Form- N. Subsurface Sewage Disposal System Form -Not for Voluntary'Assessments 137 Lumbert Mill Rd 'J Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. []The system has a septic tank and SAS and the SAS is within a Zone 1,of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: o , 4) System Failure Criteria Applicable'to All Systems: You must indicate "Yes"or"No"'to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Form �r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r_ > 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) s , 4) System Failure Criteria Applicable to All Systems: (coot.) Yes . No ' ❑ ® Static liquid level in the distribution box above'outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow' El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or ` tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply ® I well. - ❑'� ® "' 'Any portion of a cesspool'or privy is within 50 feet of a private water supply well. t Of° ® 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 r .;• system.passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility-with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be a necessary to correct•the failure. , I 5) Large Systems:To be considered a large system the system must serve a facility with a design ` flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to.each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 16 f Commonwealth of Massachusetts ' fug Title 5 Official Inspection' Form :4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r ' 137 Lumbert Mill Rd J- Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered yes to any question in Section C.5 the s stem is considered a significant Y 9 threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumpinginformation 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? ® Ell 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? N ­ ❑ 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? Wasthe facility'owner'(and occupants if different from owner) provided with information on'the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at•the.Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 r Commonwealth of Massachusetts f. Title 5 Official Inspection Form. 54 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is Centerville MA 02632 12-18-2020 required for every page. City/Town State 'x` Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 12-2020 Date t t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official: Inspection Form 'M rr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >" 137 Lumbert Mill Rd J Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ' Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.712 612 01 8 Title 5 Official Inspecfion Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form - Kp Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Lumbert Mill Rd Property Address Nancy Karami 11 Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): , Depth below grade: 24"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other'(ezplain)`: Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc-rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 cam," Commonwealth of Massachusetts - iw Title 5 Official Inspection Form. rr. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): :.. Depth below grade: 18"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: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" .Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form. hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): , Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping`., • Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): v.t + r 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusettsrvi - 1 Title 5 Official-{Inspection Form oi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Lumbert Mill Rd J Property Address Nancy Karami Owner Owner's Name information is Centerville r'required for ever y MA 02632 12-18-2020 City/Town/Town page. Y State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order.' ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No , 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,ji Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is required for every Centerville c , MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t 10. Pump Chamber(locate on site plan): I Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 L Commonwealth of Massachusetts ' Title 5 Official Inspection Form' MI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is Centerville MA 02632 12-18=2020 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure,,level of ponding, damp soil, condition of vegetation, etc.): Infiltrator field in good working order with no sign of back-up into d-box or,surrounding stone. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration I , Depth—top of liquid to inlet invert ' Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 v Commonwealth of Massachusetts _ Q f@ Title 5 Official Inspection Form 1.1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , 13. Privy (locate on site plan): t Materials of construction: � t Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7128l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ral Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Lumbert Mill Rd •Te:i Property Address Nancy Karami Owner Owner's Name information is required for every Centerville - MA 02632 12-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t9 -1 - 7 r 6 ,d 3 e � � h r� Y :Jq ,-3 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts f� Title 5 Official Inspection. Form N Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments r 137 Lumbert Mill Rd Property Address Nancy Karami Owner Owner's Name information is required for every Centerville MA 02632 12-18-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ? ❑ Check Slope ❑ Surface water ❑ Check cellar _ ❑ Shallow wells , Estimated depth to high ground water: 124 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 ® 0Observed site (abutting property/observation hole within 150 feet4of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts ` ;w Title 5 Official Inspection Form 'Vt ibi Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments , .f,;, 137 Lumbert Mill Rd - Property Address Nancy Karami Owner Owner's Name information is Centerville - MA 02632 12-18-2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist - Complete all applicable sections of this form inclusive of: ' ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate - 4'(Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: 9 Explanation of estimated depth to hi h' roundwater included P P g f t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 :TOWN-OF-BM'ISTABL wAa� �10ChT�Qi�I.... cj - A►SSE�SSOR'$ SSM, ..Ti ilk CAFAC Y C.� LACftt�l A�C1�3'� (she) NQ. DFBlaI3��MS .DATE• _ ,,._____.:..�t�1V�I.�IC,���3A'�E: - �psrat�on D�tance ern Ede• . Maxuwm ANs'�d,Oendwatfiable�o theBodom ofLeacheFacit�ty Feet Pa�tatC�4tat+u SuP�►��e�l anc� ug Facal�tyr (zany was on sire or hvztbIfi .OQ' et v€ It tidn fa ec�) : t $dge ol"�itlatidg tyf a#ty wetlands exist vritlala 3Q4 feet o 'teacttd'gIz. r: Pret ._Fut�ist�ect bS►.: _ _ . . . . . 1 1 � � d 0 30"9Il as 3 Y,9"- s No. Ileb73 Fee_y r_/ THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer: __ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for -Migpogar �p tern �Conetruction Verna Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) O Complete System dividual Components Location Address or Lot No. /37 am Owner's Name,Address and Tel.No. Assessor'sMap/Parcel Opp Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) v Other Type of Building No. of Persons Showers( ) Cafeteria( ) u . Other Fixtures Design Flow 1-172 3 gallons per day. Calculated daily flow a 4 q gallons. Plan Date Number of sheets Revision Date Title v Size of Septic Tank O la Type of S.A.S. i J r c, Qc=c rr c1 pGt�� Description of Soil 1 ✓C`s 1-14'L d/ Nature of Repairs or Alterations(Answer wheg applicable) ' r 4 T Gu r 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 E onmental Code and not to place the system in operation until a Certifi- cate of Compliance h` C� Signed Date v Application Approved by Date Application Disapproved for a follo ing reasons Permit No. Date Issued rr s TOWN OF BARNSTABLE r LOCATION SEWAGE # ✓ V VILLAGE_ ASSESSOR'S MAP & LOT ! D ' INSTALLER'S NAME&PHONE NO. R'fii� CA1�2 SPA 7'�/C SEPTIC TANK CAPACITY //C.?O LEACHING FACILITY) /!f/{/%TI(ff�Q� S' (size) NO. OF BEDROOMS BUILDER OR OWNER-, PERMITDATE: COMPLIANCE DATE: I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by It :� No. 4Z6 3 ` Fee THE COMMONWEALTH OF MASSACHUSETTS _Entered in computer: !:ev Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASS) CHUSETTS Tipprication for Migozar *polem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( • ) ❑C mplete System *bdividual Components Location Address or Lot No. 7 ILL Yn. S Owner's Name,Address and Tel.No. `^ Assessor's Map/Parcel ti:R� Le vvi S -) ') ." t1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 15 i outs 5-t, 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 C2 gallons per day. Calculated daily flow 14�-1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. r T ��11UC.`t` w Description,of-Soil /!1!v c1_2 Nature of Repairs or Alterations(Answer wheQ applicable) -- `/1 / O' "" r 7 Date last inspected: r' Agreement: 1 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 'ronental Co de and not to place the system in operation until a Certifi- cate of Compliance hj�,beorr-is d by'this- 14eattrr-"�"" � Signed Date Application Approved by Date 9//,ter=;�2 Application Disapproved for a follo4ing reasons ` Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(V-< Abandoned( )by --C-fA 0C-7 S t at `ov r-r -k` Q Ft L-iEtJt has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _ dated Installer Designer _ j The issu a of s e t shall not be construed as a guarantee that the syste' i I function as deli ned4/wHIZ g!Date Inspector % �' i l f rt _____________®__________________— No. — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS oigoal 6potem Construction Permit Permission is hereby granted to Construct( !)Repair )Upgrade�j �C�" on � ( ) System located at 1 C iJ *u �vT P, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: C/- 1�T q Approved by. J `1 116199 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) z� . , � hereby certify that the application for disposal works construction permit signed by me dated �'—l��` , concerning the property located at f 3 7 meets all of the following criteria: 6The failed system is connected to a residential dwelling only. There are no commercial or business C yses 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. 6-' There are no wetlands within 100 feet of the proposed septic system • ere are no private wells within 150 feet of the proposed septic system •/fihere 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] Z, 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) ) B) G.W.Elevation J010+the MAX.High G.W. Adjustmen3i = l DIFFERENCE BETWEEN A.and_B_- SIGNED : `- DATE: /C[ [Sketch proposed plan of system on back]. q:health folder.cert O v F TOWN OF BAMSTABLE h ` qqLOCA71 ON AZZ SEWAGE # VVV —"riI,LAGE ASSESSOR'S MAP & LOT 0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /7 Q O LEACHING FACILITY: (type) /N Y"'d-W-W E (size) // X J Z NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: q 11 &1 q I COMPLIANCE DATE: C�Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ` A sec k F � y y TOWN OF BARNSTABLE � LOCATION /3 IJ -2- Al /2�,; SEWAGE T a VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS_ BUILDER OR OWNER C1-1 -7(-/e k-- PERMITDATE: 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'i Furnished br � I.�` 1 t ,�• �, ��3 �� i3�c.k. r 3 TOWN OF BAMSTABLE �. � LOCATION .' �y/7� cam% /lid � (`�d ' SEWAGE # t ✓ tk ; "a.LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.—AJiI SEPTIC TANK CAPACITY //v O LEACHING FACILITY: (size) _ c // X 3 Z NO.OF BEDROOMS BUILDER OR OWNE nn PERMTTDATE: t''`' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by GX (D e c.Y Alm �> > 1. 3,2_ '� 13 y TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 0 DEPARTMENT OF ENVIRONMENTAL PRO ONE WINTER STREET. BOSTON, MA 02108 61.1.292.5 WILLIAM F.WELD Govcmor A TRUDY COJiE 7 SSecrctm%• ARGEO PAUL CELLUCCI �lj' 19e�AVID B"STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'S O1_A , Cor missioncr PART A �? / ) �'7 a CERTIFICATION Property Address: 13 7 l)v.� c r 7 M' I I KU �c y c✓�J•(/ Daterf y/ 23 /y 8 5if d i ffe of Owner: Oate of Inspection: (If different) �`^J C�44e K • Name of Inspector: Troy Williams J W. I am a DEP approved system inspector pursuant to Section 1S.340 of Title S (310 CMR 1S.000) Company Name: Troy .Williams Septic Inspections Mailing Address: 19 Hummel DriVP , South flannl5 , MA 02660 Telephone Number:.T508T385-1300 e%2 C-3-)- CERTIFICATION STATEMENT I certify that 1 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: asses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature:` `� /4Ya �� Date: y/,).3 /58 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. INSPECTION SUMMARY: Check A, 8, C, or D: Al SYSTEM 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. COMMENTS: 61 SYSTEM CONDITIONALLY PASSES: /V//9 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. Indicate yes,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. lr-.�i ud 0�/75/f7) ` V•q• 1 or 10 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 137 Lumbert Mill Road, Centerville,MA Property Address: Sandy Cotter Owner: April 23, 1998 Date of Inspection: B] 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ////9 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within SO feet of a surface water Cesspool or privy is within SO feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, 11=APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet 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 SO 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 SO feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid).. 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 137 Lumbert Mill Road,Centerville,MA Owner: Sandy Cotter Date of Inspection: April 23, 1998 D) SYSTEM FAILS: N//7 You must indicate ei;,.er "Yes" or "No" as to each of the following: 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 112 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] LARGE SYSTEM FAILS: Ai119 You must indicate either 'Yes' or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No 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 owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. ��..• ..a oilsis; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 137 Lumbert Mill Road, Centerville,MA. Property Address: Sandy Cotter Owner: April 23, 1998 Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes i 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, mat erial-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. wJ4 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) 115.302(3)(b)J f-vi-d 04/25/91) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 137 Lumbert Mill Road, Centerville,MA Owner: Sandy Cotter Date of Inspection: April 23, 1998 RESIDENTIAL: FLOW CONDITIONS Design flow: 41416 g.p.d./bedroom for S.A.S. Number of bedrooms: Y Number of current residents: Garbage grinder (yes or no): No Laundry connected to system (yes or no): Y�S Seasonal use (yes or no): A/Q Water meter readings, if available (last two (2)year usage (gpd): 97 = 8q�Opp Sump Pump (yes or no): /VO Last date of occupancy: 0L��� e_cA , COMMERCIAUINDUSTRIAL: A114 Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes orno)_ Non-sanitary waste discharged to the Title S system: (yes or no) Water meter readings, if available. Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: n ti� a System pumped as pan of insp ction. (yes or no)jp If yes, volume pumped: gallons Reason for pumping: TYPE QF 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information:1C176. Sewage odors detected when arriving at the site: (yes or no) A/o I r•� ..0 0 )5 ici ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 Lumbert Mill Road,Centerville,MA Owner: Sandy Cotter Date of Inspection: April 23, 1998 BUILDING SEWER: JV/0 (Locate on site plan) Depth below grade: Material of construction: _cast iron _ 40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) . SEPTIC TANK:2 (locate on site plan) Depth below grade: Material of construction: -,/-Concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: s �x`/ X /a p— 'o ~ Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: 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: /Y How dimensions were determined: Comments: (recommendation .for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet i , structural integrity, evidence of leakage, etc.) invert, dJ VJ ��A ✓~Jtr� 77...� H o 0 d .Y_ O �. a - iL GREASE TRAP: (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) • I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 Lumbert Mill Road, Centerville,MA Owner: Sandy Cotter Date of Inspection: April 23, 1998 TIGHT OR HOLDING TANK:A�69 (Tank must be pumped prior to, or 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/day Alarm level: Alarm in working order_ Yes; No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: le—y Comments: (no if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) (� — Tr WL✓ Cc� a✓cr Q, tics .J PUMP CHAMBER: / //,V (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.) Ir—i—d 04/25/911 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 Lumbert Mill Road, Centerville,MA Owner: Sandy Cotter Date of Inspection.April 23, 1998 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: // . / leaching pits, number:�� n A . 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.) ff G` ti s.CESSPOOLS y :/ � ' 1 � o� �'�Spc o� (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: y1///-g (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) I r�v1•mod 0 /1S/9�) P.9• a or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 Lumbert Mill Road, Centerville,MA Owner: Sandy Cotter Date of Inspection: April 23, 1998 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) taw+ti. L.at T w� k �y 627 -ram,k ye . p43oK (r�v1•mod 0�/21/9�) P-q• 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 Lumbert Mill Road, Centerville,MA Owner: Sandy Cotter Date of Inspection: April 23, 1998 Depth to Groundwater /S fFeet — adjusted high groundwater level 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 V/ Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) ��✓r...r/L w a!�<,r v�.k�o S + �. a r Lc,� ,S J I OJ 0 �..�. c� � .3 n o T /D c c, f- t s� I n �� 5 y rU.�4 a &-'1 Ir.v1•.d 0�%75/771 P.O. 10 l.f t n /�U�c 43 7 L0,CR'710N SEWAGE PERMIT NO.. VILLAGE INSTA LLER'S NAME & ADDRESS B UItDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED J i I P"' CD 1 1 0 — - d Ly, �� ,� J...7 No.-. .. FlzR....Z............. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH t>.uJ L.... ----OF........ ................ Appliratiuu -fur Biupuuttl Workii Towitrurtiuu rrulit Application is hereby made for a Permit to Construct (�or Repair ( �,,Individual Y'Sage Disposal System at: _ter✓/,�, / oiGG---- �.--•-•----..... - r�2at�on•Addr - - ¢V or Lot . �; 0 e ..._ l l.� �tl.�U / �11- CG;...:�'.!�i Owner .. ddr s � .� Installer Address Type of Building Size Lot---1,5 51...Sq. feet V Dwelling—No. of Bedrooms................._ Expansion Attic ( ) Garbage Grinder ( ) a4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ...................................................... Design Flow_____,_________................J --gallons per person per day. Total daily flow___-______-_----_-�� .�......'.gallons. W WSeptic Tank - Liquid capacitv/Z- .gllons Length................ Width-------......... Diameter---------------- Depth.-.--------..,-. x Disposal Trench—No_ ___________________•-Width�_.-......_................ Total Length................. Total leaching area--------------------sq. ft. Seepage Pit No......Z......... Diameter. '��.... Depth below inlet_&_ . ........ Total leaching areu sc 1. ft. Z Other Distribution box ( --yoo, Dosi Percolation Test Results Performed b .__.t .�__�__ 1 ----_-_�'_� �. Date._ e,65-T k-Pit No. 1................minutes per inch Depth of Test Pit- ." -- Depth to ground Test Pit No. 2.... -------minutes er inch Depth of Test Pit.___ ground .. .Q"Depth to d r_ ✓ � - P P P g �: O �•.......... ... . . 'oi'-_-----to c03�-• -Mc- L©NE---- � Description of Soil. .......� f --- --�------•- 44 r�Q x /�' r,? ��------. esr! ..._.._. 90 �ls� �`- U -------- - - - - ---------- e 'I• Fss/DNAL�N.O l--- - V Nature of Repairs or Alterations—Answ when applicable..._............................................................................................ -------------------------------------------------------------------•---••----------•----•---------•--•---•-••----•-------------....._.....................---.......--•-•---....------------------.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in { operation until a Certificate of Compliance has been is ued by the and of healt i. c ------ Sign �` ,St n �.._....... Q ate k Application Approved By..... . --•--- ---•-. i ............ 1C ate Application Disapproved for the following reasons-------------------------------- -------•-------•-••--•-••---•-----••--•-•-..._..------------•-•-----------._... -•-----------------------------------•-•------------••---•----------------•---•-•---•------------------------------------------------------------------------------------------------------------------ Date PermitNo......................................................... Issued-----_-------------------------------------------------- Date ate' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 41`4-- . ..`.' ........oF.... �''''rw.�..:..V:.�. .................................. Trrtifirate of (l ampliattre THINS TO CERT�I, Y, That the Indivi ual Sewage Disposal System constructed ( ) or Repaired ( ) - --•�-----�- ------------------------------ ----•---------------- ------ ----- --- �......--"' ` •7` sta1 err - 6 at-----•---•--•---•--•--•-••-- .... _/ � �G� has been installed in accordance with the provisions of Article XI o, The State Sanitary Code as described in the application for Disposal Works Construction Permit No.................V�.�...... ...... dated----- r�.... .;�„ -.......... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONS RUED AS GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � J Inspector................................................................................... DATE •------DATE1.1-4/ / 7 � THE COMMONWEALTH OF MASSACHUSETTS --- BOARD OF HEALTH �� '�'" 0 j � cs`�ol Gw3 �.✓ ,J/ ....../...................OF.:...,!'�..... ............. b { ' ..._...� FEE- ..................... Bi pviial lVarkii (lamitrurtil t -rmit Permission is hereby granted__--.-. �................ s::':.... ..•------------•------------------------•---•--------.......-•-•-- to Cons t uct or Rep ir ( an I dividu } Sewage isposal System st,et rw� as shown on the application for Disposal Works Construction er it __.......__. Dated..0_ ` ... 'e F Board of He lth DATE.- / -- r FORM IZSS HOBBS & WARREN. INC.. PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration -for Uiopoottl Workfi Tonfitrurtioo Vern fit Application is hereby made for a Permit to.Construct (tom') or Repair ( ) an Individual Sewage Disposal System at: ` ................ ..CAA..................... -- -•------ Addre /J Cf/r : cation_ �•-'�� �� {PLC( /y or Lot /�� 1, � Owner Addces Installer Address ,. Q Type of Building Size Lot--- r ....Sq. feet" U Dwelling—No. of Bedrooms------------ ---� .______ . Expansion Attic ( ) Garbage Grinder ( ) H _ ------.-- aOther—Type of Building _______ ___________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------------------- - ,��._... Mons per erson per day. Total daily flow..................... _ .--._-_gallons. W Design Flow g P P P Y y ' g� WSeptic Tank ZLiquid capacity®9_-,;_,_t. allons Length---------------- Width................ Diameter................ Depth--.._-____..__. x Disposal Trench—No- -------------------- Wicdlth--__-_-_------_---_- Total Length-._-_-_-----.---�V. Total leaching area----._---_---- ----_sq. ft. Seepage Pit No..._...e__--_-_-- Diameter GS_--:�----- Depth below inlet_.` ___._. Total leaching are. ___sq, ft. Z Other Distribution box ( � Dosinptgak (? )� '—' Percolation Test Results Per b '_---._:�'-_": ° =_...____.�'. �... a Date..... �� ss Pit No. 1................minutes per inch Depth of "Pest Pit. ........... Depth to groun r "'` � .- BE�Rfi- L14 Test Pit No. 2.....4�_........minutes.per inch Depth of Test Pit--_�.'_.�`'. Depth to groun � ter''�''�?d,I -U, a+ -----M.cGL-O L`1E----- O Descri Lion of Soil ' ��`r-ter+ `= B,? �� ' - --- - -- - - _.. � �Ju -d4 O Q U r w✓o '//CC;t/ - -- `.....=`.... = 'l `` ------------• �` ' : —`'''�'j t'1 C E i W ----------- ----------------- - ----------------------- �'' U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------------------------ ----------------------------------------------------------------------------------- ------------------------------------------------------------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig @d ---------_--_ f r Date Application Approved BY---- ;�' z �'--- ----•-- .... Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo........................................................ Issued........................................................ �= s � . � _ � — v � b �3 f d THE COMMONWEALTH OF MASSACHUSETTS BOARD OFHEALTH ...... oL ...............OF.... -?....................................:. Appliratinn -for Uhipoiittl Works Towitrurtion rru i Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: 13 Location-Address or Lot No. ..............................................TJ.A----------•----------•-------•--•---....... Owner Address - ......•---• �. Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms---------------3........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons.-_-___--�............... Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------------------------------------------•-------•-----•-------------------_----- W Design Flow............._......._______.__._...gallons per person per day. Total daily flow-_---_______�Q_._._._............gallons. WSeptic Tank—Liquid capacity------------gallons Length------(....... Width._�....... Diameter................ Depth................ x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--•----------••--•---------------------------------------------•-•-•--... Date-------------------------- ------.----- Test Pit No. 1------z-.....minutes per inch Depth of "Pest Pit_._______-____--_ Depth to ground water--------------------_- G4 Test Pit`No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ t� .. ----------------------------------------- ................................ -- O D escription of ..M-E _M. _ R� _ I�I� W U Nature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------------------------------------------. ------------------------------------•-•---------•-.----.------------.-------•-----.--------------------------.-.------------.-------.-----------------------.----------.-.----•---------------.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. r-� Sig ed- ----•- ---------------------� ` 1.. 1 TT - Uo" �( S � Date Application Approved By- ,A Lt�l -. . •.............•------- •` �1 S' 7 Date Application Disapproved for the following reasons-.........................................--..................................................................... -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- '9 Date PermitNo........................................................ Issued--------- ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........0... OF.......... ............................... Cnrrtifirate of Tomphatirr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V' or Repaired ( ) E�Ec�►- o....... �ccQ-��F. _ ._.. by V ---------------------------------------------------------------- Installer I�oT q LC) )tt�E k_...... -----.�-QYAD-- C _�_E1Z.�_�.�lY ------------------------------------------ at... -•-------- bas been installed in accordance with the provisions of Ar6cl� 1I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No �__/___.�� '7.............. dated------ -_ -_.._7_:=y7-----_.... THE. ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATIJ U� C ---------------•-----------•----••- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH > > �� / ...CS.w�.................OF.r�C...�..�tZ..�.5.�.1M�J I&..------------ No . .......... FEE. 'Bi-spoiial ork,i tln4 trurtiou Vrrmit Permission is hereby granted------ ------ /�Q'.�L'----------------------------------------•---••------------------------------ to Construct (�4 or Repair ( ) an Individual Sewage Disposal System at No. CST. j 17N\l�>`12.-1 AI.1..L...-- Q*�17 �- C t, ._-1..LKQLQ k'---------------------- Street _ as shown on the application for Disposal Works Construction Permit No Z., ____n. Dated--- .� `---% ---------- ✓� � ., DATE-------.7L U -q--- •----�-�-�-�- ------------------------------ Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No.. �'. ....7 Fua....� .. ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALTH c- Appliratiun -fur R-qv uttl Workii Tvtv�lrurtiun Vrrnift Application is hereby made for a Permit to Construct ( /O or Repair ( ), an Individual Sewage Disposal System at: Location_Address or Lot No. ----••' St"1_►�.1H....•-------••-------•---•---•----------- ------•---------------------------•---....._..................-----•--•----------•--••----------- Owner Address DETE, Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms________________3------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons..........(ca---------------- Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------- W Design Flow..............� ..................... per person per day. Total daily flow------------- —C.....................gallons. WSeptic Tauk—Liquid capacity------------gallons Length------L------- Width-_. ---._.. Diameter---------------- Depth------------- x Disposal Trench—No-____________________ Width-------------------- Total Length.................... Total leaching -area....................sq. ft. Seepage Pit No.............._r.___. Diameter.................... Depth below inlet_................... Total leaching area-___--.._.__-.__-_sq. fi. Z Other Distributiolrbu)( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................... ._. Date..............-------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water..-._---__---__._-.--. rXq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_---.-.._------_-__---. R; ----------------------------•-•---'-......--•--------------•----•-•-••-.._.._..._........"•----'--...................................................-----" O Description of Soi1.S�_"'A0" L��i it't $, �i)F)&C)It- t-�t�`.'. �-" �`-1`"�_" i-It -�'I'j.��1--`:_ x ---- ----�•---------- -------- W x U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----'•----------------------------------------------------------------------------------------•--•---------•--------•------------••------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 1 Date Application Approved B �/ __ . �L. }`s l Date Application Disapproved for the following reasons______________________' —---•-----•-•----- ----------------•-------------------------------- --•----------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------[-�----------------------------- 1 Date Permit No--------------------------------------------------------- Issued..........3—o.Lq--- 1-1---1•cl...]_!-...... 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